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Background: Mediated by outcomes such as improved exercise capacity, cardiac rehabilitation (CR) reduces morbidity and mortality. For accuracy, an individual CR patient's change must be measured reliably, an issue not typically considered in practice. Drawing from psychometric theory, we calculated reliable change indices (RCIs), to measure individual CR patients’ true clinical change, apart from that from error and test practice/exposure, in exercise capacity, anxiety, and depression. Methods: Indirectly calculated exercise capacity (peak metabolic equivalents [METs]) and psychological symptoms were each measured twice, 1 week apart, by administering treadmill tests or the Hospital Anxiety and Depression Scale (HADS) to separate samples of 35 (mean age: 59.0 years; 6 women) and 96 (mean age: 64.4 years; 32 women) CR patients, respectively. Using test-retest reliability and mean difference scores from these samples to estimate error and practice/exposure effects, we calculated RCIs for a separate cohort (n = 2066; mean age: 62.0 years; 533 women) who completed 6-month CR, and compared change distributions (worsened/unchanged/improved) based on critical RCIs, mean and percent changes, cut-off scores, and standard deviations. Results: Practice/exposure effects were nonsignificant, except the mean HADS anxiety score decreased significantly (P ≤ 0.013; d = 0.17, small effect). Test-retest reliabilities were high (METs r = 0.934; HADS anxiety score r = 0.912; HADS depression score r = 0.90; P < 0.001). Among 2066 CR patients, RCI distributions differed (P < 0.001) from those of most other change criteria. Conclusions: Change ascertainment depends on criterion choice. A Canadian Cardiovascular Society CR quality indicator of increase by 0.5 MET may be too small to assess individuals’ functional capacity change. RCIs offer a pragmatic approach to benchmarking reliable change frequency, and pending further validation, could be used for feedback to individual patients. Résumé: Contexte: Grâce à des résultats tels que l'amélioration de la capacité d'exercice, la réadaptation cardiaque (RC) réduit la morbidité et la mortalité. Pour être précis, le changement de RC d'un patient doit être mesuré de manière fiable, un aspect qui n'est généralement pas pris en compte dans la pratique. En nous inspirant de la théorie psychométrique, nous avons déterminé des indices de changement fiables afin de mesurer le véritable changement clinique individuel des patients en RC en lien avec la capacité d'entraînement, l'anxiété et la dépression et indépendamment des erreurs et de la pratique du test/l'exposition au test. Méthodologie: La capacité d'entraînement calculée indirectement (l’équivalent métabolique maximum [MET]) et les symptômes psychologiques ont été mesurés deux fois, à une semaine d'intervalle, par le biais de tests sur tapis roulant ou de l’échelle de l’évaluation de l'anxiété et de la dépression en milieu hospitalier (HADS), auxquels ont respectivement été soumis des échantillons de 35 personnes en RC (âge moyen : 59,0 ans; 6 femmes) et de 96 personnes en RC (âge moyen : 64,4 ans; 32 femmes). En recourant à la fiabilité test-retest et aux écarts moyens dans les scores de ces échantillons pour faire une approximation des effets d'erreur et de pratique/exposition, nous avons déterminé des indices de changement fiables pour une cohorte distincte (n = 2 066; âge moyen : 62,0 ans; 533 femmes) qui a terminé une RC de six mois, et comparé la répartition des changements (aggravé/inchangé/amélioré) sur la base des indices de changement fiables critiques, des changements moyens et en pourcentage, des scores-seuils et des écarts types. Résultats: Les effets de la pratique/exposition étaient peu significatifs, sauf une diminution du score moyen de l'anxiété sur l’échelle HADS (p ≤ 0,013; d = 0,17, petit effet). La fiabilité test-retest était élevée (MET, r = 0,934; score de l'anxiété sur l’échelle HADS, r = 0,912; score de la dépression sur l’échelle HADS, r = 0,90; p < 0,001). Parmi les 2 066 patients en RC, la répartition des indices de changement fiables différait (p < 0,001) de celle de la plupart des autres critères de changement. Conclusions: Le constat du changement dépend du choix du critère. Une augmentation de 0,5 MET selon l'indicateur de qualité en RC de la Société canadienne de cardiologie est peut-être trop faible pour évaluer le changement de capacité fonctionnelle des individus. Les indices de changement fiables offrent une approche pragmatique pour comparer la fréquence du changement fiable et, en attendant une vérification plus poussée, ils pourraient être utilisés comme rétroaction fournie individuellement aux patients.

