cardiac rehabilitation

IJCS

Review Article

Home-Based Vs. Usual and Center-Based Cardiac Rehabilitation: Effects on Aerobic Fitness and Quality of Life

Cauã Teixeira Mota et al. Claudia Lucia de Moraes Forjaz

Abstract

Home-based cardiac rehabilitation has been proposed as an alternative to expand access to treatment for patients with cardiovascular diseases. This systematic review evaluated the effects of home-based cardiac rehabilitation, with emphasis on physical exercise, on aerobic fitness, quality of life, and adverse events compared with usual cardiac rehabilitation and center-based cardiac rehabilitation. A literature search was conducted in the PubMed database, including only randomized controlled clinical trials involving adults and older adults with coronary artery disease or heart failure. Twenty-three studies conducted in different countries were identified; however, none was performed in Brazil. The total sample comprised 2,298 participants, of whom 24% were women. All studies implemented aerobic training, either alone or combined with resistance training, and the vast majority maintained remote contact with participants every one to two weeks. Comparisons between pre- and post-intervention outcomes showed that home-based cardiac rehabilitation improved aerobic fitness and/or quality of life in 22 studies, with greater improvements than those observed with usual cardiac rehabilitation and outcomes comparable to those achieved with center-based cardiac rehabilitation. Furthermore, the incidence of adverse events was low and similar across the three rehabilitation models. Overall, home-based cardiac rehabilitation improves aerobic fitness and quality of life more effectively than usual cardiac rehabilitation and provides benefits comparable to those of center-based cardiac rehabilitation without increasing the risk of adverse events, supporting its use in the treatment of cardiovascular diseases. Nevertheless, the absence of studies conducted in Brazil highlights the need for further research on this rehabilitation model in the Brazilian context.

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IJCS

Editorial

HFrEF, HFmrEF, and HFpEF: Are They a Continuum or Different Faces of a Syndrome?

Even Edilce Mol et al. Camila Hartmann Lídia Ana Zytynski Moura

Heart failure (HF) is a significant and growing public health problem. Recent projections have shown that the prevalence of HF in the United States will increase by 46% between 2012 and 2030. This is driven by an increase in the life expectancy of the population combined with a reduction in mortality from the disease resulting from advances in therapies in recent years.

Of all the classifications of HF, the most used one is based on left ventricular ejection fraction (LVEF), which is categorized into three groups: HF with preserved ejection fraction (HFpEF) (LVEF ≥50%), HF with reduced ejection fraction (HFrEF) (LVEF ≤40%), and HF with moderate or mildly reduced ejection fraction (HFmrEF) (LVEF 41–49%). Although the prognosis appears to be similar among HF subtypes based on ejection fraction, ^, there are differences between the groups in terms of clinical-epidemiologic profile and functional capacity.

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IJCS

Original Article

Home-based Virtual Reality Exercise Program During the Maintenance Stage of Cardiac Rehabilitation: A Randomized Controlled Trial

Ágata Vieira et al. Cristina Melo Andreia Noites Jorge Machado Joaquim Mendes

Abstract

Background:

Home-based virtual reality technology may become an alternative to cardiac rehabilitation.

Objectives:

To evaluate the effects of a specific, home-based exercise program, performed either through a virtual reality (Kinect) or a conventional format (booklet) in the maintenance stage of cardiac rehabilitation for six months on functional muscle strength of the lower limbs, physical activity and exercise tolerance.

Methodology:

This is a randomized clinical trial (ClinicalTrials.gov — NCT02753829) with individuals with coronary artery disease from a hospital in Porto, Portugal, randomly allocated to an experimental group “1” (EG1; n = 11), submitted to a virtual reality exercise program (Kinect); an experimental group “2” (EG2; n = 11), submitted to an exercise program described in a booklet (conventional format); or a control group (CG) (n=11), submitted to routine care. Parameters of functional muscle strength of the lower limbs (sit-to-stand test), physical activity (accelerometer) and exercise tolerance (stress test) were assessed and compared between the groups. Descriptive and inferential statistics were applied, with 95% with a significance level of 0.05.

