eHealth in cardiac rehabilitation

TeleCR is an innovative and (cost-)effective preventive care delivery strategy that can overcome the challenges associated with traditional centre-based cardiac rehabilitation (CR). This chapter describes how it can be implemented in daily practice. From an organizational point of view, it implies a shift in traditional and operational workflows and reorganization of the (non-)human resources for care delivery. The establishment of a well-coordinated tele-team, the definition of clear goals, profound progress monitoring and follow-up, and the creation of an environment that promotes sustained delivery of teleCR are paramount. Tackling the current legal and technological challenges is another prerequisite for successful implementation.

How to improve adherence to medication and lifestyle measures

Pharmacological and non-pharmacological adherence are essential for reducing cardiovascular (CV) mortality and morbidity; however, non-adherence is a major issue. Correct medication intake is complex, in particular for certain groups of patients. Modification of habits and changing to a healthier lifestyle may be even more difficult. Nevertheless, factors influencing non-adherence and adherence facilitators have been identified, and specific strategies to overcome multiple barriers to both types of adherence are available. In this context, adequate health education and communication are fundamental. Models and theories of change and adherence and theories of behavioural change are presented in this chapter. New technologies, such as digital health tools, which assist patients and health professionals to maintain therapeutic goals, may be helpful. Participation in cardiac rehabilitation (CR) and secondary prevention programmes with a multifaceted approach can also improve adherence.

Management of non-conventional risk factors

Evidence supports the association of some non-conventional or yet to be established risk factors (RFs), such as serum uric acid (UA) or high-sensitivity C-reactive protein (hs-CRP), with the risk of arterial hypertension (HTN), metabolic syndrome, and chronic kidney disease and a worse prognosis in patients with known coronary vascular disease (CVD). However, there is no evidence from randomized controlled trials to support their use in guiding therapy. In the secondary prevention setting, detection of peripheral vascular damage and kidney dysfunction may provide significant additional prognostic implications.

Diet and nutritional aspects of cardiac rehabilitation

Cardiac rehabilitation (CR) and prevention programmes aim to reduce total mortality and rehospitalization and increase health-related quality of life (HRQoL) by supporting behavioural changes such as healthier food habits. Nutritional studies have shown that an approach paying equal attention to what is consumed and what is excluded is more effective in preventing cardiovascular disease (CVD). Mediterranean and dietary approaches to stop hypertension (DASH) diets are the best studied dietary patterns. Both improve a variety of risk features and are associated with lower risk of clinical events in secondary prevention. Patients with acute coronary syndrome (ACS) may respond positively to simple dietary advices, whereas critically ill patients should be appropriately supported in order to reduce the risk of malnutrition and early death. Body weight management in patients with established CVD should be adjusted to individual conditions, risk factors (RFs), and comorbidities, and should be clearly distinguished from simple primary prevention strategies. Unintentional weight loss should be avoided, as an association with increased disease burden, frailty, and adverse outcome has been confirmed. Future studies should focus on the development of specific nutritional guidelines for these patients.

Modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular risk factors

Physical activity (PA) and exercise training (ET) are highly effective in the prevention of cardiovascular disease (CVD) via improvement of cardiovascular risk factors (CV RFs), such as blood pressure (BP), lipid profile, glycaemic control, body fat mass, and inflammation. In the first part of this chapter, we describe the currently observed effects of PA and exercise intervention on these RFs. In the second part, we explain which exercise modalities should be selected to optimize these CVD RFs, especially for those patients with multiple CVD RFs.

