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Special Issue "Cardiac Rehabilitation"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (30 January 2019)

Special Issue Editor

Guest Editor
Prof. Dr. Darren Warburton

Cardiovascular Physiology and Rehabilitation Laboratory, University of British Columbia, Vancouver, BC, Canada
E-Mail
Interests: Indigenous health, chronic disease prevention and treatment, exercise medicine, physical activity promotion, quality of life, lifestyle intervention, well-being, health promotion

Special Issue Information

Dear Colleagues,

Cardiac rehabilitation is widely considered an important and often essential step in reducing the burden associated with cardiovascular disease in contemporary society. Patients that engage in formal supervised and unsupervised cardiac rehabilitation programs have consistently been shown to reduce the risk for premature mortality and chronic disease, while improving their overall health and well-being. Over the past 10 years, there have been marked advancements in the field of cardiac rehabilitation supporting the importance of adopting healthy lifestyle behaviours in the primary and secondary prevention of cardiovascular disease and other related chronic medical conditions. In this present Special Issue we will examine more closely recent innovations and advancements in cardiac rehabilitation. We will also evaluate the current evidence regarding the ability of cardiac rehabilitation to reduce the risk for chronic disease and premature mortality and to improve health and wellness. We will also assess best practices from across the global community establishing key examples and/or predictors of success in cardiac rehabilitation settings. As such, through this Special Issue, we will provide greater insight into what is being done on the international stage, the level of evidence regarding health and wellness benefits associated with cardiac rehabilitation, and the key predictors of success.

Prof. Dr. Darren Warburton
Guest Editor

Manuscript Submission Information

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Keywords

  • Cardiac rehabilitation
  • Primary and secondary prevention of chronic disease
  • Lifestyle management
  • Motivational interviewing
  • Behavioural change
  • Lifestyle intervention
  • Cardiovascular disease prevention and control

Published Papers (19 papers)

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Research

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Open AccessArticle
“With Every Step, We Grow Stronger”: The Cardiometabolic Benefits of an Indigenous-Led and Community-Based Healthy Lifestyle Intervention
J. Clin. Med. 2019, 8(4), 422; https://doi.org/10.3390/jcm8040422
Received: 31 January 2019 / Revised: 12 March 2019 / Accepted: 25 March 2019 / Published: 27 March 2019
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Abstract
Community-based and Indigenous-led health and wellness approaches have been widely advocated for Indigenous peoples. However, remarkably few Indigenous designed and led interventions exist within the field. The purpose of this study was to evaluate an Indigenous-led and community-based health and wellness intervention in [...] Read more.
Community-based and Indigenous-led health and wellness approaches have been widely advocated for Indigenous peoples. However, remarkably few Indigenous designed and led interventions exist within the field. The purpose of this study was to evaluate an Indigenous-led and community-based health and wellness intervention in a remote and rural Indigenous community. This protocol was designed by and for Indigenous peoples based on the aspirations of the community (established through sharing circles). A total of 15 participants completed a 13-week walking and healthy lifestyle counselling program (incorporating motivational interviewing) to enhance cardiometabolic health. Measures of moderate-to-vigorous physical activity (MVPA; 7-day accelerometry and self-report), predicted maximal aerobic power (VO2max; 6-min walk test), resting heart rate and blood pressure, and other health-related physical fitness measures (musculoskeletal fitness and body composition) were taken before and after the intervention. The intervention led to significant (p < 0.05) improvements in VO2max (7.1 ± 6.3 % change), with the greatest improvements observed among individuals with lower baseline VO2max (p < 0.05, r = -0.76). Resting heart rate, resting systolic blood pressure, and resting diastolic blood pressure decreased significantly (p < 0.05) after the intervention. Self-reported and accelerometry-measured frequency of MVPA increased significantly (p < 0.05), and the total MVPA minutes (~275 min/week) were above international recommendations. Change in VO2max was significantly correlated with change in self-reported (r = 0.42) and accelerometry-measured (r = 0.24) MVPA minutes. No significant changes were observed in weight, body mass index, waist circumference, body fat (via bioelectrical impedance), grip strength, and flexibility. These findings demonstrate that a culturally relevant and safe, community-based, Indigenous-led, health and wellness intervention can lead to significant and clinically relevant improvements in cardiometabolic health and physical activity behaviour, with the greatest changes being observed in the least active/fit individuals. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
High-Intensity Interval Training is Associated with Improved Long-Term Survival in Heart Failure Patients
J. Clin. Med. 2019, 8(3), 409; https://doi.org/10.3390/jcm8030409
Received: 21 February 2019 / Revised: 15 March 2019 / Accepted: 19 March 2019 / Published: 25 March 2019
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Abstract
This matched-control cohort study explored the effects of high-intensity interval training (HIIT) on left ventricle (LV) dimensions and survival in heart failure (HF) patients between 2009 and 2016. HF patients who underwent the multidisciplinary disease management program (MDP) were enrolled. Non-exercising participants, aged [...] Read more.