Results:

Significant improvements in functional muscle strength of the lower limbs were observed in EG1 compared to EG2, at three months (19.5 ± 7.7 versus 11.9 ± 4.7, p = 0.042), and at six months (23.0 ± 7.7 versus 14.6 ± 4.6, p = 0.027) of intervention.

Conclusions:

The program did not demonstrate superior results, in relation to the control group and among the different formats, in physical activity and effort tolerance. In relation to the functional muscle strength of the lower limbs, the virtual reality format showed significantly better results when compared to the conventional format only.

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IJCS

Editorial

A New Look at the Importance of Multidisciplinary Group Interventions in Cardiac Rehabilitation

Gabrielle de Souza Rocha et al. Julio Cesar Fraulob Aquino

Chronic non-communicable diseases (NCDs) are the main cause of death worldwide, being responsible for premature deaths, loss of quality of life, with great socioeconomic impact. More than 17 million (around 45%) of NCD deaths in the world are caused by cardiovascular (CV) diseases. Similar findings are found in Brazil, where 72% of all deaths are attributed to NCDs, 30% due to CV disease.

There is increasing evidence that staying physically active contributes to preserve and recover physical and emotional health, and that a sedentary lifestyle is strongly related to CV disease and early mortality. In this context, the benefits of CV rehabilitation, with emphasis on physical exercise, have emerged in the literature, and correlated with a reduction in CV morbidity and mortality, significant improvement of quality of life and longer life expectancy.

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IJCS

Original Article

Interdisciplinary Group Intervention on Nutritional Profile, Quality of Life, and Stress During Cardiopulmonary Rehabilitation: A Randomized Clinical Trial

Giana de Freitas Rodrigues et al. Daniela da Rosa Vieira Patrícia Pereira Ruschel Cynthia Seelig … Christian Coronel Sandra Mari Barbiero

Abstract

Background:

Participating in therapeutic operative groups with nutritional and psychological interventions might influence the recovery of patients in cardiopulmonary rehabilitation programs.

Objective:

To evaluate the effectiveness of group interventions on the nutritional profile, stress, and quality of life of patients in cardiopulmonary rehabilitation.

Methods:

In this randomized clinical trial, adult patients of the Cardiopulmonary and Metabolic Rehabilitation (CPMR) unit were randomized into control group (CG), receiving standard follow-up assessment by the CPMR unit, and intervention group (IG), which additionally participated in 6 meetings of an interdisciplinary group with a nutritionist and a psychologist. Anthropometric data and results from a food frequency questionnaire (FFQ), Lipp’s Inventory of Stress Symptoms for Adults (ISSL), and the 12-Item Short Form Health Survey (SF-12) were analyzed. Student’s t-tests, Generalized Estimation Equations (GEE), Mann-Whitney tests, and Bonferroni tests were used for statistical analyses, with a significance level of 5%.

Results:

The sample consisted of 76 patients: 31 in the IG (64±9.2 years old) and 45 in the CG (61.4±11.8 years old). There was a significant reduction (p<0.001) in weight, body mass index, and waist circumference, and an increase (p=0.010) in the consumption of healthy food only in the IG. The consumption of unhealthy food was reduced in both groups (p<0.001), the physical aspect of quality of life improved (p=0.018), and women presented better physical (p=0.011) and mental results (p=0.008).

Conclusions:

This group intervention was effective regarding the nutritional status of patients in cardiopulmonary rehabilitation. The physical aspect of quality of life showed improvements in both groups.

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IJCS

Editorial

Exercise-based Cardiovascular Rehabilitation in Chronic Heart Failure: does Exercise Intensity Matter?

Gabriel Dias Rodrigues

It is well recognized that chronic heart failure (CHF) is a multifactorial syndrome that reduces physical exercise tolerance. Exercise-based cardiac rehabilitation program is on the frontline of non-pharmacological therapies for CHF patients, counterbalancing the disease-induced issues of physical capacity.