Background: Extension of dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome is associated with a reduction in ischemic events but also increased bleeding. The DAPT score identifies individuals likely to derive overall benefit or harm from DAPT extension. We sought to evaluate the impact of providing the DAPT score to treating physicians on the decision to extend DAPT beyond 1 year after non–ST-segment elevation myocardial infarction. Methods: Moderate to high-risk non–ST-segment elevation myocardial infarction patients were enrolled from July 2016 to May 2018 in 13 Canadian hospitals by 52 cardiologists. Participating cardiologists were randomly assigned 1:1 to receive their individual patients’ DAPT scores before the 1-year follow-up visit vs not receiving their patients’ DAPT scores. Rates of DAPT extension were compared among the randomized groups. Results: At 1 year, 370 of the 585 (63.2%) patients discharged on DAPT were receiving DAPT. Among patients on DAPT at 1 year, the median (25th, 75th percentile) DAPT score was 2 (1,3). DAPT was extended beyond 1 year in 36.2% randomly assigned to provision of DAPT score vs 35.7% in the control group (P = 0.93). In the subgroup of patients with DAPT score ≥ 2, DAPT extension was 49.5% in the DAPT score provision arm vs 40.4% in the control arm (P = 0.22); among patients with DAPT score < 2, DAPT termination was 78.6% in the DAPT score provision arm vs 70.6% in the control arm (P = 0.26) (P value for interaction = 0.1). Conclusions: In this exploratory randomized trial, provision of the DAPT score to treating physicians had no impact on the duration of DAPT treatment beyond 1 year. Résumé: Introduction: La prolongation de la bithérapie antiplaquettaire au-delà d'un an après un syndrome coronarien aigu est associée à la réduction des accidents ischémiques, mais aussi à l’augmentation des hémorragies. Le score de bithérapie antiplaquettaire permet de déterminer les individus susceptibles d’obtenir des avantages globaux ou des inconvénients de la prolongation de la bithérapie antiplaquettaire. Nous avons cherché à évaluer les répercussions de l’obtention du score de bithérapie antiplaquettaire par les médecins traitants sur la décision quant à la prolongation de la bithérapie antiplaquettaire au-delà d'un an après l'infarctus du myocarde sans élévation du segment ST. Méthodes: De juillet 2016 à mai 2018, 52 cardiologues de 13 hôpitaux du Canada ont inscrit des patients exposés à un risque modéré à élevé d’infarctus du myocarde sans élévation du segment ST. Nous avons réparti de façon aléatoire selon un rapport 1:1 les cardiologues participants qui recevaient les scores de bithérapie antiplaquettaire individuels de leurs patients avant la consultation de suivi après un an vs ceux qui ne recevaient pas les scores de bithérapie antiplaquettaire de leurs patients. Nous avons comparé les taux de prolongation de la bithérapie antiplaquettaire des groupes répartis de façon aléatoire. Résultats: Après un an, 370 (63,2 %) patients sur 585 qui avaient eu à la sortie de l’hôpital une bithérapie antiplaquettaire recevaient la bithérapie antiplaquettaire. Parmi les patients qui prenaient la bithérapie antiplaquettaire après un an, le score médian de bithérapie antiplaquettaire (25e, 75e percentiles) était de 2 (1, 3). La bithérapie antiplaquettaire était prolongée au-delà d'un an chez 36,2 % des patients répartis de façon aléatoire qui avaient un score de bithérapie antiplaquettaire vs 35,7 % dans le groupe témoin (P = 0,93). Dans le sous-groupe de patients qui avaient un score de bithérapie antiplaquettaire ≥ 2, la prolongation de la bithérapie antiplaquettaire était de 49,5 % dans le bras qui avait un score de bithérapie antiplaquettaire vs 40,4 % dans le bras témoin (P = 0,22); parmi les patients qui avaient un score de bithérapie antiplaquettaire < 2, la cessation de la bithérapie antiplaquettaire était de 78,6 % dans le bras qui avait un score de bithérapie antiplaquettaire vs 70,6 % dans le bras témoin (P = 0,26) (valeur P pour l’interaction = 0,1). Conclusions: Dans cet essai exploratoire à répartition aléatoire, l’obtention du score de la bithérapie antiplaquettaire par les médecins traitants n’a pas engendré de répercussions sur la durée de la bithérapie antiplaquettaire au-delà d'un an.

BACKGROUND After myocardial infarction, guidelines recommend higher-potency P2Y12 receptor inhibitors, namely ticagrelor and prasugrel, over clopidogrel. HYPOTHESIS We aimed to determine the contemporary use of higher-potency antiplatelet therapy in Canadian patients with non-ST-elevation myocardial infarction (NSTEMI). METHODS A total of 684 moderate-to-high risk NSTEMI patients were enrolled in the prospective Canadian ACS Reflective II registry at 12 Canadian hospitals and three clinics in five provinces between July 2016 and May 2018. Multivariable logistic regression modeling was performed to assess factors independently associated with higher-potency P2Y12 receptor inhibitor use at discharge. RESULTS At hospital discharge, 78.3% of patients were treated with a P2Y12 receptor inhibitor. Among patients discharged on a P2Y12 receptor inhibitor, use of higher-potency P2Y12 receptor inhibitor was 61.4%. After adjustment, treatment in-hospital with PCI (OR 4.48, 95%CI 3.34-6.03, p

Purpose To examine: (1) the rate of clinical events precluding cardiac rehabilitation (CR) continuation, (2) CR attendance by component in those without events, and (3) the association between disease severity (eg, tobacco use, diabetes, and depression) and component attendance (eg, exercise, diet, stress management, and tobacco cessation). Methods Retrospective analysis of electronic records of the CR program in London, Ontario, from 1999 to 2017. Patients in the supervised program are offered exercise sessions 2 times/wk with a minimum of 48 prescribed sessions tailored to patient need. Patients attending ≥1 session without major factors that would limit their exercise ability were included. Intervening events were recorded, as was component attendance. Results Of 5508 enrolled, supervised patients, 3696 did not have a condition that could preclude exercise. Of those enrolled, one-sixth (n = 912) had an intervening event; these patients were less likely to work, more likely to have medical risk factors, had more severe angina and depression, and lower functional capacity. The remaining cohort attended a mean of 26.5 ± 21.3 sessions overall (median = 27; 19% attending ≥48 sessions), including 20.5 ± 17.4 exercise sessions (median = 21). After exercise, the most common components attended were individual dietary and psychological counseling. Patients with more severe angina and depressive symptoms as well as tobacco users attended significantly fewer total sessions, but more of some specific components. Conclusions In one-sixth of patients, CR attendance and completion are impacted by clinical factors beyond their control. Many patients are taking advantage of components specific to their risk factors, buttressing the value of individually tailored, menu-based programming.

The survival rate of patients with ischemic heart disease (IHD) is increasing. However, survivors experience increased risk for neurological complications. The mechanisms for this increased risk are unknown. We tested the hypothesis that patients with IHD have greater carotid and cerebrovascular stiffness, and these indexes predict white matter small vessel disease. Fifty participants (age, 40-78 yr), 30 with IHD with preserved ejection fraction and 20 healthy age-matched controls, were studied using ultrasound imaging of the common carotid artery (CCA) and middle cerebral artery (MCA), as well as magnetic resonance imaging (T1, T2-FLAIR), to measure white matter lesion volume (WMLv). Carotid β-stiffness provided the primary measure of peripheral vascular stiffness. Carotid-cerebral pulse wave transit time (ccPWTT) provided a marker of cerebrovascular stiffness. Pulsatility index (PI) and resistive index (RI) of the MCA were calculated as measures of downstream cerebrovascular resistance. When compared with controls, patients with IHD exhibited greater β-stiffness [8.5 ± 3.3 vs. 6.8 ± 2.2 arbitrary units (AU)

