Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial.
JAMA cardiology
Importance:Guidelines recommend that cardiac rehabilitation (CR) exercise training should not start until 6 weeks after sternotomy, although this is not evidence based. Limited data suggest that starting earlier is not detrimental, but clinical trials are needed. Objective:To compare the effectiveness and safety of CR exercise training started either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Design, Setting, and Participants:This was an assessor-blind, noninferiority, parallel-group, randomized clinical trial that conducted participant recruitment from June 12, 2017, to March 17, 2020. Participants were consecutive cardiac surgery sternotomy patients recruited from 2 outpatient National Health Service rehabilitation centers: University Hospital, Coventry, UK, and Hospital of St Cross, Rugby, UK. Interventions:Participants were randomly assigned to 8 weeks of twice-weekly supervised CR exercise training starting either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Exercise training adhered to existing guidelines, including functional strength and cardiovascular components. Main Outcomes and Measures:Outcomes were assessed at baseline (inpatient after surgery), after CR (10 or 14 weeks after sternotomy), and 12 months after randomization. The primary outcome was the change in 6-minute walk test distance from baseline to after CR. Secondary outcomes included safety, functional fitness, and quality of life. Results:A total of 158 participants (mean [SD] age, 63 [11.5] years, 133 male patients [84.2%]) were randomly assigned to study groups; 118 patients (usual-care CR, 61 [51.7%]; early CR, 57 [48.3%]) were included in the primary analysis. Early CR was not inferior to usual-care CR (noninferiority margin, 35 m); the mean change in 6-minute walk distance from baseline to after CR was 28 m greater in the early CR group (95% CI, -11 to 66; P = .16). Mean differences for secondary outcomes were not statistically significant, indicating noninferiority of early CR. There were 46 vs 58 adverse events and 14 vs 18 serious adverse events in usual-care CR and early CR, respectively. There was no difference between the groups in the likelihood of participants having an adverse or serious adverse event. Conclusions and Relevance:Starting exercise training from 2 weeks after sternotomy was as effective as starting 6 weeks after sternotomy for improving 6-minute walk distance. With appropriate precautions, clinicians and CR professionals can consider starting exercise training as early as 2 weeks after sternotomy. Trial Registration:ClinicalTrials.gov Identifier: NCT03223558.
10.1001/jamacardio.2022.1651
The role of cardiac rehabilitation in patients with heart disease.
McMahon Sean R,Ades Philip A,Thompson Paul D
Trends in cardiovascular medicine
Cardiac rehabilitation is a valuable treatment for patients with a broad spectrum of cardiac disease. Current guidelines support its use in patients after acute coronary syndrome, coronary artery bypass grafting, coronary stent placement, valve surgery, and stable chronic systolic heart failure. Its use in these conditions is supported by a robust body of research demonstrating improved clinical outcomes. Despite this evidence, cardiac rehabilitation referral and attendance remains low and interventions to increase its use need to be developed.
10.1016/j.tcm.2017.02.005
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation.
Piepoli Massimo F,Conraads Viviane,Corrà Ugo,Dickstein Kenneth,Francis Darrel P,Jaarsma Tiny,McMurray John,Pieske Burkert,Piotrowicz Ewa,Schmid Jean-Paul,Anker Stefan D,Solal Alain Cohen,Filippatos Gerasimos S,Hoes Arno W,Gielen Stefan,Giannuzzi Pantaleo,Ponikowski Piotr P
European journal of heart failure
The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.
10.1093/eurjhf/hfr017
Outcomes in cardiopulmonary rehabilitation.
Pashkow P
Physical therapy
Physical therapists, as integral members of the multidisciplinary team in cardiac and pulmonary rehabilitation, should be knowledgeable about methods for assessing outcomes for their patients, and they need to understand the value of aggregated data in improving interventions. Definitions are discussed, and appropriate data used to monitor function are identified, including data used in the assessment of well-being. Results of outcome studies from current cardiac and pulmonary literature are presented. A discussion of how to select outcomes to assess and the value of outcome information for program management is included. Therapists are in a position to encourage and participate in widespread, collaborative measurement of disease-specific clinical outcomes, patient functioning, and well-being, which should improve the effectiveness and efficiency of cardiopulmonary rehabilitation.
10.1093/ptj/76.6.643
Effects of Different Rehabilitation Protocols in Inpatient Cardiac Rehabilitation After Coronary Artery Bypass Graft Surgery: A RANDOMIZED CLINICAL TRIAL.
Zanini Maurice,Nery Rosane Maria,de Lima Juliana Beust,Buhler Raquel Petry,da Silveira Anderson Donelli,Stein Ricardo
Journal of cardiopulmonary rehabilitation and prevention
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.
10.1097/HCR.0000000000000431
Home-based cardiac rehabilitation using information and communication technology for heart failure patients with frailty.
ESC heart failure
AIMS:Cardiac rehabilitation (CR) is an evidence-based, secondary preventive strategy that improves mortality and morbidity rates in patients with heart failure (HF). However, the implementation and continuation of CR remains unsatisfactory, particularly for outpatients with physical frailty. This study investigated the efficacy and safety of a comprehensive home-based cardiac rehabilitation (HBCR) programme that combines patient education, exercise guidance, and nutritional guidance using information and communication technology (ICT). METHODS AND RESULTS:This study was a single-centre, open-label, randomized, controlled trial. Between April 2020 and November 2020, 30 outpatients with chronic HF (New York Heart Association II-III) and physical frailty were enrolled. The control group (n = 15) continued with standard care, while the HBCR group (n = 15) also received comprehensive, individualized CR, including ICT-based exercise and nutrition guidance using ICT via a Fitbit® device for 3 months. The CR team communicated with each patient in HBCR group once a week via the application messaging tool and planned the training frequency and intensity of training individually for the next week according to each patient's symptoms and recorded pulse data during exercise. Dietitians conducted a nutritional assessment and then provided individual nutritional advice using the picture-posting function of the application. The primary outcome was the change in the 6 min walking distance (6MWD). The participants' mean age was 63.7 ± 10.1 years, 53% were male, and 87% had non-ischaemic heart disease. The observed change in the 6MWD was significantly greater in the HBCR group (52.1 ± 43.9 m vs. -4.3 ± 38.8 m; P < 0.001) at a 73% of adherence rate. There was no significant change in adverse events in either group. CONCLUSIONS:Our comprehensive HBCR programme using ICT for HF patients with physical frailty improved exercise tolerance and improved lower extremity muscle strength in our sample, suggesting management with individualized ICT-based programmes as a safe and effective approach. Considering the increasing number of HF patients with frailty worldwide, our approach provides an efficient method to keep patients engaged in physical activity in their daily life.
10.1002/ehf2.13934