Cardiac Rehabilitation and Implications During the COVID-19 Era

Quick Takes

  • Cardiac rehabilitation is an evidence-based intervention for secondary prevention.
  • In some studies, home based cardiac rehabilitation is also able to achieve comparable outcomes in functional capacity, health-related quality of life, and risk factor modification as equivalent center-based therapy.
  • As the COVID-19 pandemic continues, the integration of a home-based rehabilitation program is imperative to improve the delivery of care, patient safety and cardiovascular outcomes.

What is Cardiac Rehabilitation?

Cardiac rehabilitation (CR) is a comprehensive, multidisciplinary, secondary prevention program aimed to optimize cardiovascular health. The programs are multifaceted and address psychosocial, physical, and emotional processes involved in cardiovascular health. The goal of CR is to improve modifiable risk factors, increase functional capacity, and reduce morbidity and mortality.1

CR consists of exercise training, dietary counseling, medication management, tobacco cessation counseling, and psychosocial assessment interventions. The length of the program can vary per individual, but a typical program lasts three months with a prescription for 36 sessions of 60-90 minutes in duration. Home-based CR (HBCR) incorporates a similar structure described above in a manner that can be performed at a patient's home through virtual methods.2

Who Qualifies for Cardiac Rehabilitation?

CR is recommended in all patients with acute coronary syndrome (ACS) within the last 12 months, coronary revascularization, chronic heart failure, symptomatic angina or peripheral artery disease, heart valve surgery, and cardiac transplantation (Class 1A recommendation for secondary prevention by the American Heart Association (AHA) and American College of Cardiology (ACC)).1,3,4 Additionally, the Centers for Medicare and Medicaid Services (CMS) have added CR to the list of approved telehealth services expected to remain in effect until December 31, 2021.5

Clinical Significance of Cardiac Rehabilitation

Exercise-based CR following myocardial infarction (MI) or revascularization is associated with a reduction in cardiovascular mortality (relative risk [RR], 95 % confidence interval (CI): 0.74, 0.64-0.86) as well as a lower risk of hospital admission (0.82, 0.70-0.96).6 Another meta-analysis concluded that CR was associated with a lower risk of reinfarction (Odds ratio [OR], 95% CI: 0.53, 0.38-0.76) in patients following MI.7 CR is associated with a 20-30% reduction in hospital readmission following a cardiac event the prior year.8

Home-Based versus Center-Based Cardiac Rehabilitation and Patient-Centered Outcomes

Several randomized controlled trials have investigated outcomes in HBCR in relation to CBCR, namely improvements in cardiorespiratory fitness, quality of life, risk factor modification, and mortality.9,10 For example, HBCR participants displayed improvement in 6-minute-walk test distances (462m ± 74m vs 421m ± 90m, p=0.03), higher adherence rates, and improved physical fitness in comparison to CBCR.9,10 Among patients with heart failure, tele-rehabilitation HBCR did not demonstrate significant differences in the 6-minute-walk distance by the end of a 12-week program as compared to CBCR.11 Secondary outcomes investigating quality of life, patient satisfaction, and muscle strength suggested equivalence as well.11 In the CopenHeartRFA trial, patients self-selected whether they would prefer HBCR or CBCR after undergoing either atrial fibrillation ablation or heart valve surgeries. HBCR patients had better physical performance and health at baseline as compared to CBCR patients, but both groups were able to achieve similar cardiovascular improvements in peak oxygen uptake, maximum watt via stationary bike, and distance improvement on 6-minute walk testing.12 Similar results were seen in a small (n=28), randomized trial evaluating HBCR and CBCR, with no significant differences observed between groups for METS on exertion or recovery rate in the first minute after exercise.13

HBCR was also analyzed in a recent AHA/ACC Scientific Statement, which concluded that HBCR achieved equivalent outcomes in functional capacity, health-related quality of life, and risk factor modification as CBCR.4

Home-Based Cardiac Rehabilitation in the Era of COVID-19

Given the importance of CR, the ACC and Canadian Cardiovascular Society have issued guidelines for the reintroduction of cardiac services during the COVID-19 pandemic.14,15 HBCR is an attractive means to achieve a higher percentage of CR participation by removing transportation costs and access issues for many patients.4 Accordingly, in the interest of patient safety and outcomes, there has been a shift of focus towards this care model during the pandemic.

Expert consensus has suggested the utilization of technology, personal smartphones, and online platforms to continue to deliver virtual HBCR.14 Centers have started and will continue to innovate HBCR programs with remote monitoring tracking, applications, online coaching, and virtual interviewing to achieve optimal results. Physical activity will be geared towards body-weight exercises negating the need for exercise equipment. This will include push-ups, squats, sit-to-stand, and balancing/stretching exercises, for example.2 Additionally, remote tracking will allow both health care providers and patients to track daily physical activity, nutrition, and vital sign parameters in a method that will empower patients and provide staff meaningful data to help customize plans. Although there are many advantages to remote HBCR, one potential barrier is the use of technology itself among the elderly or disabled, for example. Elderly patients may not be as technologically savvy and be able to utilize all the different applications and tools that are available. Furthermore, HBCR will require smartphones, internet capabilities, and computers which may not be available for some individuals due to financial constraints and digital inequality.16

Data pertaining specifically to referrals to HBCR and outcomes of such are not currently unavailable. However, there will likely be an increase in HBCR and tele-rehabilitation given the recent approval of virtual cardiac rehab by the CMS.5 Clinical trials assessing CR and physical activity during COVID-19 are currently in the recruiting phase.