Since a successful exercise rehabilitation program should be efficient and safe, the search for optimal combinations of exercise volume and intensity has sparked interest in the current literature. Although studies have shown feasible combinations of low volume and high intensity, and vice versa, the optimal dose-response of exercise in cardiovascular rehabilitation remains unknown. Classically, aerobic training with moderate intensity (i.e., between 60% and 80% VO_2peak or heart rate reserve – HRreserve) is a safe approach to improve physical capacity and provide a cardioprotective effect in CHF disease. As a promising method, short bouts of high-intensity exercise, called high-intensity interval training, seems to be superior than moderate continuous training to reverse left ventricle remodeling and improve aerobic capacity, endothelial function, and quality of life in post-infarction heart failure patients.

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IJCS

Editorial

Cardiovascular Rehabilitation at Distance: A New Moment

Ricardo Vivacqua Cardoso Costa

Cardiovascular rehabilitation consists of a non-pharmacological intervention process in individuals with metabolic, pulmonary, or cardiovascular disorders, aiming at reducing symptoms, quality of life improvement, and the possible increase in life expectancy.

It consists, predominantly, in the practice of regular, individualized physical exercises, in addition to guidance concerning other risk factors, including physical inactivity, as well as nutritional and psychological support, intending to slow down and cause possible regression of the patient’s pathology.^,

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IJCS

Original Article

Short-Term Effects of a Resistance Training Program Using Elastic Tubing in Patients with Heart Disease

João Pedro Lucas Neves Silva et al. Tamara Iasmin de Sá Ferreira Gabriela Côrtes Cavalleri Mayara Moura Alves da Cruz … Bianca Pinhal Galindo Natália Turri da Silva Bruna Spolador de Alencar Silva Marceli Rocha Leite Ana Paula Coelho Figueira Freire Ercy Mara Cipulo Ramos Luiz Carlos Marques Vanderlei Francis Lopes Pacagnelli

Abstract

Background

Resistance training is effective in cardiac rehabilitation; however, it is conventionally performed using free weights or machines, which can pose logistic challenges to patients with restricted mobility. For its ease of access and cost-effectiveness, elastic tubing is a particularly appealing alternative, but it remains underutilized for this purpose.

Objective

To evaluate muscle strength, functional capacity, aerobic capacity, and quality of life in patients with heart disease in phase II of cardiovascular rehabilitation after a resistance training intervention based solely on elastic tubing.

Methods

Thirteen patients with heart disease (age 63.33±10.80 years) trained with elastic tubing twice weekly for 6 weeks, with progressive load increase every 15 days. The following muscle groups were evaluated and trained: shoulder abductors and flexors, elbow flexors, and knee flexors and extensors. Muscle strength was evaluated using a dynamometer; functional capacity, with a 6-minute walk test and cardiopulmonary exercise test; and quality of life, using the SF-36 questionnaire. Data normality was assessed using the Shapiro–Wilk test. The paired Student’s t-test was used for comparisons before and after training, at a significance level of <5%.

Results

There were significant differences in muscle strength (except for elbow flexion) and functional capacity (485.5 ± 123.3 vs 578.7 ± 110.5; p=0.0399) after the intervention. No statistical differences were found in cardiorespiratory fitness or quality of life.

Conclusions

Short-term resistance training with elastic tubing improved peripheral muscle strength and functional capacity in patients with heart disease, and should be encouraged for this population. (Int J Cardiovasc Sci. 2020; xx(x):xxx-xxx)

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IJCS

Viewpoint

Coronavirus Disease (COVID-19) Pandemic: An Opportunity Window to Implement Home-Based Cardiac Rehabilitation

Renata Rodrigues Teixeira de Castro

The World Health Organization declared that the new coronavirus outbreak is a public health emergency of pandemic proportions. The outbreak has caused various governments to take protective measures such as lockdown of cities, travel bans, prohibition of group gatherings and public events, and social distancing. Many health and exercise training facilities were closed, as well as cardiac rehabilitation services. These restrictions are disrupting people’s daily activities.

