The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology.

The role of comprehensive cardiac rehabilitation is well established in the secondary prevention of cardiovascular diseases such as coronary artery disease and heart failure. Numerous trials have demonstrated both the effectiveness as well as the cost-effectiveness of comprehensive cardiac rehabilitation in improving exercise capacity and quality of life, and in reducing cardiovascular mortality and morbidity. However, the current COVID-19 pandemic has led to closure of many cardiac rehabilitation centres in Europe resulting in many eligible patients unable to participate in the optimisation of secondary prevention and physical performance. This elicits an even louder call for alternatives such as cardiac telerehabilitation to maintain the delivery of the core components of cardiac rehabilitation to cardiovascular disease patients. The present call for action paper gives an update of recent cardiac telerehabilitation studies and provides a practical guide for the setup of a comprehensive cardiac telerehabilitation intervention during the COVID-19 pandemic. This set up could also be relevant to any cardiovascular disease patient not able to visit cardiac rehabilitation centres regularly after the COVID-19 pandemic ceases.

Determinants of participation in cardiac telerehabilitation during the first surge of COVID-19.

BACKGROUND: Participation rates in cardiac rehabilitation (CR) are low. In multiple trials, telerehabilitation (TR) has been demonstrated to be effective. Still, real-life evidence is scarce. During the first surge of the COVID-19 pandemic our centre deployed a TR programme. This study aimed to characterise the patient population that had, for the first time, the opportunity to participate in cardiac TR and to analyse if there were determining factors for participation or non-participation in TR. METHODS: All patients enrolled in CR in our centre during the first wave of the COVID-19 pandemic were included in this retrospective cohort study. Data was collected from the hospital electronic records. RESULTS: 369 patients were contacted in the setting of TR. 69 patients could not be reached and were excluded from further analysis. 208 (69%) patients that were contacted agreed to participate in cardiac TR. No significant differences in baseline characteristics were seen between TR participants and TR non-participants. A full model logistic regression did not reveal any significant determinants on participation rate in TR. CONCLUSION: This study demonstrates that the rate of participation in TR was high (69%). Of the analysed characteristics, none was directly correlated with the willingness to participate in TR. Further research is needed to further assess determinants, barriers and facilitators of TR. Also, research is needed on better delineating digital health literacy and on how to reach also those patients that are less motivated and or less digitally literate.

A Mobile Application to Perform the Six-Minute Walk Test (6MWT) at Home: A Random Walk in the Park Is as Accurate as a Standardized 6MWT.

The six-minute walk test (6MWT) provides an objective measurement of a person's functional exercise capacity. In this study, we developed a smartphone application that allows cardiac patients to do a self-administered 6MWT at home on a random trajectory. In a prospective study with 102 cardiovascular disease patients, we aimed to identify the optimal circumstances to perform a smartphone-measured 6MWT, i.e., the best algorithm and the best position to wear the smartphone during the test. Furthermore, we investigated if a random walk is as accurate as a standardized 6MWT. When considering both the reliability and accuracy of the distance walked, the best circumstances to perform a standardized smartphone-measured 6MWT are wearing the smartphone in a strap around the patient's arm and using an algorithm that relies on the processed step count data acquired from Google Fit. Furthermore, we demonstrated that a smartphone-measured walk along a random trajectory is as accurate to determine a cardiac patient's functional exercise capacity as a standardized (smartphone-measured) 6MWT. We conclude this paper by presenting how our 6MWT application can be used in a home setting to remotely follow up on cardiac patients' functional exercise capacity.

Cardiac Telerehabilitation　- A Solution for Cardiovascular Care in Japan.

Cardiac rehabilitation (CR) is a well-known intervention for the secondary prevention of cardiovascular diseases. However, in Japan, the outpatient CR participation rate is estimated to be very low. Cardiac telerehabilitation (CTR) can be defined as a remote CR program using digital health technology to support it. Evidence regarding the use of CTR has been accumulated, and the COVID-19 pandemic has accelerated the need for CTR. Japan has sufficient potential to benefit from CTR because, nationally, digital literacy is high and the infrastructure for telemedicine is developed. To overcome several barriers, evidence of CTR in Japan, well-educated multidisciplinary CTR teams, a good combination of center-based CR and CTR, and sophisticated systems including social insurance and adequate legislation need to be developed immediately. CTR has the potential to increase the low CR participation rate in Japan. CTR also has many different effects that not only cardiologists, but also paramedics who engage in CTR, have to be aware of.

Patient experiences and willingness-to-pay for cardiac telerehabilitation during the first surge of the COVID-19 pandemic: single-centre experience.

BACKGROUND: The first surge of the ongoing COVID-19 pandemic led to a shutdown of all non-urgent medical services such as cardiac rehabilitation. Therefore, centres had to develop remote and innovative ways to deliver the core components of CR during this shutdown. This increase in usage of remote rehabilitation services provides a chance to assess patients' experiences and willingness-to-pay of remote CR sessions. METHODS: This was a prospective single-centre study. From 17 July 2020, to 19 August 2020, we conducted an anonymous survey about the patient experiences of the cardiac telerehabilitation services provided at Jessa Hospital Hasselt during the COVID-19 pandemic. A link to an electronic questionnaire was sent via email to 155 patients who were invited to participate in the cardiac telerehabilitation sessions during the closure of the rehabilitation centre due to COVID-19. RESULTS: Fifty-five patients (35% of all invited patients) did participate in remote CR and completed the questionnaire. The mean age of the respondents was 65.4 ± 10.5 years, 63% were male and 70% of the participants were retired. A total of 91% possessed a smartphone and all those patients used their smartphone regularly to send text messages. Ninety-four per cent of the participants were satisfied with the provided telerehabilitation sessions and 70% of the participants would be prepared to pay for these sessions like for centre-based CR sessions. Twenty per cent of patients would even prefer the telerehabilitation sessions above centre-based CR sessions. CONCLUSION: Most patients believed that remote CR could be an option after the COVID-19 pandemic when it is combined with centre-based CR sessions. Patients are willing to pay the same amount for a telerehabilitation session as a centre-based CR session. This demonstrates that highly motivated patients are open to shift certain parts of CR from face-to-face interactions to digital interactions.

Use of cardiac telerehabilitation during COVID-19 pandemic in Belgium.

BACKGROUND: The COVID-19 pandemic has forced many cardiac rehabilitation centres to focus more on the remote delivery of cardiac rehabilitation (CR) components. This increased focus and the lessons learned from this period could enhance the implementation of telerehabilitation and increase the participation in CR in Belgium. METHODS: We conducted a survey between April and May 2020 about the implementation of telerehabilitation services during the COVID-19 pandemic. The electronic questionnaire was sent via email to the heads of 42 Belgian CR centres. Three reminders via email were sent during the study period. RESULTS: 27 CR centres (64%) returned completed questionnaires after three mailings. 52% of the CR centres provided remote CR services during the lockdown due to the COVID-19 pandemic. All CR centres that provided remote CR services delivered exercise training. The most used medium to deliver the CR components were online videos (71%) followed by online information on the website (64%) and emails (64%). CONCLUSION: It is interesting that the COVID-19 pandemic has encouraged many CR centres to implement remote delivery of CR components. This can help to speed up the research and implementation of telerehabilitation in daily clinical practice. The COVID-19 pandemic could be the push for a large multicentre implementation study that could prove that telerehabilitation is feasible and effective in the Belgian setting.