Summary

Cardiac rehabilitation is an evidence-based foundational intervention for secondary prevention that is endorsed by multiple guidelines. However, it remains an underutilized resource. Nonetheless, available data suggest that HBCR is equivalent to CBCR. As COVID-19 has disrupted the traditional facility-based CR model,17 HBCR has been shown to be an effective alternative. As the COVID-19 pandemic continues, cardiovascular providers must continue to innovate by defining and monitoring patient and CR program outcomes, integrate technology to improve care delivery, assimilate HBCR with CBCR, and ultimately plan for a hybrid model of CR once physical distancing restrictions are eased.

References

  1. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation 2005;111:369-76.
  2. Besnier F, Gayda M, Nigam A, Juneau M, Bherer L. Cardiac rehabilitation during quarantine in COVID-19 pandemic: challenges for center-based programs. Arch Phys Med Rehabil 2020;101:1835-38.
  3. Ross A, Mark W, Forman DE, et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings. Circulation 2012;125:1321-29.
  4. Thomas RJ, Beatty AL, Beckle TM, et al. 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. Circulation 2019;140:e69-e89.
  5. CMS Approves Telehealth Cardiac Rehab During COVID-19 Pandemic (ACC.org). 2020. Available at: www.acc.org/latest-in-cardiology/articles/2020/10/15/17/10/cms-approves-telehealth-cardiac-rehab-during-covid-19-pandemic. Accessed 10/01/2020.
  6. Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane Systematic Review and meta-analysis. J Am Coll Cardiol 2016;67:1-12.
  7. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011;162:571-584.e2.
  8. Dunlay SM, Pack QR, Thomas RJ, Killian JM, Roger VL. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med 2014;127:538-46.
  9. Kraal JJ, Van den Akker-Van Marle ME, Abu-Hanna A, Stut W, Peek N, Kemps HM. Clinical and cost-effectiveness of home-based cardiac rehabilitation compared to conventional, centre-based cardiac rehabilitation: results of the FIT@Home study. Eur J Prev Cardiol 2017;24:1260-73.
  10. Chen Y-W, Wang C-Y, Lai Y-H, et al. Home-based cardiac rehabilitation improves quality of life, aerobic capacity, and readmission rates in patients with chronic heart failure. Medicine 2018;97:e9629.
  11. Hwang R, Bruning J, Morris NR, Mandrusiak A, Russell T. Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. J Physiother 2017;63:101-07.
  12. Tang LH, Kikkenborg Berg S, Christensen J, et al. Patients' preference for exercise setting and its influence on the health benefits gained from exercise-based cardiac rehabilitation. Int J Cardiol 2017;232:33-39.
  13. Bravo-Escobar R, González-Represas A, Gómez-González AM, et al. Effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic heart disease at moderate cardiovascular risk: a randomised, controlled clinical trial. BMC Cardiovasc Disord 2017;17:66.
  14. Moulson N, Bewick D, Selway T, et al. Cardiac rehabilitation during the COVID-19 era: guidance on implementing virtual care. Can J Cardiol 2020;36:1317-21.
  15. Wood DA, Mahmud E, Thourani VH, et al. Safe reintroduction of cardiovascular services during the COVID-19 pandemic. J Am Coll Cardiol 2020;75:3177- 83.
  16. van Deursen AJ. Digital inequality during a pandemic: quantitative study of differences in COVID-19-related internet uses and outcomes among the general population. J Med Internet Res 2020;22:e20073.
  17. COVID-19 and Telehealth (AACVPR website). 2020. Available at: https://higherlogicdownload.s3.amazonaws.com/AACVPR/6fd6170d-682c-4fbc-b79c-08e3d62c2526/UploadedImages/COVID-19/AACVPR_COVID-19_Ongoing-Advocacy-for-Telehealth.pdf. Accessed 01/11/2021.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Interventions and ACS, Interventions and Vascular Medicine, Exercise

Keywords: Primary Prevention, Quality of Life, Centers for Medicare and Medicaid Services (U.S.), COVID-19, Cardiac Rehabilitation, American Heart Association, Secondary Prevention, Atrial Fibrillation, Patient Readmission, Peripheral Arterial Disease, Odds Ratio, Acute Coronary Syndrome, Patient Safety, Confidence Intervals, Patient Satisfaction, Pandemics, Goals, Medication Therapy Management, Physical Exertion, Tobacco Use Cessation, Medicare, Heart Failure, Exercise, Exercise Therapy, Heart Transplantation, Myocardial Infarction, Counseling, Risk Factors, Morbidity, Muscle Strength, Health Personnel, Prescriptions, Body Weight, Technology, Internet, Patient-Centered Care, Heart Valves, Vital Signs, Hospitals, Oxygen


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