The current study evaluated the hypothesis that six months of exercise-based cardiac rehabilitation (CR) would improve sympathetic neural recruitment in patients with ischemic heart disease (IHD). Microneurography was used to evaluate action potential (AP) discharge patterns within bursts of muscle sympathetic nerve activity (MSNA), in eleven patients with IHD (1 female; 61±9 years) pre- (Pre-CR) and post- six months of aerobic and resistance training-based CR (Post-CR). Measures were made at baseline and during maximal voluntary end-inspiratory (EI-APN) and end-expiratory apneas (EE-APN). Data were analyzed during 1-minute of baseline and the second half of apneas. At baseline, overall sympathetic activity was less Post-CR (all P0.05) but increases in both within-burst AP firing frequency (∆Pre-CR: 2±3 AP spikes/burst vs. ∆Post-CR: 4±3 AP spikes/burst; P=0.02) and AP cluster recruitment (∆Pre-CR: -1±2 vs. ∆Post-CR: 2±2; P

Objective To examine whether explaining causal links among endothelial pathophysiology, cardiac risk factors, symptoms and health behaviors (termed causal information) enhances patients’ depth of knowledge about cardiovascular disease self-management and their perceptions of the cardiac rehabilitation and secondary prevention (CRSP) program. Methods Newly referred CRSP patients (N = 94) were cluster randomized to usual care (control; UC) or usual care with causal information (intervention; UC + CI). Depth of knowledge (factual vs. deep) was measured with an adapted cognitive-reasoning task. Patients’ cardiovascular knowledge and beliefs about the efficacy of a CRSP program were assessed. Results After controlling for education level, patients in UC + CI demonstrated deeper knowledge about cardiovascular management than did those in UC. The UC + CI group showed higher factual knowledge than their counterparts after covarying education, occupation status and BMI. The UC + CI group also rated the CRSP program as more credible than those in UC, after controlling for age. Deep knowledge mediated the relationship between group conditions and perceived credibility of CRSP. Conclusion Causal information can enhance the depth of patients’ understanding of cardiovascular disease management and perceived treatment credibility of the CRSP program. Practice implications Explaining causal links may help improve patient education delivery and enhance patient engagement in CRSP.

This chapter will examine the objectives, indications, and phases of cardiac rehabilitation, as well as the components of a cardiac rehabilitation program, and considerations for specific cardiovascular surgical populations.

Background A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool. Methods A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018–May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later. Results Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later. Conclusions Preliminary results support broader dissemination, and hence a genericized version has been created (http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html). Continuing education credits have been secured.

Objective To test a scalable health system intervention to improve long term adherence to secondary prevention treatments among patients who have had a recent myocardial infarction. Design Three arm, pragmatic randomised controlled trial with blinded outcome assessment. Setting Nine cardiac centres in Ontario, Canada. Participants 2632 patients with obstructive coronary artery disease after a myocardial infarction, identified from a centralised cardiac registry. Interventions Participants were randomised 1:1:1 to receive usual care, five mail-outs developed through a user centred design process, or mail-outs plus phone calls. The phone calls were delivered first by an interactive automated system to screen for non-adherence to treatment. Trained lay health workers followed up as necessary. Interventions were coordinated centrally but delivered from each patient’s hospital site. Main outcome measures Co-primary outcomes were completion of cardiac rehabilitation and adherence to recommended medication. Data were collected by blinded assessors through patient report and from administrative health databases at 12 months. Results 2632 patients (mean age 66, 71% male) were randomised: 878 to the full intervention (mail plus phone calls), 878 to mail only, and 876 to usual care. Of the respondents, 174 (27%) of 643 in the usual care group, 200 (32%) of 628 in the mail only group, and 196 (37%) of 531 allocated to the full intervention completed cardiac rehabilitation (adjusted odds ratio 1.55, 95% confidence interval 1.18 to 2.03). In the mail plus phone group, 11.7%, 6.0%, 14.4%, 32.9%, and 35.0% reported adherence to 0, 1, 2, 3, and 4 drug classes after one year, respectively, in comparison with 12.5%, 6.8%, 13.6%, 30.2%, and 36.8% in the mail only group, and 12.2%, 8.4%, 13.1%, 30.3%, and 36.1% in the usual care group, respectively (mail only v usual care, odds ratio 0.98, 95% confidence interval 0.81 to 1.19; full intervention v usual care, 0.99, 0.82 to 1.20). Conclusions Scalable interventions delivered by mail plus phone can increase completion of cardiac rehabilitation after myocardial infarction but not adherence to medication. More intensive interventions should be tested to improve adherence to medication and to evaluate the association between attendance at cardiac rehabilitation and adherence to medication. Trial registration ClinicalTrials.gov NCT02382731 , registered 9 March 2015 before any patient enrolment.

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients’ relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient–professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.

Background The impact of burst high-intensity exercise on physiological, cardiometabolic, and biochemical variables compared with traditional moderate-intensity continuous exercise training (MICT) has yet to be assessed in patients with type 2 diabetes (T2D). We compared the impact of multiple short-duration, high-intensity burst exercise sessions to MICT on cardiometabolic variables in patients with T2D. Methods Forty newly diagnosed patients with T2D not receiving lipid lowering or hypoglycemic medications were randomized to 40 minutes of MICT (60% of maximal heart rate) 5 days per week or 3 continuous bursts of 12 minutes of high-intensity exercise (85% of maximal heart rate) 5 days per week for 3 months. Body mass index, hemoglobin A 1C (HbA 1C ), and lipid profile were assessed before and after 3 months of exercise training. Results Burst exercise resulted in greater body mass index reduction than did MICT (–2.1 ± 1.2 kg/m 2 vs –0.7 ± 0.7 kg/m 2 , respectively; P P 1C levels in the burst exercise group (8.14% ± 0.49% to 7.32% ± 0.39%) compared with the MICT group (8.18% ± 0.35% to 7.94% ± 0.41%). Compared with MICT, burst exercise was associated with a greater reduction in low-density lipoprotein cholesterol (–11 vs –4%; P P P Conclusions Findings from the current study support better cardiometabolic benefits of burst exercise compared with MICT over 3 months in patients with newly diagnosed T2D.