This matched-control cohort study explored the effects of high-intensity interval training (HIIT) on left ventricle (LV) dimensions and survival in heart failure (HF) patients between 2009 and 2016. HF patients who underwent the multidisciplinary disease management program (MDP) were enrolled. Non-exercising participants, aged (mean (95% confidence interval)) 62.8 (60.1–65.5) years, were categorized as the MDP group (n = 101). Participants aged 61.5 (58.7–64.2) years who had completed 36 sessions of HIIT were treated as the HIIT group (n = 101). Peak oxygen consumption (VO2peak) and LV geometry were assessed during the 8-year follow-up period. The 5-year all-cause mortality risk factors and overall survival rates were determined in the longitudinal observation. An increased VO2peak of 14–20% was observed in the HIIT group after exercise training. Each 1-mL/kg/min increase in VO2peak conferred a 58% improvement in 5-year mortality. Increased LV end-systolic diameter (LVESD) was significantly (p = 0.0198) associated with increased mortality. The 8-month survival rate was significantly improved (p = 0.044) in HIIT participants compared to non-exercise participants. HF patients with VO2peak ≥14.0 mL/kg/min and LVESD <44 mm had a significantly better 5-year survival rate (98.2%) than those (57.3%) with lower VO2peak and greater LVESD. Both HIIT-induced increased VO2peak and decreased LVESD are associated with improved survival in HF patients. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Systematic Review of Capnography with Mask Ventilation during Cardiopulmonary Resuscitation Maneuvers
J. Clin. Med. 2019, 8(3), 358; https://doi.org/10.3390/jcm8030358
Received: 26 February 2019 / Revised: 8 March 2019 / Accepted: 9 March 2019 / Published: 13 March 2019
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Abstract
The latest guidelines identify capnography as an instrument used to assess bag-valve-mask ventilation during cardiopulmonary resuscitation (CPR). In this review, we analyzed the feasibility and reliability of capnography use with face mask ventilation during CPR maneuvers in adults and children. This systematic review [...] Read more.
The latest guidelines identify capnography as an instrument used to assess bag-valve-mask ventilation during cardiopulmonary resuscitation (CPR). In this review, we analyzed the feasibility and reliability of capnography use with face mask ventilation during CPR maneuvers in adults and children. This systematic review was completed in December 2018; data for the study were obtained from the following databases: EBSCOhost, SCOPUS, PubMed, Índice Bibliográfico Español en Ciencias de la Salud (IBECS), TESEO, and Cochrane Library Plus. Two reviewers independently assessed the eligibility of the articles; we analyzed publications from different sources and identified studies that focused on the use of capnography with a face mask during CPR maneuvers in order to describe the capnometry value and its correlation with resuscitation outcomes and the assistance of professionals. A total of 888 papers were collected, and 17 papers were included that provided objective values for the use of capnography with a mask for ventilation. Four were randomized clinical trials (RCT) and the rest were observational studies. Four studies were completed in adults and 13 were completed in newborns. After the analysis of the papers, we recommended a capnographic level of C in adults and B in newborns. Despite the little evidence obtained, capnography has been demonstrated to facilitate the advanced clinical practice of mask ventilation in cardiopulmonary resuscitation, to be reliable in the early detection of heart rate increase in newborns, and to asses in-airway patency and lung aeration during newborn resuscitation. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Age-Related Improvements in Peak Cardiorespiratory Fitness among Coronary Heart Disease Patients Following Cardiac Rehabilitation
J. Clin. Med. 2019, 8(3), 310; https://doi.org/10.3390/jcm8030310
Received: 31 January 2019 / Revised: 28 February 2019 / Accepted: 4 March 2019 / Published: 5 March 2019
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Abstract
While cardiorespiratory fitness (VO2peak) can be improved with exercise and training, it is unclear whether older age is associated with an attenuated VO2peak improvement among patients with coronary artery disease (CAD) who complete a cardiac rehabilitation (CR) program. A [...] Read more.
