In the JournalsPerspective

Comprehensive cardiac rehab confers improved functional capacity, BP reduction

Comprehensive cardiac rehabilitation, including education classes, may improve functional capacity and lower BP more than exercise-only cardiac rehabilitation or usual care in patients with CVD, according to a study published in Heart.

“This first-ever [randomized controlled trial] in Latin America and third ever in a [low-income and middle-income country], has demonstrated that [cardiac rehab] results in clinically meaningful improvements in functional capacity and reductions in blood pressure, and that comprehensive [cardiac rehab] is superior to no [cardiac rehab] in improving functional capacity,” Gabriela Suellen da Silva Chavez, PhD student in the physical therapy department at Federal University of Minas Gerais, Belo Horizonte, Brazil, and colleagues wrote.These results also support the importance of delivering comprehensive [cardiac rehab] in [low-income and middle-income countries] to ensure patients achieve the benefits associated with [cardiac rehab].”

Researchers recruited 115 adults with CAD or MI or who underwent PCI or CABG and was referred to cardiac rehab at a center in Brazil between March 2015 and April 2017.

All participants completed pretest assessments, including the incremental shuttle walk test, BP and adiposity.

Participants were then randomly assigned to the wait-list control group (n = 39; 69.2% men; mean age, 59 years), the exercise-only cardiac rehab group (n = 39; 71.8% men; mean age, 59 years) or the comprehensive cardiac rehab group (n = 37; 73% men; mean age, 61 years).

The control group received usual care, which included follow-up appointments with physicians when medically appropriate. Patients assigned the exercise-only cardiac rehabilitation intervention received an individualized exercise prescription and supervised sessions for 6 months. The comprehensive cardiac rehab intervention consisted of the exercise portion with the addition of 24 education sessions delivered in a group setting directly before or after an exercise session, where patients were educated on diet, exercise, mental health and risk factor management.

The primary outcome was functional capacity, as indicated by incremental shuttle walk test distance, which was performed again at 6 months. Secondary outcomes included BP, BMI, waist circumference, glucose and lipids.

Researchers found that the incremental shuttle walk test distance improved from pretest to 6 months with exercise-only cardiac rehab (from 391.5 m to 488.1 m; mean change, 96.5 m; P < .001) and with comprehensive cardiac rehab (from 358.4 m to 464.8 m; mean change, 106.4 m; P < .001). Those participating in comprehensive cardiac rehab also had greater functional capacity than those receiving usual care (mean difference = 75.6 m; 95% CI, 1.4-150.2).

In addition, those receiving comprehensive cardiac rehab experienced reductions in systolic BP (–6.2 mm Hg; P = .04).

“These benefits likely translate to significant reductions in mortality, although an adequately powered trial to demonstrate this is needed,” the researchers wrote. “Thus, advocacy for greater implementation of comprehensive [cardiac rehab] is needed, with the aim of improving the care of cardiac patients in Brazil, as well as in other Latin American countries, and in [low-income and middle-income countries] more broadly.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

Comprehensive cardiac rehabilitation, including education classes, may improve functional capacity and lower BP more than exercise-only cardiac rehabilitation or usual care in patients with CVD, according to a study published in Heart.

“This first-ever [randomized controlled trial] in Latin America and third ever in a [low-income and middle-income country], has demonstrated that [cardiac rehab] results in clinically meaningful improvements in functional capacity and reductions in blood pressure, and that comprehensive [cardiac rehab] is superior to no [cardiac rehab] in improving functional capacity,” Gabriela Suellen da Silva Chavez, PhD student in the physical therapy department at Federal University of Minas Gerais, Belo Horizonte, Brazil, and colleagues wrote.These results also support the importance of delivering comprehensive [cardiac rehab] in [low-income and middle-income countries] to ensure patients achieve the benefits associated with [cardiac rehab].”

Researchers recruited 115 adults with CAD or MI or who underwent PCI or CABG and was referred to cardiac rehab at a center in Brazil between March 2015 and April 2017.

All participants completed pretest assessments, including the incremental shuttle walk test, BP and adiposity.

Participants were then randomly assigned to the wait-list control group (n = 39; 69.2% men; mean age, 59 years), the exercise-only cardiac rehab group (n = 39; 71.8% men; mean age, 59 years) or the comprehensive cardiac rehab group (n = 37; 73% men; mean age, 61 years).

The control group received usual care, which included follow-up appointments with physicians when medically appropriate. Patients assigned the exercise-only cardiac rehabilitation intervention received an individualized exercise prescription and supervised sessions for 6 months. The comprehensive cardiac rehab intervention consisted of the exercise portion with the addition of 24 education sessions delivered in a group setting directly before or after an exercise session, where patients were educated on diet, exercise, mental health and risk factor management.

The primary outcome was functional capacity, as indicated by incremental shuttle walk test distance, which was performed again at 6 months. Secondary outcomes included BP, BMI, waist circumference, glucose and lipids.

Researchers found that the incremental shuttle walk test distance improved from pretest to 6 months with exercise-only cardiac rehab (from 391.5 m to 488.1 m; mean change, 96.5 m; P < .001) and with comprehensive cardiac rehab (from 358.4 m to 464.8 m; mean change, 106.4 m; P < .001). Those participating in comprehensive cardiac rehab also had greater functional capacity than those receiving usual care (mean difference = 75.6 m; 95% CI, 1.4-150.2).

In addition, those receiving comprehensive cardiac rehab experienced reductions in systolic BP (–6.2 mm Hg; P = .04).

“These benefits likely translate to significant reductions in mortality, although an adequately powered trial to demonstrate this is needed,” the researchers wrote. “Thus, advocacy for greater implementation of comprehensive [cardiac rehab] is needed, with the aim of improving the care of cardiac patients in Brazil, as well as in other Latin American countries, and in [low-income and middle-income countries] more broadly.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Vera Bittner

    Vera Bittner

    The authors conducted a small single-center, single-blind randomized controlled trial in Brazil that compared no cardiac rehabilitation with comprehensive cardiac rehabilitation and exercise only cardiac rehabilitation. Participants in the comprehensive cardiac rehabilitation arm achieved better functional capacity than those who did not attend cardiac rehabilitation. There was no significant difference between the waitlist group and the exercise-only group. There was greater improvement in BP in the comprehensive cardiac rehabilitation arm than in the other two arms despite a high percentage of guideline-directed pharmacologic therapy in all three arms.

    The study was underpowered, making results difficult to interpret. I do not think that we can extrapolate to mortality benefits based on the current study results, but morbidity and mortality benefits have been shown elsewhere in larger randomized controlled trials of comprehensive cardiac rehabilitation and in observational datasets. I cannot think of any reason why Brazil should be different than other geographic regions.

    In the U.S., Canada and most of Europe, comprehensive cardiac rehabilitation is considered the standard. Results from the current study have little immediate relevance for clinical practice in these regions.

    I am less familiar with cardiac rehabilitation practices globally and thus cannot judge any potential impact on other regions which may currently not have cardiac rehabilitation or favor exercise-only approaches.

    We basically know what works in cardiac rehabilitation. The gaps are primarily in implementation. How do we achieve 100% referral of eligible individuals? How do we create an infrastructure that makes it feasible for referred individuals to enroll in a program? How do we overcome non-infrastructure barriers to enrollment? How do we improve adherence to the prescribed program? Lastly, among those who graduate from a program, how do we make it easier for patients to maintain the improvements achieved?

    • Vera Bittner, MD, MSPH
    • Cardiology Today Editorial Board Member
      University of Alabama at Birmingham

    Disclosures: Bittner reports no relevant financial disclosures.