Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care



## Current status of cardiac rehabilitation during covid-19
Before the COVID-19 pandemic, CR remained a significantly underused resource with up to 75% to 80% of eligible patients not participating. [bib_ref] Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular..., Thomas [/bib_ref] [bib_ref] Ensuring cardiac rehabilitation access for the majority of those in need: a..., Grace [/bib_ref] Although the the majority of Canadian CR care appears to have been delivered as CBCR, up to w80% of programs offered an alternative to CBCR delivery as well. [bib_ref] Ensuring cardiac rehabilitation access for the majority of those in need: a..., Grace [/bib_ref] This included home-based, communitybased, or a hybrid model of initially supervised encounters transitioning to unsupervised settings. Smartphones, "apps," or text messaging have been employed to some degree in approximately w30% of programs. The degree to which more extensive VCR programs exist in Canada has not been elicited.
Patient participation in VCR is determined by eligibility criteria based on risk stratification for cardiac events and patient factors such as access to required technology and selfmotivation. The majority of VCR programs limit participation to low-to moderate-risk patients, with higher-risk patients enrolled in CBCR. Graded exercise testing (GXT) is used to inform the risk-stratification process.
During the COVID-19 pandemic, up to 50% of all Canadian CR programs have ceased providing any care (unpublished data, personal communication, Dr Paul Oh). Those that continued to provide care were adapted by labour-intensive telephone interviews in response to a lack of in-person intake assessments, a potential inability to perform routine GXT risk-stratification, and a lack of inperson exercise monitoring for those deemed to be at high risk of cardiac events. These programs have also innovated using a virtual model to deliver all other CR care components.

## Care-delivery challenges and obstacles
There are several specific areas of concern surrounding the transition todand the delivery ofdVCR. These include challenges faced owing to resource limitations, loss of inperson interactions, difficulties with risk stratification and supervision, and a lack of specific VCR delivery standards (Supplemental . The notion of VCR safety requires greater scrutiny, particularly in older and frail cardiovascular patients with comorbid illnesses.
During the initial implementation phases of VCR, centres face possible CR staff redeployment because of COVID-19erelated issues; a potential lack of centre and patient experience with virtual care delivery; and uncertain access to affordable, effective technologies. Limited access to technology or a lack of technology literacy has the potential to exacerbate care-delivery gaps in vulnerable populations including the elderly, those of lower socioeconomic status, and those living in rural settings.
Furthermore, a lack of evidence exists for entirely virtual programs (ie, without any access to in-person intake assessments, the absence of risk stratification by GXT, and the inclusion of high-risk patients). This makes the identification and enrollment of high-risk patients particularly challenging, as intake GXT followed by clinical and electrographic monitoring to provide safe and effective exercise therapy are mainstays of CR delivery for this population. Without an intake GXT, exercise prescription must rely on estimates and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time. subjective measures, although the use of wearables may provide reasonable estimates on target heart rate guidance for exercise.

## Implementing virtual cardiac rehabilitation
The protection of CR staff and patients from undue risk of nosocomial infection and the potential limited availability and use of personal protective equipment resources should remain primary considerations during all stages of the implementation process of VCR. Implementation should focus initially on the collation, use, and repurposing of existing resources, equipment, and technology over complex restructuring. This will allow for rapid delivery to mitigate the negative impact of a lack of CR in at-risk cardiovascular populations.

## Program goals
Centres should initially prioritize basic, safe, and timely care over complex and comprehensive care, particularly for those with no previously established virtual program Step 1). Once a program is established, the focus should shift to ensuring that traditional CR care delivery standards are met, protocolized patient assessment and follow-up are defined, and workflow is optimized . Program evaluation should comprise, at a minimum, referral reason, CR intake and discharge dates, and data elements to assess adherence to Canadian Association of Cardiovascular Prevention and Rehabilitation (CACPR) Quality Indicators. [bib_ref] Pan-Canadian development of cardiac rehabilitation and secondary prevention quality indicators, Grace [/bib_ref] Once the preliminary establishment and quality assurance mechanisms are in place, centres should seek appropriate resources and supportive technologies to enhance care delivery and should aim to develop robust and sustainable VCR solutions not only to continue to provide high-quality care during the COVID-19 pandemic but also to address care gaps that may have existed before the pandemic .