While cardiorespiratory fitness (VO2peak) can be improved with exercise and training, it is unclear whether older age is associated with an attenuated VO2peak improvement among patients with coronary artery disease (CAD) who complete a cardiac rehabilitation (CR) program. A retrospective review of patient demographics and VO2peak data from January 2012 to December 2017 was performed. CAD patients were included if they had successfully completed the supervised 6-month CR program (>75% of exercise prescription) and two VO2peak assessments (respiratory exchange ratio (RER) >1.0). Among all patients, there was an improvement in VO2peak from 21.1 ± 6.3 mL/kg/min to 26.5 ± 7.9 mL/kg/min (+26% ΔVO2peak). Patients in the younger age category (age category 1: 30–39 years old) tended to have a greater percent of relative VO2peak improvement when compared to all other age categories (e.g., adults 50 years of age and older). In the regression analysis, VO2peak improvement was associated with younger age (β = −0.286, p < 0.0001), after adjustment for the baseline VO2peak (β = −0.456, p < 0.0001), final prescribed exercise speed at CR program completion (β = 0.254, p < 0.0001), body mass index (β = −0.172, p < 0.0001), and male sex (β = 0.153, p < 0.0001). Nonetheless, the study findings indicate that older adults who complete CR may be able to obtain clinically relevant improvements in VO2peak of greater than 20%, and therefore, should be referred for CR. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
Open AccessArticle
Importance of Completing Hybrid Cardiac Rehabilitation for Long-Term Outcomes: A Real-World Evaluation
J. Clin. Med. 2019, 8(3), 290; https://doi.org/10.3390/jcm8030290
Received: 30 January 2019 / Revised: 22 February 2019 / Accepted: 22 February 2019 / Published: 28 February 2019
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Abstract
Community-based hybrid cardiac rehabilitation (CR) programs offer a viable alternative to conventional centre-based CR, however their long-term benefits are unknown. We conducted a secondary analysis of the CR Participation Study conducted in London, Ontario, between 2003 and 2006. CR eligible patients hospitalized for [...] Read more.
Community-based hybrid cardiac rehabilitation (CR) programs offer a viable alternative to conventional centre-based CR, however their long-term benefits are unknown. We conducted a secondary analysis of the CR Participation Study conducted in London, Ontario, between 2003 and 2006. CR eligible patients hospitalized for a major cardiac event, who resided within 60 min, were referred to a hybrid CR program; 381 of 544 (64%) referred patients initiated CR; an additional 1,498 CR eligible patients were not referred due to distance. For the present study, CR participants were matched using propensity scores to CR eligible non-participants who resided beyond 60 min, yielding 214 matched pairs. Subjects were followed for a mean (standard deviation, SD) of 8.56 (3.38) years for the outcomes of mortality or re-hospitalization for a major cardiac event. Hybrid CR participation was associated with a non-significant 16% lower event rate (Hazard Ratio [HR]: 0.84, 95% CI: 0.59–1.17). When restricting to pairs where CR participants achieved a greater than 0.5 metabolic equivalent exercise capacity increase (123 pairs), CR completion was associated with a 51% lower event rate (HR: 0.49, 95% CI: 0.29–0.81). Successful completion of a community-based hybrid CR program may be associated with decreased long-term mortality or recurrent cardiac events. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Early Effects of Sacubitril/Valsartan on Exercise Tolerance in Patients with Heart Failure with Reduced Ejection Fraction
J. Clin. Med. 2019, 8(2), 262; https://doi.org/10.3390/jcm8020262
Received: 22 January 2019 / Revised: 17 February 2019 / Accepted: 18 February 2019 / Published: 20 February 2019
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Abstract
Background. Sacubitril/valsartan in heart failure (HF) with reduced ejection fraction (HFrEF) was shown to be superior to enalapril in reducing the risk of death and hospitalization for HF. Our aim was to evaluate the cardiopulmonary effects of sacubitril/valsartan in patients with HFrEF. Methods. [...] Read more.