PURPOSE Having previously reported that comprehensive cardiac rehabilitation (CCR) is effective for secondary prevention post-transient ischemic attack (TIA)/mild nondisabling stroke (MNDS), we present psychometric findings for the same sample that elucidate subacute TIA/MNDS psychological outcomes and test whether CCR would be independently associated with psychological improvements. METHODS In this prospective cohort trial patients with ≥1 risk factor, recruited from a stroke prevention clinic within 12 months (mean = 11.5 weeks) post-TIA/MNDS, entered CCR. RESULTS Of the 110 recruited patients, 100 (mean age = 65.4 years; 46 females) entered CCR and 80 completed CCR (mean duration = 7.6 months). At CCR entry, 16.5% and 39.2% screened positively for depression and anxiety, decreasing nonsignificantly at exit to 4.2%, and significantly to 16.9% (P = .008), respectively. Age-corrected deficits occurred more frequently than expected (P ≤ .03); at entry, mental health status (13.3%), clock-drawing (31.6%), oral-verbal fluency (16.9%), word-list learning (11.2%), and recall (12.6%); at exit, clock-drawing (30.0%). Entry-to-exit, mean depression, anxiety, mental and physical health status, word-list learning, memory, digit-symbol coding, and oral-verbal fluency scores improved significantly (P ≤ .031). No reliable change indices were significant. Psychological service recipients improved significantly more than nonrecipients in depression (P = .049). Baseline North American Adult Reading Test score predicted exercise attendance (R = 0.275; P = .044); New York Heart Association (NYHA) class and depression score predicted exit physical health status (R = 0.770, P < .001); and depression score predicted exit mental health status (R = 0.523, P < .001). CONCLUSIONS Anxiety and executive dysfunction persisted post-TIA/MNDS. Although promising for secondary prevention post-TIA/MNDS, CCR was not independently associated with psychological improvements. CCR psychological treatment may benefit depression. Subacute NYHA class and depression may later affect quality of life.

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription—the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.

Background Autonomic dysregulation represents a hallmark of coronary artery disease ( CAD ). Therefore, we investigated the effects of exercise‐based cardiac rehabilitation ( CR ) on autonomic function and neuro‐cardiovascular stress reactivity in CAD patients. Methods and Results Twenty‐two CAD patients (4 women; 62±8 years) were studied before and following 6 months of aerobic‐ and resistance‐training–based CR . Twenty‐two similarly aged, healthy individuals ( CTRL ; 7 women; 62±11 years) served as controls. We measured blood pressure, muscle sympathetic nerve activity, heart rate, heart rate variability (linear and nonlinear), and cardiovagal (sequence method) and sympathetic (linear relationship between burst incidence and diastolic blood pressure) baroreflex sensitivity during supine rest. Furthermore, neuro‐cardiovascular reactivity during short‐duration static handgrip (20s) at 40% maximal effort was evaluated. Six months of CR lowered resting blood pressure ( P P P CTRL and improved sympathetic baroreflex sensitivity in CAD patients ( P P >0.05) and cardiovagal baroreflex sensitivity ( P =0.11) were unchanged following CR , yet values were not different pre‐ CR from CTRL (all P >0.05). Furthermore, before CR , CAD patients displayed greater blood pressure and muscle sympathetic nerve activity reactivity to static handgrip versus CTRL (all P CR (all P CTRL . Conclusions Six months of exercise‐based CR was associated with marked improvement in baseline autonomic function and neuro‐cardiovascular stress reactivity in CAD patients, which may play a role in the reduced cardiac risk and improved survival observed in patients following exercise training.

Globally, there are ∼ 26 million people living with heart failure (HF), 50% of them with reduced ejection fraction, costing countries billions of dollars each year. Improvements in treatment of cardiovascular diseases, including advanced HF, have allowed an unprecedented number of patients to survive into old age. Despite these advances, patients with HF deteriorate and often require advanced therapies. As the proportion of elderly patients in the population increases, there will be an increasing number of patients to be evaluated for advanced therapies and an increasing number that do not qualify for, won't be considered for, or decline orthotopic heart transplantation. The purpose of this article is to review the benefits of palliative care (PC), exercise-based cardiac rehabilitation (ExCR), device therapy (cardiac resynchronization therapy and mitral clip), and mechanical circulatory support (MCS) in advanced HF patients who are transplant ineligible. PC interventions should be introduced early in the course of a patient's diagnosis to manage symptoms, address goals of care, and improve patient-centered outcomes. Further improvement in health-related quality of life as well as functional capacity can be achieved safely in patients with advanced HF through patient participation in ExCR. Device therapy and MCS can reduce HF hospitalizations and improve survival. In fact, early survival with MCS approaches that of heart transplantation. Despite their being transplant ineligible, there are a variety of treatment options available to patients to improve their quality of life, decrease hospitalizations, and potentially improve mortality.

Community-based hybrid cardiac rehabilitation (CR) programs offer a viable alternative to conventional centre-based CR, however their long-term benefits are unknown. We conducted a secondary analysis of the CR Participation Study conducted in London, Ontario, between 2003 and 2006. CR eligible patients hospitalized for a major cardiac event, who resided within 60 min, were referred to a hybrid CR program, 381 of 544 (64%) referred patients initiated CR, an additional 1,498 CR eligible patients were not referred due to distance. For the present study, CR participants were matched using propensity scores to CR eligible non-participants who resided beyond 60 min, yielding 214 matched pairs. Subjects were followed for a mean (standard deviation, SD) of 8.56 (3.38) years for the outcomes of mortality or re-hospitalization for a major cardiac event. Hybrid CR participation was associated with a non-significant 16% lower event rate (Hazard Ratio [HR]: 0.84, 95% CI: 0.59&ndash, 1.17). When restricting to pairs where CR participants achieved a greater than 0.5 metabolic equivalent exercise capacity increase (123 pairs), CR completion was associated with a 51% lower event rate (HR: 0.49, 95% CI: 0.29&ndash, 0.81). Successful completion of a community-based hybrid CR program may be associated with decreased long-term mortality or recurrent cardiac events.