Although staying at home can contain virus spread, it will certainly reduce regular physical activity and increase sedentary behavior, which can increase the risk of development and worsening of chronic conditions.^– Therefore, there is a strong evidence for continuing physical activity at home even during the pandemic situation.

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Editorial

Neuromuscular Electrical Stimulation: A Promising Modality of Exercise Training in Cardiovascular Rehabilitation Phase I?

Sergio Chermont et al. Mônica Quintão

There are currently few indications for the use of neuromuscular electrical stimulation (NMES) in cardiac patients that are based on systematic reviews or even meta-analyses from the perspective of evidence-based practice. Therefore, the therapeutic potential of NMES is probably still poorly explored. Previous studies have shown benefits of NMES in patients with stable chronic heart failure (CHF). However, we wonder whether the application of this technique in cardiac patients has been extensively explored. We are certainly dealing with a new therapeutic possibility so far rarely recommended and employed in patients with cardiovascular diseases, especially in intrahospital cardiovascular rehabilitation. In this scenario, what could be added to the current knowledge and its main indications?

In the absence of well-defined protocols, feasibility and safety studies may be considered as a starting point for further studies and for paving the way clinical trials and to determine whether or not the conduct is favorable for a patient`s specific clinical condition. So, what would be the role of NMES in heart surgery?

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Editorial

Physical Activity, Exercise and Sport: A Five-Star Path for a Better Cardiovascular Health

Claudio Gil Soares de Araújo et al. Claudio Tinoco Mesquita

Why we must exercise? Although this question has many answers, many other questions arise from it. Which are the benefits of exercising? How much exercise is good for health? Is high-intensity exercise better than moderate-intensity exercise? Are there risks in exercising? What to do if someone does not like to exercise? Do cardiologists know the literature on exercise and heart? These are sounding questions that should be covered to understand the real need of exercising.

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Original Article

Neuromuscular Electrical Stimulation on Hemodynamic and Respiratory Response in Patients Submitted to Cardiac Surgery: Pilot Randomized Clinical Trial

Telma Cristina Fontes Cerqueira et al. Manoel Luiz de Cerqueira Neto Auristela Julia Guilhermino Carvalho Géssica Uruga Oliveira … Amaro Afrânio de Araújo Filho Vitor Oliveira Carvalho Lucas de Assis Pereira Cacau Walderi Monteiro da Silva Júnior José Teles de Mendonça Valter Joviniano de Santana Filho

Abstract

Background:

Neuromuscular electrical stimulation seems to be a promising option to intensify the rehabilitation and improve the exercise capacity of patients in the immediate postoperative period of cardiac surgery.

Objective:

This study aimed to evaluate the hemodynamic (heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure) and respiratory (respiratory rate and oxygen saturation) responses to neuromuscular electrical stimulation in the immediate postoperative period in patients submitted to cardiac surgery and to verify its feasibility and safety.

Methods:

This is a pilot randomized controlled trial, wherein critical patients in the immediate postoperative period of cardiac surgery were randomly assigned to a control group, using sham neuromuscular electrical stimulation, or an experimental group, submitted to neuromuscular electrical stimulation sessions (FES), for 60 min, with a 50-Hz frequency, 200-µs pulse duration, time on: 3 s, and time off: 9 s. Data distribution was evaluated by the Shapiro-Wilk test. The analysis of variance was used and a p-value < 0.05 was considered significant.

Results:

Thirty patients were included in the study. The neuromuscular electrical stimulation was applied within the first 23.13 ± 5.24 h after cardiac surgery, and no changes were found regarding the hemodynamic and respiratory variables between the patients who underwent neuromuscular electrical stimulation, and those in the control group.

Conclusions:

In the present study, neuromuscular electrical stimulation did not promote changes in hemodynamic and respiratory responses of patients in the immediate postoperative period of cardiac surgery.

