A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial.

BACKGROUND: Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. OBJECTIVE: This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app-based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. METHODS: In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients' smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients' usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. RESULTS: Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually. CONCLUSIONS: TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945.

High-intensity interval training for patients with coronary artery disease: Finding the optimal balance.

BACKGROUND: The optimal characteristics of high-intensity interval training (HIIT) for patients with coronary artery disease (CAD) within cardiac rehabilitation (CR) are unclear. We assessed a HIIT protocol designed to balance patient safety, efficacy and enjoyment. METHODS: Twenty-nine patients with CAD completed 6-weeks (× 2 sessions per week) of HIIT within outpatient (phase 2) CR. HIIT comprised 15 repetitions × 30-seconds cycling at ∼85-90% maximum heart rate, interspersed with 30-seconds of active recovery. Key outcomes covered patient safety, efficacy (peak aerobic capacity, body composition, blood pressure and vascular function), and patient adherence and enjoyment. RESULTS: No cardiovascular-related adverse events were reported in relation to HIIT sessions. Patients showed significant improvement in peak aerobic capacity (mean +12%, p < 0.001, effect size d = 0.38), blood pressure (brachial systolic -7mmHg, p < 0.001, d = -0.59) and total body fat (-4%, p < 0.001, d = -0.49). Central adaptations were prominent (aortic systolic BP -5mmHg, p = 0.001, d = -0.50; visceral fat -10%, p = 0.001, d = -0.41). Patient enjoyment of training was high (5.5 out of 7 using the Exercise Enjoyment Scale) and measures of affective state improved following training (assorted p < 0.018). CONCLUSIONS: This HIIT protocol appears safe, effective and enjoyable for patients with CAD within CR. Improved aerobic fitness, blood pressure and body fat levels were observed indicating improved cardiovascular-risk. High patient enjoyment and improved mood suggest the HIIT could be sustainable for patients in the longer-term.

Evaluation of an mHealth-Based Adjunct to Outpatient Cardiac Rehabilitation.

A pilot study was conducted to determine if a smartphone-based adjunct to standard care could increase the completion rate of a cardiac rehabilitation program (CRP). Based on historical completion rates, 66 participants who were about to commence a hospital-based CRP were randomized so that half received three devices embedded with near-field communication, namely, a smartphone [pre-installed with an application (app) designed specifically for cardiac rehabilitation], portable blood pressure monitor, and weight scale while completing the CRP. The completion rate among participants who were randomized to the intervention group was 88%, compared to 67% in the control group ( = 0.038). This combined with the week-to-week frequency with which participants in the intervention group measured their blood pressure ( 5/week) demonstrated the ability of the intervention to increase the proportion of patients who completed the CRP. No significant differences were found between the treatment groups for the measurements taken at baseline and prior to discharge from the CRP. A statistically significant correlation ( = 0.472; = 0.013) was found between the average time participants walked each day (as estimated via the smartphone app) and participants' six minute walking distance (6MWD) before they were discharged from the CRP (a clinically validated measurement).

High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease: A Meta-analysis of Physiological and Clinical Parameters.

INTRODUCTION: Exercise-based cardiac rehabilitation for patients with coronary artery disease (CAD) significantly improves their outcome, although the optimal mode of exercise training remains undetermined. Previous analyses have been constrained by small sample sizes and a limited focus on clinical parameters. Further, results from previous studies have been contradicted by a recently published large RCT. METHOD: We performed a meta-analysis of published randomised controlled trials to compare high intensity interval training (HIIT) and moderate intensity continuous training (MCT) in their ability to improve patients' aerobic exercise capacity (VO2peak) and various cardiovascular risk factors. We included patients with established coronary artery disease without or without impaired ejection fraction. RESULTS: Ten studies with 472 patients were included for analyses (218 HIIT, 254 MCT). Overall, HIIT was associated with a more pronounced incremental gain in participants' mean VO2peak when compared with MCT (+1.78mL/kg/min, 95% CI: 0.45-3.11). Moderate intensity continuous training however was associated with a more marked decline in patients' mean resting heart rate (-1.8/min, 95% CI: 0.71-2.89) and body weight (-0.48kg, 95% CI: 0.15-0.81). No significant differences were noted in the level of glucose, triglyceride and HDL at the end of exercise program between the two groups. CONCLUSION: High intensity interval training improves the mean VO2peak in patients with CAD more than MCT, although MCT was associated with a more pronounced numerical decline in patients' resting heart rate and body weight. The underlying mechanisms and clinical relevance of these results are uncertain, and remain a potential focus for future studies.

Exploring the role of music therapy in cardiac rehabilitation after cardiothoracic surgery: a qualitative study using the Bonny method of guided imagery and music.

BACKGROUND: Cardiac rehabilitation integrates physical, psychological, and vocational strategies to restore and sustain optimal health. OBJECTIVE: An innovative study using music therapy (Bonny Method of Guided Imagery and Music [BMGIM]) explored the experiences of cardiac rehabilitation participants in an outpatient setting at 2 major metropolitan teaching hospitals. METHODS: Commencing 6 to 15 weeks after cardiothoracic surgery, 6 study participants were recruited for 6 weekly music therapy (BMGIM) sessions. Qualitative analysis of the patient narrative within a semiotic framework demonstrated that patients used music therapy to spontaneously explore their recovery process. RESULTS: Five grand themes emerged: (1) looking through the frame, (2) feeling the impact, (3) spiralling into the unexpected, (4) sublime plateau, and (5) rehearsing new steps. The themes related to physical changes, adjustment after surgery, and anticipated lifestyle. CONCLUSIONS: This study demonstrates that music therapy (BMGIM) may be used to access and understand the internal recovery process of postcardiothoracic surgical patients, providing an additional clinical tool to augment the external rehabilitation process.