In response to acute physiological stress, the sympathetic nervous system modifies neural outflow through increased firing frequency of lower-threshold axons, recruitment of latent subpopulations of higher-threshold axons, and/or acute modifications of synaptic delays. Aging and coronary artery disease (CAD) often modify efferent muscle sympathetic nerve activity (MSNA). Therefore, we investigated whether CAD ( n = 14; 61 ± 10 yr) and/or healthy aging without CAD (OH; n = 14; 59 ± 9 yr) modified these recruitment strategies that normally are observed in young healthy (YH; n = 14; 25 ± 3 yr) individuals. MSNA (microneurography) was measured at baseline and during maximal voluntary end-inspiratory (EI) and end-expiratory (EE) apneas. Action potential (AP) patterns were studied using a novel AP analysis technique. AP frequency increased in all groups during both EI- and EE-apnea (all P < 0.05). The mean AP content per integrated burst increased during EI- and EE-apnea in YH (EI: Δ6 ± 4 APs/burst; EE: Δ10 ± 6 APs/burst; both P < 0.01) and OH (EI: Δ3 ± 3 APs/burst; EE: Δ4 ± 5 APs/burst; both P < 0.01), but not in CAD (EI: Δ1 ± 3 APs/burst; EE: Δ2 ± 3 APs/burst; both P = NS). When APs were binned into “clusters” according to peak-to-peak amplitude, total clusters increased during EI- and EE-apnea in YH (EI: Δ5 ± 2; EE: Δ6 ± 4; both P < 0.01), during EI-apnea only in OH (EI: Δ1 ± 2; P < 0.01; EE: Δ1 ± 2; P = NS), and neither apnea in CAD (EI: Δ −2 ± 2; EE: Δ −1 ± 2; both P = NS). In all groups, the AP cluster size-latency profile was shifted downwards for every corresponding cluster during EI- and EE-apnea (all P < 0.01). As such, inherent dysregulation exists within the central features of apnea-related sympathetic outflow in aging and CAD.

Purpose The Canadian Cardiovascular Society initiated a pan-Canadian process for development of quality indicators (QIs) for cardiac rehabilitation (CR). Before implementation, the QIs underwent pilot testing to ensure they were acceptable and feasible for field implementation. The objectives of this test were to assess (1) the technical feasibility of measuring the QIs; (2) the workload required to measure the QIs; and (3) acceptability of measuring the QIs and issues with their implementation. Methods The 2 indicators chosen for field testing were QI-1 (% of eligible inpatients referred) and 2b (median wait time from CR referral receipt to enrollment). The approach consisted of 3 steps: (1) data extraction to test technical feasibility; (2) completing a workload diary; and (3) providing input through a semistructured interview regarding acceptability and implementation issues. Three academic CR sites were selected to undertake the field test. Results QI-1 ranged from 51.0% to 68.4%, and QI-2b was reported as 27 days (median) by one site, and 22 days (mean) by another. It was not considered feasible for CR programs to assess all potentially CR-eligible inpatients for CR referral exclusions. Compilation required 4.2 hours for QI-1 and 1.8 hours for QI-2b. QI assessment was acceptable to the programs, but changes in practice would be needed at each site to implement the QIs. Conclusions CR programs may require enhancement of information-tracking processes to enable QI measurement. It was recommended that the QIs be implemented, but should undergo minor revisions to enhance feasibility.

Introduction: Heart failure (HF) affects approximately 2% of the population with major effects on morbidity and mortality. Over 80% of existing Heart Function Clinics (HFC) are located within a hospital setting. The CoHealth (Ontario) “hub-and-spoke” model encourages community-based HFCs for patients who are less complex or relatively stable while more complex/unstable patients receive care in a hospital-based HFC. The purpose of this project was to explore patient populations and achievement of established quality indicators (QIs) within a specialist-supported community-based HFC in a Family Health Team (FHT-HFC) and a HFC in a tertiary hospital (H-HFC) over 12 months. Methods: Retrospective standardized chart reviews were conducted from all 60 patients enrolled in the FHT-HFC since its inception in 2010 to 2015, and 100 patients followed in the H-HFC in 2013. QIs were measured and compared at enrollment, 6 months and 12 months. Results: Patients attending the H-HFC vs FHT-HFC had no difference in age, sex or etiology of HF. However, patients at the H-HFC were significantly more likely to have reduced LV function, have marked HF symptoms, and more likely to have a recent hospital admission. Both cohorts had multiple comorbidities, with greater frequencies of MI, ICD/CRT/pacemaker, smoking and respiratory disease in the H-HFC group. By 6 months’ post enrollment, the number of patients with a HF with a reduced ejection fraction (HFrEF) in the H-HFC (n=65) who were on an ACEi/ARB, beta-blocker, and MRA increased from 75% to 82%, 86% to 88%, and 29% to 34% (vs 99% to 99%, 77% to 89% and 33% to 39%, respectively in the FHT-HFC (n=28)). Over the 12 months following enrollment in a HFC the proportion of patients with NYHA class III symptoms decreased from 67% to 38% (H-HFC) vs 47% to 14% (FHT-HFC) (p < 0.05) and HF hospital admissions were reduced by 31% (H-HFC) vs 68% (FHT-HFC) (p < 0.05). At 12 months 34% (H-HFC) vs 20% (FHT-HFC) (p=0.07) of patients were enrolled in a cardiac rehabilitation program. Conclusion: While the H-HFC and FHT-HFC patients had similar demographics and comorbidities, H-HFC patients tended to more frequently have HFrEF, were more symptomatic and more likely to have been recently hospitalized. Participation in either the H-HFC or FHT-HFC was associated with medication optimization, decreased symptoms and fewer hospitalizations compared to the previous year. In conclusion, this retrospective study shows that the “hub and spoke” HFC model may have merit but needs further evaluation on a wider, more formal scale.