Background. Sacubitril/valsartan in heart failure (HF) with reduced ejection fraction (HFrEF) was shown to be superior to enalapril in reducing the risk of death and hospitalization for HF. Our aim was to evaluate the cardiopulmonary effects of sacubitril/valsartan in patients with HFrEF. Methods. We conducted an observational study. Ninety-nine ambulatory patients with HFrEF underwent serial cardiopulmonary exercise tests (CPET) after initiation of sacubitril/valsartan in addition to recommended therapy. Results. At baseline, 37% of patients had New York Heart Association (NYHA) class III. After a median follow-up of 6.2 months (range 3–14.9 months) systolic blood pressure decreased from 117 ± 14 to 101 ± 12 mmHg (p < 0.0001), left ventricular ejection fraction (LVEF) increased from 27 ± 6 to 29.7 ± 7% (p < 0.0001), peak oxygen consumption (VO2) improved from 14.6 ± 3.3 (% of predicted = 53.8 ± 14.1) to 17.2 ± 4.7 mL/kg/min (% of predicted = 64.7 ± 17.8) (p < 0.0001), minute ventilation/carbon dioxide production relationship (VE/VCO2 Slope) decreased from 34.1 ± 6.3 to 31.7 ± 6.1 (p = 0.006), VO2 at anaerobic threshold increased from 11.3 ± 2.6 to 12.6 ± 3.5 mL/kg/min (p = 0.007), oxygen pulse increased from 11.5 ± 3.0 to 13.4 ± 4.3 mL/kg/min (p < 0.0001), and ∆VO2/∆Work increased from 9.2 ± 1.5 to 10.1 ± 1.8 mL/min/watt (p = 0.0002). Conclusion. Sacubitril/valsartan improved exercise tolerance, LVEF, peak VO2, and ventilatory efficiency at 6.2 months follow-up. Further studies are necessary to better clarify underlying mechanisms of this functional improvement. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
A Longitudinal Examination of the Social-Ecological Correlates of Exercise in Men and Women Following Cardiac Rehabilitation
J. Clin. Med. 2019, 8(2), 250; https://doi.org/10.3390/jcm8020250
Received: 23 January 2019 / Revised: 13 February 2019 / Accepted: 14 February 2019 / Published: 16 February 2019
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Abstract
Cardiac patients who engage in ≥150 min of moderate- to vigorous-intensity physical activity (MVPA)/week have lower mortality, yet MVPA declines even following cardiac rehabilitation (CR), and is lower in women. A randomized trial of nine socioecological theory-based exercise facilitation contacts over 50 weeks [...] Read more.
Cardiac patients who engage in ≥150 min of moderate- to vigorous-intensity physical activity (MVPA)/week have lower mortality, yet MVPA declines even following cardiac rehabilitation (CR), and is lower in women. A randomized trial of nine socioecological theory-based exercise facilitation contacts over 50 weeks versus usual care (1:1 parallel arms) was undertaken (NCT01658683). The tertiary objective, as presented in this paper, was to test whether the intervention impacted socioecological elements, and in turn their association with MVPA. The 449 participants wore an accelerometer and completed questionnaires post-CR, and 26, 52 and 78 weeks later. At 52 weeks, exercise task self-efficacy was significantly greater in the intervention arm (p = 0.01), but no other differences were observed except more encouragement from other cardiac patients at 26 weeks (favoring controls). Among women adherent to the intervention, the group in whom the intervention was proven effective, physical activity (PA) intentions at 26 weeks were significantly greater in the intervention arm (p = 0.04), with no other differences. There were some differences in socioecological elements associated with MVPA by arm. There were also some differences by sex, with MVPA more often associated with exercise benefits/barriers in men, versus with working and the physical environment in women. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
Open AccessArticle
Clinical and Rehabilitative Predictors of Peak Oxygen Uptake Following Cardiac Transplantation
J. Clin. Med. 2019, 8(1), 119; https://doi.org/10.3390/jcm8010119
Received: 21 December 2018 / Revised: 14 January 2019 / Accepted: 16 January 2019 / Published: 19 January 2019
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Abstract
The measurement of peak oxygen uptake (VO2peak) is an important metric for evaluating cardiac transplantation (HTx) eligibility. However, it is unclear which factors (e.g., recipient demographics, clinical parameters, cardiac rehabilitation (CR) participation) influence VO2peak following HTx. Consecutive HTx patients with [...] Read more.