Specific issues with physical activity after cardiac rehabilitation

The transition between phase II (structured, supervised) and phase III (long-term, unsupervised) cardiac rehabilitation (CR) provides an opportunity to promote regular physical activity (PA) in cardiac patients, with the aim of maintaining functional capacity and improving cardiovascular (CV) prognosis. Unfortunately, barriers at the individual and organizational/environmental level may lead to poor adherence to PA, with a consequent need for a call to action by the whole multidisciplinary CR staff. In particular, improvement of patients’ self-efficacy—defined as beliefs about one’s ability to perform a specific action—is clearly associated with better adherence to the programme. The gold standard is individualized prescription of a PA plan—type, intensity, duration, and frequency—which should be monitored and revised periodically on the basis of serial direct evaluations of cardiorespiratory fitness. If this is not available, good PA practice focusing on training intensity and volume should be recommended. In selected cases, the delivery of a long-term PA programme could be supported by digital health tools.

Early assessment and risk stratification

A pre-participation medical assessment before cardiac rehabilitation (CR) is mandatory in order to deliver a safe programme tailored to the individual patient. This initial evaluation also aims to increase patient adherence and the efficiency of the programme. The entry assessment includes the following components: history, global patient evaluation including clinical questionnaires, physical examination, laboratory analysis, and non-invasive cardiovascular testing. Following this assessment, a risk stratification should be performed to determine the appropriate CR modalities.

Cardiac rehabilitation for geriatric and frail patients

The progressive ageing of populations leads to a high burden of elderly patients with cardiac disease and is associated with comorbidities, cognitive/psychological deterioration, disability, social deprivation, and frailty. All these conditions complicate the clinical course of cardiac disease and worsen the outcome. Cardiac rehabilitation (CR), as a multidisciplinary intervention, improves mortality, morbidity, re-hospitalization, physical function, and quality of life in adult patients after acute cardiac events. Older patients without clinical complexity can follow a CR programme slightly different from that for middle-aged patients, mainly based on aerobic training, with similar functional improvement. CR for elderly cardiac patients with comorbidities, sarcopenia, or frailty should be based mainly on strength exercise integrated with aerobic and balance training, but the most appropriate exercise programme has yet to be defined. Future studies should test whether interventions tailored to the presence and severity of frailty are effective in improving specific outcomes, with particular reference to functional capacity, physical function, health-related quality of life (HQoL), disability, frailty, hospitalization, and institutionalization.

Educational intervention

The impact of a cardiac disease diagnosis on patients is multidimensional. Educational interventions are at the core of the delivery of effective therapy and require multidisciplinary teamwork to identify specific impacts on individuals and coordinate activities to support changes in lifestyle behaviour. Motivational interviewing and negotiation, based on a comprehensive assessment of patients’ circumstances, should identify the support they require to engage in preventive programmes. Interventions to help patients to apply new knowledge to their everyday lives should be underpinned by the use of recognized educational principles to optimize their adoption of new behaviours. Meaningful communication between professionals and patients must be timely and ongoing, to allow appropriate feedback on progress and revision of forward plans for optimal cardiac rehabilitation (CR) and secondary prevention. The quality of programmes delivered should be evaluated regularly using specified criteria.

Recovering from acute heart events

Despite extraordinary advances in pharmacological and interventional therapies, cardiac rehabilitation (CR) and secondary prevention programmes have maintained a class I indication with level of evidence A in patients after acute coronary syndrome (ACS) and a class I recommendation with level of evidence B in patients after surgical revascularization and with chronic ischaemic heart disease (IHD). In post-acute or chronic heart failure (New York Heart Association (NYHA) class II–III, both with reduced or preserved ejection fraction (EF)), CR has a class I recommendation with level of evidence A. In patients with recent valvular heart surgery, there is an important indication for CR intervention early after surgery. Once admitted to CR, patients should have their clinical status assessed or reviewed before starting any activities, particularly exercise training. Assessment should cover medical history, personal goals and preferences, physical parameters, disease-specific status, disease management, psychosocial health, risk factors, functional exercise capacity, health-related quality of life (HRQoL), and the impact of physical deconditioning of comorbidities. Previous exercise levels, aids used, goals, and residual exercise capacity/function should also be considered. If patients are not clinically stable, CR interventions should be deferred. However, if patients are stable, intervention should be started as soon as possible after an acute cardiac event after appropriate functional assessment.