© 2015 the American Physiological Society. This study tested the hypothesis that coronary artery disease (CAD) alters the cortical circuitry associated with exercise. Observations of changes in heart rate (HR) and in cortical blood oxygenation level-dependent (BOLD) images were made in 23 control subjects [control; 8 women; 63 ± 11 yr; mean arterial pressure (MAP): 90 ± 9 mmHg] (mean ± SD) and 17 similarly aged CAD patients (4 women; 59 ± 9 yr; MAP: 87 ± 10 mmHg). Four repeated bouts each of 30%, 40%, and 50% of maximal voluntary contraction (MVC) force (LAB session), and seven repeated bouts of isometric handgrip (IHG) at 40% MVC force (fMRI session), were performed, with each contraction lasting 20 s and separated by 40 s of rest. There was a main effect of group (P = 0.03) on HR responses across all IHG intensities. Compared with control, CAD demonstrated less task-dependent deactivation in the posterior cingulated cortex and medial prefrontal cortex, and reduced activation in the right anterior insula, bilateral precentral cortex, and occipital lobe (P < 0.05). When correlated with HR, CAD demonstrated reduced activation in the bilateral insula and posterior cingulate cortex, and reduced deactivation in the dorsal anterior cingulate cortex, and bilateral precentral cortex (P < 0.05). The increased variability in expected autonomic regions and decrease in total cortical activation in response to the IHG task are associated with a diminished HR response to volitional effort in CAD. Therefore, relative to similarly aged and healthy individuals, CAD impairs the heart rate response and modifies the cortical patterns associated with cardiovascular control during IHG.

Stefanie De Jesus,1 Lyndsay Fitzgeorge,2 Karen Unsworth,3 David Massel,4,5 Neville Suskin,4,5 Harry Prapavessis,1 Michael Sanatani6 1Department of Kinesiology, The University of Western Ontario, 2School of Health Sciences, FanshaweCollege, 3Cardiac Rehabilitation & Secondary Prevention Program, St. Joseph’s Hospital, 4Division of Cardiology & Program of Experimental Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, 5Lawson Health Research Institute, 6Department of Medical Oncology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada Purpose: Exercise is beneficial to quality of life after cancer treatment, yet few cancer survivors meet exercise guidelines. Our study sought to determine the feasibility of an oncology rehabilitation exercise program embedded within a cardiac rehabilitation program. Methods: Patients who rated their fatigue >4/10 after completion of adjuvant chemotherapy for breast cancer were screened for eligibility and the outcomes were assessed (Piper Fatigue Scale, Functional Assessment of Cancer Therapy-Breast [FACT-B], Edmonton Symptom Assessment System, body composition, stress test, and physical activity measurement [accelerometer]). Participants received individualized exercise prescription. Following the 16-week program, repeat assessment plus patient acceptance and satisfaction survey was completed. The primary end point was the composite of accrual rate >25%, program adherence >80%, and mean compliance with accelerometer use >80%. Results: Twenty of 24 screened patients consented to the study and completed the baseline assessment. Adherence was 30.3%. Mean accelerometer use was 3.88/7 days (78%). Fatigue at baseline was rated at 4.82/10, and at 3.59 (p = 0.09) after the intervention. Overall well-being (FACT-B) score changed from 92.7 to 98.3 (p = 0.05). There were no significant changes in body composition (except for bone mineral content), aerobic exercise capacity, or activity patterns. Conclusion: Although the primary outcome was not met, our study indicates that an oncology exercise rehabilitation program can be incorporated into an existing cardiac rehabilitation program. Based on feedback received, we propose that in order to achieve exercise goals, frequent, encouraging, and tailored feedback and group sessions to foster a sense of community may additionally be needed to strengthen adherence to a prescribed exercise program. Keywords: breast cancer rehabilitation, fatigue, exercise, community setting

The Canadian Cardiovascular Society (CCS) is implementing the Canadian Heart Health Strategy and Action Plan recommendation to build knowledge infrastructure, through its Data Definitions and Quality Indicator (QI) project. The CCS selected cardiac rehabilitation (CR) and secondary prevention as a content area for QI development. In accordance with the CCS QI Best Practice Methodology, rapid reviews of the literature were conducted. A long list of 37 QIs, in the areas of structure, process, and outcome were developed. Through an online survey, 26 (42%) of all contacted external experts rated each QI on importance, scientific acceptability, and feasibility, using a 7-point scale. The overall mean rating was 5.4 ± 1.4. Through a consensus process, the working group excluded 8 QIs based on this feedback, and several others were revised. A 30-day Web consultation was then undertaken, to solicit input from the broader CCS and CR community. A "top 5" list of QIs was requested by the CCS, which were: (1) inpatients referred to CR; (2) wait times from referral to CR enrollment; (3) patient self-management education; (4) increase in exercise capacity; and (5) emergency response strategy. Knowledge translation activities are now under way to promote utilization of the QIs and ultimately improve CR care.

Background— Communication between cardiac rehabilitation (CR) and primary care providers (PCPs) is paramount to promoting long-term risk reduction after the completion of CR. The objectives of this study were to investigate receipt of CR discharge summaries by PCPs, as well as timing, and satisfaction with and perceptions of CR summaries. Methods and Results— Five hundred seventy-seven eligible PCPs of consenting enrollees from 8 regional or urban Ontario CR programs were invited to participate in this cross-sectional study. Discharge summaries were tracked from the CR program to the PCP’s office. PCPs who received a summary were mailed a survey assessing their perceptions of the summaries. Of the 138 (24.0%) eligible consenting PCPs, 71 (51.5%) received CR discharge summary, of whom 64 (90.1%) completed the survey. All PCPs desired to receive discharge summaries, with most wanting it transmitted via fax (n=38, 61.3%). Forty-seven (77.1%) PCPs reported they had or will use information in the summary for patient care. PCPs who did not receive the discharge summary in advance of their patient’s first post-CR visit (n=7, 10.9%) were significantly less likely to use it in patient care ( P Conclusions— Approximately half of CR discharge summaries reach PCPs, revealing a large gap in continuity of patient care.