The measurement of peak oxygen uptake (VO2peak) is an important metric for evaluating cardiac transplantation (HTx) eligibility. However, it is unclear which factors (e.g., recipient demographics, clinical parameters, cardiac rehabilitation (CR) participation) influence VO2peak following HTx. Consecutive HTx patients with cardiopulmonary exercise testing (CPET) between 2007–2016 were included. VO2peak was measured from CPET standard protocol. Regression analyses determined predictors of the highest post-HTx VO2peak (i.e., quartile 4: VO2peak > 20.1 mL/kg/min). One hundred-forty HTx patients (women: n = 41 (29%), age: 52 ± 12 years, body mass index (BMI): 27 ± 5 kg/m2) were included. History of diabetes (Odds Ratio (OR): 0.17, 95% Confidence Interval (CI): 0.04–0.77, p = 0.021), history of dyslipidemia (OR: 0.42, 95% CI: 0.19–0.93, p = 0.032), BMI (OR: 0.90, 95% CI: 0.82–0.99, p = 0.022), hemoglobin (OR: 1.29, 95% CI: 1.04–1.61, p = 0.020), white blood cell count (OR: 0.81, 95% CI: 0.66–0.98, p = 0.033), CR exercise sessions (OR: 1.10, 95% CI: 1.04–1.15, p < 0.001), and pre-HTx VO2peak (OR: 1.17, 95% CI: 1.07–1.29, p = 0.001) were significant predictors. Multivariate analysis showed CR exercise sessions (OR: 1.10, 95% CI: 1.03–1.16, p = 0.002), and pre-HTx VO2peak (OR: 1.16, 95% CI: 1.04–1.30, p = 0.007) were independently predictive of higher post-HTx VO2peak. Pre-HTx VO2peak and CR exercise sessions are predictive of a greater VO2peak following HTx. These data highlight the importance of CR exercise session attendance and pre-HTx fitness in predicting VO2peak post-HTx. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Pre-Operative Frailty Status Is Associated with Cardiac Rehabilitation Completion: A Retrospective Cohort Study
J. Clin. Med. 2018, 7(12), 560; https://doi.org/10.3390/jcm7120560
Received: 9 November 2018 / Revised: 12 December 2018 / Accepted: 14 December 2018 / Published: 17 December 2018
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Abstract
While previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) on outcomes after cardiac surgery, the association between pre-operative frailty and post-operative CR completion is unclear. The purpose of this retrospective cohort study was to determine if pre-operative frailty scores impacted CR [...] Read more.
While previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) on outcomes after cardiac surgery, the association between pre-operative frailty and post-operative CR completion is unclear. The purpose of this retrospective cohort study was to determine if pre-operative frailty scores impacted CR completion post-operatively and if CR completion influenced frailty scores in 114 cardiac surgery patients. Frailty was assessed with the use of the Clinical Frailty Scale (CFS), the Modified Fried Criteria (MFC), the Short Physical Performance Battery (SPPB), and the Functional Frailty Index (FFI). A Mann-Whitney test was used to compare frailty scores between CR completers and non-completers and changes in frailty scores from baseline to 1-year post-operation. CR non-completers were more frail than CR completers at pre-operative baseline based on the CFS (p = 0.01), MFC (p < 0.001), SPPB (p = 0.007), and the FFI (p < 0.001). A change in frailty scores from baseline to 1-year post-operation was not detected in either group using any of the four frailty assessments. However, greater improvements from baseline to 1-year post-operation in two MFC domains (cognitive impairment and low physical activity) and the physical domain of the FFI were found in CR completers as compared to CR non-completers. These data suggest that pre-operative frailty assessments have the potential to identify participants who are less likely to attend and complete CR. The data also suggest that frailty assessment tools need further refinement, as physical domains of frailty function appear to be more sensitive to change following CR than other domains of frailty. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Predictors of Exercise Capacity in Patients with Hypertrophic Obstructive Cardiomyopathy
J. Clin. Med. 2018, 7(11), 447; https://doi.org/10.3390/jcm7110447
Received: 15 October 2018 / Revised: 8 November 2018 / Accepted: 14 November 2018 / Published: 18 November 2018
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Abstract
Hypertrophic obstructive cardiomyopathy (HOCM) patients exhibit compromised peak exercise capacity (VO2peak). Importantly, severely reduced VO2peak is directly related to increased morbidity and mortality in these patients. Therefore, we sought to determine clinical predictors of VO2peak in HOCM [...] Read more.