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Original Article

Effects of Conventional and Virtual Reality Cardiovascular Rehabilitation in Body Composition and Functional Capacity of Patients with Heart Diseases: Randomized Clinical Trial

João Pedro Lucas Neves Silva et al. Luiz Felipe Marques Novaes Lorrany Caroline Rocha dos Santos Bianca Pinhal Galindo … Margaret Assad Cavalcante Bruna Corral Garcia de Araújo Francis Lopes Pacagnelli Ana Paula Coelho Figueira Freire

Abstract

Background:

Virtual reality is an alternative therapeutic resource to be inserted into cardiovascular rehabilitation, stimulating the practice of physical activity through man-machine interaction.

Objective:

To compare the effects of conventional and virtual reality cardiac rehabilitation on body composition and functional capacity in patients with heart disease.

Methods:

Randomized clinical trial with 27 cardiac patients divided into conventional rehabilitation group (CRG) and virtual reality rehabilitation group (VRG). They underwent a rehabilitation program with 60-minute training sessions twice a week for eight weeks. The VRG training consisted of exercises from the Xbox 360^® with Kinect(tm), using YourShape(tm) and Dance Central 3(tm) games. The CRG used conventional treadmills for aerobic exercise and free weights for resistance exercise. Bioimpedance and 6-minute walk test (6MWT) were evaluated at baseline and after training. For main outcome analysis, Student t and Mann Whitney tests were used with a 5% significance level.

Results:

The VRG showed a significant increase in body fat percentage and fat weight when compared to the CRG, and a smaller amount of total water. There was a significant improvement in functional capacity evidenced by the increase in the distance covered in the 6MWT (54.00 m and 32.25 m in the CRG and VRG, respectively), but the gains did not differ between the groups.

Conclusion:

The two rehabilitation modalities had no effect on the body composition of the groups. In addition, the improvement in functional capacity was similar in both groups.

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Editorial

Digital Tools and Cardiovascular Rehabilitation

Ricardo Stein et al. Leandro Tolfo Franzoni

Cardiovascular diseases are the leading cause of death worldwide. The inclusion of patients with such diseases in cardiovascular rehabilitation (CR) programs is an evidence-based conduct, since it has the potential to improve the individual’s clinical condition and manage several risk factors associated with these diseases. The association of aerobic and resistance exercises is a recommended combination in many CR programs. However, technological tools have been studied and used in order to increase the range of methods to optimize the results in the scenario of secondary prevention of cardiac diseases. In addition, combining modern strategies and conventional models can be a form of motivation for the patient by making CR interactive and funnier. In this case, virtual reality (VR) has also been used, including in our country.^,

A study published by Silva et al. in this issue of the International Journal of Cardiovascular Sciences compares the effects of conventional rehabilitation with VR on body composition and functional capacity of patients with cardiac diseases. It is a randomized controlled trial (RCT) in which 27 patients with cardiac diseases were enrolled to participate in an eight-week CR program. The sample was divided into two groups: a) conventional rehabilitation; b) rehabilitation with VR. The sessions lasted 60 minutes for both groups and the weekly frequency was twice a week. Conventional rehabilitation consisted of two parts: 25 minutes of aerobic exercise followed by 25 minutes of exercises with weights (upper and lower limbs). The intensity control during aerobic exercise was performed by monitoring the heart rate reserve determined by the Karvonen equation (50% and 80%). For resistance exercises, intensity was controlled by rating of perceived exertion (up to 13 on the Borg scale). Rehabilitation with VR was performed using Microsoft’s Xbox 360 with Kinect. The twenty-five minutes of games consisted of exercises for the upper and lower limbs and 25 minutes of dancing with the Dance Central 3 game. In the first part, velcro weights were used in the ankle and dumbbells in the hands for the resistance exercises. The intensity was only controlled in the first part of the activity. Functional capacity was measured through a 6-minute walk test, which significantly increased in both groups. Similarly, both groups had the capillary blood glucose reduced. However, as opposed to what was expected, none of the two strategies significantly reduced fat percentage and body weight. In fact, the VR group presented a significant increase in these two variables compared to the conventional rehabilitation group.

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