Coronary artery disease (CAD) poses a risk to the cerebrovascular function of older adults and has been linked to impaired cognitive abilities. Using magnetic resonance perfusion imaging, we investigated changes in resting cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to hypercapnia in 34 coronary artery disease (CAD) patients and 21 age-matched controls. Gray matter volume images were acquired and used as a confounding variable to separate changes in structure from function. Compared to healthy controls, CAD patients demonstrated reduced CBF in the superior frontal, anterior cingulate, insular, pre- and post-central gyri, middle temporal and superior temporal regions. Subsequent analysis of these regions demonstrated decreased CVR in the anterior cingulate, insula, postcentral and superior frontal regions. Except in the superior frontal and precentral regions, regional reductions in CBF and CVR were identified in brain areas where no detectable reductions in gray matter volume were observed, demonstrating that these vascular changes were independent of brain atrophy. Because aerobic fitness training can improve brain function, potential changes in regional CBF were investigated in the CAD patients after completion of a 6-month exercise-based cardiac rehabilitation program. Increased CBF was observed in the bilateral anterior cingulate, as well as recovery of CBF in the dorsal aspect of the right anterior cingulate, where the magnitude of increased CBF was roughly equal to the reduction in CBF at baseline compared to controls. These exercise-related improvements in CBF in the anterior cingulate is intriguing given the role of this area in cognitive processing and regulation of cardiovascular autonomic control.

Cardiac rehabilitation (CR) is most often provided in a hospital setting. Home-based models of care have been developed to overcome geographic, among other, barriers in patients at a lower risk. This study assessed whether clinical and geographic factors were related to the use of either a hospital-based or a home-based program. Secondary analysis was undertaken within a study of 1268 cardiac outpatients recruited from 97 cardiologist practices where clinical data were extracted. Participants completed a survey including the Duke Activity Status Index. They reported CR utilization in a second survey mailed 9 months later, including CR site and program model. Geographic information systems were used to determine the distances and the drive times to the CR site attended from patients' homes. Overall, 469 (37.0%) participants attended CR at one of 41 programs. Of the 373 (79.5%) participants with complete geographic data, 43 (11.5%) reported attending home-based CR. The sole clinical difference was in activity status, where patients attending a hospital-based program had lower activity status (P0.01). There were no differences in model attended on the basis of geographic parameters including urban versus rural dwelling or drive times (P0.05). In conclusion, only one-tenth of outpatients participated in a home-based program, and this allocation was unrelated to geographic considerations. Although patients should continue to be appropriately triaged on the basis of clinical risk to ensure safety, more targeted allocation of patients to home-based services may be warranted. This may optimize the degree of participation and potentially patient outcomes.

Background and Purpose— Comprehensive cardiac rehabilitation (CCR), which integrates structured lifestyle interventions and medications, reduces morbidity and mortality among cardiac patients. CCR has not typically been used with cerebrovascular populations, despite important commonalities with heart patients. We tested feasibility and effectiveness of 6-month outpatient CCR for secondary prevention after transient ischemic attack or mild, nondisabling stroke. This article presents risk factors. A future article will discuss psychological outcomes. Methods— Consecutive consenting subjects having sustained a transient ischemic attack or mild, nondisabling stroke within the previous 12 months (mean, 11.5 weeks; event-to-CCR entry) with ≥1 vascular risk factor, were recruited from a stroke prevention clinic providing usual care. We measured 6-month CCR outcomes following a prospective cohort design. Results— Of 110 subjects recruited from January 2005 to April 2006, 100 subjects (mean age, 64.9 years; 46 women) entered and 80 subjects completed CCR. We obtained favorable, significant intake-to-exit changes in: aerobic capacity (+31.4%; P P =0.008), total cholesterol/high-density lipoprotein (−11.6%; P P =0.003), waist circumference (−2.44 cm; P 2 ; P =0.003), and body weight (−1.43 kg; P =0.001). Low-density lipoprotein (−0.24 mmol/L), high-density lipoprotein (+0.06 mmol/L), systolic (−3.21 mm Hg) and diastolic (−2.34 mm Hg) blood pressure changed favorably, but nonsignificantly. A significant shift toward nonsmoking occurred ( P =0.008). Compared with intake, 11 more individuals (25.6% increase) finished CCR in the lowest-mortality risk category of the Duke Treadmill Score ( P Conclusions— CCR is feasible and effective for secondary prevention after transient ischemic attack or mild, nondisabling stroke, offering a promising model for vascular protection across chronic disease entities. We know of no similar previous investigation, and are now conducting a randomized trial.

Background Available evidence has demonstrated survival benefits associated with multidisciplinary cardiovascular risk-reduction (CR) (ie, cardiac rehabilitation) programs. The degree to which program capacity meets eligible service demands in Ontario is unknown. We sought to estimate the supply-need care-gap associated with CR programs across regions (Local Health Integration Networks [LHINs]) in Ontario. Methods We conducted a cross-sectional, population-based study during 2006. Administrative data provided estimates of the population eligible for multidisciplinary CR services due to (1) recent cardiovascular hospitalizations and (2) incident diabetes. An Ontario-wide survey of CR programs provided service supply estimates. The coverage rate and the absolute supply-need mismatch were use to quantify the care-gap by LHIN. Results Based on cardiac hospitalizations alone, 53,270 patients in Ontario in 2006 (508.7 per 100,000) were eligible for CR services; 128,869 patients (1245 per 100,000) would have been eligible if newly diagnosed (incident cases) diabetic patients were included. Capacity for CR services was 18,087 patients, corresponding to 34% coverage of the eligible population (absolute unmet needs of 35,189 individuals) if capacity was entirely dedicated to recent hospitalizations and 14% coverage (absolute unmet needs of 110,782) if services were extended to include incident diabetes patients. Marked variation in disease burden, service capacity, and supply-need mismatch was observed across regions, in which supply was not correlated with need. Conclusion Despite proved benefits of multidisciplinary CR programs, unmet population needs remain high in Ontario and are unequally distributed across regions. The magnitude of unmet needs and the lack of correlation between supply and disease burden necessitate broader provincial strategies to plan, allocate, and subsidize CR programs.