Hypertrophic obstructive cardiomyopathy (HOCM) patients exhibit compromised peak exercise capacity (VO2peak). Importantly, severely reduced VO2peak is directly related to increased morbidity and mortality in these patients. Therefore, we sought to determine clinical predictors of VO2peak in HOCM patients. HOCM patients who performed symptom-limited cardiopulmonary exercise testing between 1995 and 2016 were included for analysis. Peak VO2 was reported as absolute peak VO2, indexed to body weight and analyzed as quartiles, with quartile 1 representing the lowest VO2peak. Step-wise regression models using demographic features and clinical and physiologic characteristics were created to determine predictors of HOCM patients with the lowest VO2peak. We included 1177 HOCM patients (age: 53 ± 14 years; BMI: 24 ± 12 kg/m2) with a VO2peak of 18.0 ± 5.6 mL/kg/min. Significant univariate predictors of the lowest VO2peak included age, female sex, New York Health Association (NYHA) class, BMI, left atrial volume index, E/e’, E/A, hemoglobin, N-terminal pro b-type natriuretic peptide (NT-proBNP), and a history of diabetes, hypertension, stroke, atrial fibrillation, or coronary artery disease. Independent predictors of the lowest VO2peak included age (OR, CI: 1.03, 1.02–1.06; p < 0.0001), women (4.66, 2.94–7.47; p = 0.001), a history of diabetes (2.05, 1.17–3.60; p = 0.01), BMI (0.94, 0.92–0.96; p < 0.0001), left atrial volume index (1.07, 1.05–1.21; p = 0.04), E/e’ (1.05, 1.01–1.08; p = 0.004), hemoglobin (0.76, 0.65–0.88; p = 0.0004), and NT-proBNP (1.72, 1.42–2.11; p < 0.0001). These findings demonstrate that demographic factors (i.e., age and sex), comorbidities (e.g., diabetes and obesity), echocardiography indices, and biomarkers (e.g., hemoglobin and NT-proBNP) are predictive of severely compromised VO2peak in HOCM patients. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Impact of Rehabilitation on Outcomes after TAVI: A Preliminary Study
J. Clin. Med. 2018, 7(10), 326; https://doi.org/10.3390/jcm7100326
Received: 16 August 2018 / Revised: 21 September 2018 / Accepted: 2 October 2018 / Published: 5 October 2018
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Abstract
The benefit of rehabilitation in elderly patients undergoing transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is unknown. The impact of declining rehabilitation programs on mortality has also not been described. In a longitudinal cohort study of 1056 patients undergoing [...] Read more.
The benefit of rehabilitation in elderly patients undergoing transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is unknown. The impact of declining rehabilitation programs on mortality has also not been described. In a longitudinal cohort study of 1056 patients undergoing elective TAVI between 2008 and 2016, logistic regression analysis was used to assess the relationship between treatment modality and outcome according to whether or not patients participated in a three-week rehabilitation program after TAVI. Subgroup analyses included patient outcome separated according to cardiac, geriatric, or no rehabilitation. A total of 1017 patients survived until hospital discharge (96.3%) and were offered rehabilitation, 366 patients (36.0%) declined to undergo rehabilitation, with the remaining patients undergoing either cardiac (n = 435; 42.8%) or geriatric rehabilitation (n = 216; 21.2%). Mortality at six months was lower for patients receiving rehabilitation compared with those who had not (adjusted odds ratio (OR): 0.49; 95% confidence interval (confidence interval [CI]: 0.25–0.94; p = 0.032). Sub-analysis showed the benefit of cardiac (adjusted OR: 0.31; 95% CI 0.14–0.71, p = 0.006), but not geriatric rehabilitation (adjusted OR 0.83; 95% CI 0.37–1.85, p = 0.65). A program of rehabilitation after TAVI has the potential to reduce mortality. Future studies should focus on health-orientated behavior and identifying risk factors for declining rehabilitation programs. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessArticle
Cardiac Rehabilitation Models around the Globe
J. Clin. Med. 2018, 7(9), 260; https://doi.org/10.3390/jcm7090260
Received: 23 August 2018 / Revised: 31 August 2018 / Accepted: 3 September 2018 / Published: 7 September 2018
Cited by 4 | PDF Full-text (2845 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
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. [...] Read more.