## Eligible patients
All patients eligible for conventional CBCR should be considered for participation in VCR in some capacity and ideally should include a component of exercise training. This includes patients previously excluded from VCR programs before the COVID-19 pandemic. Examples include patients at high risk of events (exercise-induced or otherwise), those with limited access to technology, vulnerable populations, the elderly, those of low socioeconomic status, and those in rural locations. Appropriate measures are required to ensure that the implementation of VCR does not widen gaps in care for these vulnerable populations. Programs with limited resources may require regular phone interactions and educational mailouts if the required technology is not available. Individual programs may also consider purchasing tablets, smart phones, or other electronic options for loan to participants to enhance a one-on one personalized experience. Enlisting family members to assist in effective communication for those who are technologically disadvantaged can be beneficial.

## Risk stratification and exercise prescription
The risk of a severe exercise-related cardiovascular event is extremely rare during CR. Current evidence would suggest similar safety profiles exist for VCR compared with CBCR. [bib_ref] Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular..., Thomas [/bib_ref] However, the evidence for those deemed at higher risk is more limited and therefore requires a cautious approach.
Risk stratification for CR participation has traditionally relied heavily on symptom-limited GXT to assess for the presence of high-risk features such as abnormal hemodynamic responses, silent or residual ischemia, dysrhythmias, exerciseinduced symptoms, and low functional capacity. The presence of these GXT findings, or other clinical parameters such as a reduced left ventricular ejection fraction (< 40%), would have previously precluded patients from at least initial participation in home or VCR programs (Supplemental Resources and References). With the alternative, however, being no CR during the current pandemic, the risk of excluding these high-risk patients compared with the accrued benefits of appropriately prescribed physical activity should be carefully balanced and a shared decision-making process undertaken. Therefore, given the important role of GXT, it should be performed under safe conditions when at all possible and clinically indicated, including for new patient intakes. When not available, increased emphasis should be placed on clinical assessment and alternate methods of obtaining functional capacity (eg, Duke Activity Status Index and selfadministered 6-minute walk test). [bib_ref] Assessment of functional capacity in clinical and research settings: a scientific statement..., Arena [/bib_ref] This includes the potential use of smartphone applications and wearable technology (Supplemental Resources and References). Although these methods cannot replace GXT, they may provide a baseline metric of functional capacity and help to guide initial prescription for exercise. In the absence of standard risk-stratification methods and available in-person monitoring, exercise prescriptions for home-based exercise should be conservative and titrated slowly, particularly for high-risk patients. The target should be the minimal level of physical activity required to obtain the required health benefit, and exercise intensity should not exceed moderate levels of intensity. Patient education on symptom and intensity assessment is therefore paramount. Patient-driven intensity assessment can be achieved by heartrate palpation, use of available wearable heart-rate monitors, and the talk test (Supplemental Resources and References). outlines further practical tips that may be of value in the establishment process.

## Planning for the ebb and flow of an uncertain future
The COVID-19 pandemic is likely to result in varying degrees of disruption of care for the foreseeable future. Once a VCR program has been established, centres should plan for an ebb and flow of care-delivery restrictions that are likely to follow the COVID-19 pandemic trajectory. Programs should also embrace the development of sustainable VCR solutions to account for care gaps that existed before the COVID-19 pandemic by planning to use the virtual care skills and infrastructure acquired to implement hybrid CR models when physical distancing recommendations eventually ease. Further guidance on planning for the different levels of restrictions on care is included in Supplemental .

# Funding sources