Both depression and smoking are highly prevalent and related to poorer outcomes in cardiac patients. In this study, the authors examined the association between depressive symptoms and smoking status, described the frequency and type of antidepressant use, and prospectively tested the effects of antidepressant use in smokers on smoking status and psychosocial outcomes. Participants comprised 1498 coronary artery disease (CAD) outpatients who completed a baseline survey which assessed depressive symptoms, current medications, and smoking status. A second survey was mailed 9 months later that assessed depressive symptoms, anxiety, insomnia, current medications and smoking status. Results showed that current and former-smokers had significantly greater depressive symptoms than non-smokers. Ten percent of patients were taking antidepressants, most frequently SSRIs, with significantly more smokers on antidepressants than former and non-smokers. At follow-up, smokers on antidepressants were less likely to have quit, had greater anxiety, depressive symptoms and insomnia than smokers not using antidepressants. This study demonstrated that smokers and quitters with CAD had greater depressive symptoms and use of antidepressants than non-smokers, but that the antidepressants utilized may not be optimizing outcomes.

Background Participation in cardiac rehabilitation (CR) programs results in multiple beneficial outcomes, including decreased morbidity and mortality. In Canada, the involvement of the primary care physician post-CR should increase the likelihood of sustaining the benefits achieved by CR and enhance the continuity of care that cardiac patients receive. Objectives To identify and describe information that is transferred from CR programs to primary care physicians in discharge summaries, and to assess the usefulness of such information from the perspective of the primary care physician. Methods For each of 21 Ontario CR sites to which patients from a larger study were referred, up to four primary care physicians were contacted to request a copy of the CR discharge summary received and their participation in a telephone interview. Discharge data were coded and enumerated. Qualitative data from 17 interviews were transcribed and coded based on grounded analyses. Results Of the 89 primary care physicians approached, 50 participated (response rate of 61.7%). Twenty-one physicians (42.0%) received the intended discharge summary from the CR site. There was great variability in clinical and service data reported, with 52.0% reporting an exercise prescription for the home or community and 42.0% reporting current medications prescribed. Four themes requiring improvement were generated from the physician interviews: patient behavioural management issues, health system factors, efficiency of data transfer and communication issues. Conclusions Major inconsistencies were noted between clinical data communicated versus what was desired. Data relating to attendance rates, behavioural management suggestions and lipid values were among the most notable omissions.

To quantitatively investigate age differences in barriers to cardiac rehabilitation (CR) enrollment and participation.Cardiac outpatients (N = 1,273, mean age = 65.9 +/- 11.2) completed a mailed survey to discern barriers to CR enrollment and participation. Both enrollees and nonenrollees were asked to rate 18 CR barriers on a 5-point Likert scale.Of the respondents, 535 (43%) reported participating in CR at 1 of 40 sites, with younger patients being more likely to participate (P = .002). Older age was positively related to total CR barriers (P.001). Older patients more strongly endorsed the following CR barriers: already exercising at home (P = .001), confidence in ability to self-manage their condition (P = .003), perception of exercise as tiring or painful (P = .001), not knowing about CR (P = .001), lack of physician encouragement (P.001), comorbidities (P.001), and perception that CR would not improve their health (P.001).Given that the benefits of CR are achieved in older patients as well as the young, interventions to overcome these modifiable barriers to enrollment and participation are needed.

Background Cardiac rehabilitation (CR) is an established means of reducing mortality, yet is grossly underutilized. This is due to both health system and patient-level factors; issues that have yet to be investigated concurrently. This study utilized a hierarchical design to examine physician and patient-level factors affecting verified CR enrollment. Design A prospective multisite study, using a multilevel design of 1490 coronary artery disease outpatients nested within 97 Ontario cardiology practices (mean 15 per cardiologist). Methods Cardiologists completed a survey regarding CR attitudes. Outpatients were surveyed prospectively to assess factors affecting CR enrollment. Patients were mailed a follow-up survey 9 months later to self-report CR enrollment This was verified with 40 CR sites. Results Five hundred and fifty (43.4%) outpatients were referred, and 469 (37.0%) enrolled in CR. In mixed logistic regression analyses, factors affecting verified CR enrollment were greater strength of physician endorsement ( P = 0.005), shorter distance to CR ( P = 0.001), being married ( P = 0.01), and fewer perceived CR barriers ( P = 0.03). Conclusion Both physician and patient factors play a part in CR enrollment. Patient CR barriers should be addressed during referral discussions, and reasons why physicians fail to uniformly endorse CR exploration. Although distance to CR was related to patient enrollment patterns, greater access to home-based CR services should be provided.

To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.

It is unclear whether the beneficial effects of habitual exercise on insulin resistance are due to concomitant weight loss, changes in diet or whether they are simply related to the transient effects of the last bout of exercise. Moreover, patients with coronary artery disease (CAD) have not been studied.Randomized controlled trial.To determine the effects of exercise training on insulin resistance (i.e. low insulin sensitivity) in CAD patients without diabetes independent of changes in weight, diet or the effect of acute exercise, 29 patients were randomized to 12 weeks of supervised exercise training and 26 to usual activity. Insulin sensitivity was determined at 72 h following their last bout of exercise using the minimal model technique. Weight was held constant by adjusting caloric intake.Following the intervention, peak oxygen uptake increased by 0.18+/-0.14 l/min in the exercise training group, which was significantly higher (P0.0001) than that in the usual activity group (0.02+/-0.14 l/min). Insulin sensitivity did not change significantly within or between groups during the study [exercise training -0.24+/-1.15 x 10(4)/min and usual activity 0.06+/-0.67 x 10(4)/min/(microU/ml)].Twelve weeks of moderate exercise training in the absence of weight loss did not result in significant change in insulin resistance in patients with CAD.

To assess the system-level barriers and facilitators of continuity of care from acute care to cardiac rehabilitation (CR), and from CR discharge to follow-up with primary health care providers.Semi-structured individual interviews with 24 key informants including CR staff, research scientists, policy makers, cardiologists and other doctors from a regional to international level were conducted regarding the processes of referral to and discharge from cardiac rehabilitation. Key informant interviews were audio taped, transcribed, and imported into QSR N6 software for Grounded analysis.Themes that emerged related to communication, referral and discharge processes, health care provider practices, inter- and intra-institutional relationships, and alternative models of delivery to improve continuity.Ramifications for enhancing referral of patients to beneficial CR services and follow-up by primary care providers to ensure maintenance of functional and health-related gains are discussed.