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. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Review

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Open AccessReview
The Effectiveness of Exercise on Cognitive Performance in Individuals with Known Vascular Disease: A Systematic Review
J. Clin. Med. 2019, 8(3), 294; https://doi.org/10.3390/jcm8030294
Received: 31 January 2019 / Revised: 23 February 2019 / Accepted: 24 February 2019 / Published: 1 March 2019
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Abstract
Patients with known vascular disease are at increased risk for cognitive impairments. Exercise has been shown to improve cognition in healthy elderly populations and those with mild cognitive impairments. We explored the literature to understand exercise as a modality to improve cognition in [...] Read more.
Patients with known vascular disease are at increased risk for cognitive impairments. Exercise has been shown to improve cognition in healthy elderly populations and those with mild cognitive impairments. We explored the literature to understand exercise as a modality to improve cognition in those with vascular disease, focusing on dose-responses. A systematic review was conducted through 2017 using Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Ovid Embase, and Ovid MEDLINE databases. Eligible studies examined effects of exercise on memory and cognition in cardiovascular (CVD) or cerebrovascular disease (CBVD). Data extracted included group characteristics, exercise dosage and outcomes measures employed. Twenty-two studies (12 CVD, 10 CBVD) met the inclusion criteria. Interventions included aerobic, resistance, or mixed training, with neuropsychological test batteries assessing cognition. In CVD populations, five studies demonstrated improved cardiovascular fitness and cognition with aerobic training, and another seven studies suggested a dose-response. In CBVD trials, four studies reported improved cognition, with no effects observed in the fifth study. Another study found enhanced cognition with resistance training and four demonstrated a positive association between functional capacity and cognition following combined aerobic and resistance training. Exercise is able to positively affect cognitive performance in those with known vascular disease. There is evidence to suggest a dose–response relationship. Further research is required to optimize prescription. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessReview
A Systematic Review of the Short-Term Health Effects of Air Pollution in Persons Living with Coronary Heart Disease
J. Clin. Med. 2019, 8(2), 274; https://doi.org/10.3390/jcm8020274
Received: 30 January 2019 / Revised: 13 February 2019 / Accepted: 21 February 2019 / Published: 24 February 2019
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Abstract
Persons living with chronic medical conditions (such as coronary artery disease (CAD)) are thought to be at increased risk when exposed to air pollution. This systematic review critically evaluated the short-term health effects of air pollution in persons living with CAD. Original research [...] Read more.
Persons living with chronic medical conditions (such as coronary artery disease (CAD)) are thought to be at increased risk when exposed to air pollution. This systematic review critically evaluated the short-term health effects of air pollution in persons living with CAD. Original research articles were retrieved systematically through searching electronic databases (e.g., Medical Literature Analysis and Retrieval System Online (MEDLINE)), cross-referencing, and the authors’ knowledge. From 2884 individual citations, 26 eligible articles were identified. The majority of the investigations (18 of 22 (82%)) revealed a negative relationship between air pollutants and cardiac function or overall health. Heart rate variability (HRV) was the primary cardiovascular outcome measure, with 10 out of 13 studies reporting at least one index of HRV being significantly affected by air pollutants. However, there was some inconsistency in the relationship between HRV and air pollutants, mediated (at least in part) by the confounding effects of beta-blocker medications. In conclusion, there is strong evidence that air pollution can have adverse effects on cardiovascular function in persons living with CAD. All persons living with CAD should be educated on how to monitor air quality, should recognize the potential risks of excessive exposure to air pollution, and be aware of strategies to mitigate these risks. Persons living with CAD should minimize their exposure to air pollution by limiting outdoor physical activity participation when the forecast air quality health index indicates increased air pollution (i.e., an increased risk). Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessReview
Cardiovascular Health Benefits of Exercise Training in Persons Living with Type 1 Diabetes: A Systematic Review and Meta-Analysis
J. Clin. Med. 2019, 8(2), 253; https://doi.org/10.3390/jcm8020253
Received: 24 January 2019 / Revised: 7 February 2019 / Accepted: 13 February 2019 / Published: 17 February 2019
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Abstract
Exercise is advocated in the management of type 1 diabetes (T1D), but the effects of different forms of exercise training on cardiovascular risk factors in T1D still remain unclear. The aim of this study was to conduct a systematic review and meta-analysis on [...] Read more.
Exercise is advocated in the management of type 1 diabetes (T1D), but the effects of different forms of exercise training on cardiovascular risk factors in T1D still remain unclear. The aim of this study was to conduct a systematic review and meta-analysis on exercise training for cardiovascular risk factors in T1D. Six electronic databases were systematically searched for randomized or non-randomized controlled studies reporting associations between exercise training and cardiovascular risk factors in T1D. Weighted mean differences (WMD) of each cardiovascular risk factor between exercise groups and control groups were calculated using a random effects model. A total of 24 studies reported the effects of exercise training on cardiovascular risk factors. Exercise training increased maximal aerobic power (3.01 mL·kg−1·min−1, 95% confidence interval, CI, 0.94 to 6.38) and reduced glycated hemoglobin (HbA1c; −0.45%, 95% CI −0.73 to −0.17), daily insulin dosage (−0.88 U·kg−1, 95% CI −1.27 to −0.48), and total cholesterol (−0.38 mmol·L−1, 95% CI −0.71 to −0.04). Exercise training did not lead to consistent changes in body mass index (BMI), blood pressure, triglycerides, high-density lipoprotein cholesterol (HDL-C), or low-density lipoprotein cholesterol (LDL-C). In persons living with T1D, exercise training is associated with a beneficial cardiovascular profile, including improvements in lipid profile, glycemic control (decreased daily insulin dosage and HbA1c), and aerobic fitness. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessReview
Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis
J. Clin. Med. 2019, 8(2), 189; https://doi.org/10.3390/jcm8020189
Received: 4 January 2019 / Revised: 28 January 2019 / Accepted: 30 January 2019 / Published: 5 February 2019
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Abstract
Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis [...] Read more.
Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13–1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20–0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36–0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02–1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessReview
Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis
J. Clin. Med. 2018, 7(12), 514; https://doi.org/10.3390/jcm7120514
Received: 1 November 2018 / Revised: 26 November 2018 / Accepted: 30 November 2018 / Published: 4 December 2018
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Abstract
A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified [...] Read more.
A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane’s tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54–0.85) and ET (HR = 0.75, 95% CrI = 0.60–0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57–0.99), ET (HR = 0.75, 95% CrI = 0.56–0.99) and PE (HR = 0.68, 95% CrI = 0.47–0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58–0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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Open AccessCase Report
Readiness for Firefighting: A Heart Transplant Patient’s Quest to Return to Work
J. Clin. Med. 2019, 8(3), 378; https://doi.org/10.3390/jcm8030378
Received: 20 January 2019 / Revised: 8 March 2019 / Accepted: 12 March 2019 / Published: 18 March 2019
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Abstract
Heart transplantation patients generally demonstrate exercise capacities that are below the minimal standards for firefighting. Therefore, it is unlikely that heart transplantation patients will receive medical and/or employer clearance for active duty. We report a case of a firefighter who sought to return [...] Read more.
Heart transplantation patients generally demonstrate exercise capacities that are below the minimal standards for firefighting. Therefore, it is unlikely that heart transplantation patients will receive medical and/or employer clearance for active duty. We report a case of a firefighter who sought to return to full-time active duty following heart transplantation. We examined his physiological readiness to return to work during occupation-specific testing. Remarkably, the patient was able to meet the minimal requirements for full active firefighting. This finding provides direct evidence to support the potential of transplant patients returning to active duty in physiologically demanding occupations. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
Open AccessCommentary
Effectiveness of Approaches to Increase Physical Activity Behavior to Prevent Chronic Disease in Adults: A Brief Commentary
J. Clin. Med. 2019, 8(3), 295; https://doi.org/10.3390/jcm8030295
Received: 31 January 2019 / Revised: 25 February 2019 / Accepted: 26 February 2019 / Published: 1 March 2019
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Abstract
Effective behavior change approaches are necessary to help individuals avoid or mitigate risk factors, engage in behavioral patterns that lead to better health, and consequently, prevent several chronic diseases. Physical inactivity is considered one of the most harmful risk factors for chronic medical [...] Read more.
Effective behavior change approaches are necessary to help individuals avoid or mitigate risk factors, engage in behavioral patterns that lead to better health, and consequently, prevent several chronic diseases. Physical inactivity is considered one of the most harmful risk factors for chronic medical conditions, and although different strategies are used to tackle this behavior, not all of them lead to the expected or desired results. This brief commentary examines recent approaches aimed at physical activity behavior change. We find that a combination of strategies focusing on streamlining the access to physical activity seems to be more effective than individual approaches, in order to increase physical activity engagement to prevent chronic diseases in adults. Full article
(This article belongs to the Special Issue Cardiac Rehabilitation)
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