Please select the eligibility criteria that correspond to the clinical trial below.
Title: Randomized Trial of a Cardiac Rehabilitation Program Delivered Remotely Through the Internet
Brief Summary: Cardiac rehabilitation programs (CRP) are a proven treatment for those with ischemic heart disease (IHD). These programs have been demonstrated to improve adherence to regular physical activity, a healthy diet and smoking cessation, as well as modify risk factors for IHD such as hypercholesterolemia, hypertension, obesity and type 2 diabetes. In addition, CRP are cost effective and can result in a 25% reduction in reoccurrence of mortality. Despite the known benefits of CRP, as little as 10% to 25% of eligible patients attend these programs. One of the main barriers to attendance is proximity to a CRP, as the majority of these programs are limited to hospitals in large urban areas. However, cardiovascular diseases do not discriminate by geography, resulting in a geographic inequity of care for patients living in rural, remote and smaller urban/sub-urban centres. Currently there are no CRP specifically designed for patients in rural and remote areas. The use of the Internet may present itself as a viable alternative. We have recently completed a pilot study of a virtual CRP (vCRP) that demonstrated significant improvements in exercise capacity and risk factors. This investigation will study the vCRP in a group of IHD patients who do not have access to hospital-based CRP.

Hypotheses A. Participation in a 4 month Internet-based cardiac rehabilitation program will result in significant improvements in exercise capacity compared to usual care, in patients with diagnosed IHD.

B. Participation in a 4 month Internet-based cardiac rehabilitation program will result in significant improvements in exercise capacity after one year compared to usual care, in patients with diagnosed IHD.

Study Population Men and women over 18 years will be identified from consecutive in-patients of the British Columbia Provincial Heart Centre at St. Paul's Hospital in Vancouver who reside in either the Northern Interior or Coast Garibaldi health areas. Patients will be eligible if they have IHD, Internet access, no previous experience with cardiac rehabilitation and no physical limitations to exercise. A total of 74 patients (37 per group) will be recruited and randomized to either usual care, or a 4 month 'virtual' cardiac rehabilitation program delivered via the Internet.

Usual Care Group Patients randomized to usual care will be provided with simple guidelines for safe exercising and healthy eating habits, and return to the care of their primary care physician. Patients will return at 4 and 16 months later for outcome assessment. There will be no contact between the study personnel and usual care patients for the duration of the study, nor will there be any attempt to control the level of patient care.

Intervention The vCRP has been developed to mimic hospital-based CRP and includes online intake forms, one-on-one chat sessions with vCRP nurse, dietitian and exercise specialist, data collection (exercise heart rate, blood pressure, glucose- if diabetic), peer-support group chat sessions, ask-an-expert chat sessions, education, progress reports and online resources. Upon randomization to the intervention, patients will receive access to the website, a heart rate monitor and a blood pressure monitor and trained in their use. The heart rate monitors allow for exercise heart rate data to be stored and downloaded to their home computer and then uploaded to the vCRP webserver. The exercise data will be reviewed weekly. A letter to the patient's primary care physician will be sent to outline the vCRP intervention, the treatment algorithms to be used and indicate under what circumstances the vCRP nurse and/or patient may contact them with regards to their management. Patients will receive one-on-one counselling by the nurse, dietitian and exercise specialist via chat sessions at 3 to 4 week intervals. After the 4 month intervention, patients will be discharged into the care of their primary care physician.

Outcomes Participants will be assessed at baseline, 4 and 16 months for risk factors and lifestyle behaviours. The primary outcomes will be the change in exercise capacity as between the two groups from baseline to 4 months, and from baseline to 16 months. Exercise capacity will be assessed as total time on a symptom-limited exercise stress test.


Options:
A: Inclusion Criteria:

* Age 20 to 80 years
* English Proficiency
* Internet Access (home or work)
* Documented CAD (most recent cardiac diagnosis); documented Myocardial Infarction (MI), successful PCI procedure

Exclusion Criteria:

* Patient intends to enroll in structured cardiac rehabilitation
* Hospitalization for Coronary Artery Bypass (CABG)
* Hospitalization for diagnostic procedure not associated with previously documented MI
* Patient coming back to hospital for planned staged PCI within 6 months
* Cardiac transplantation
* Presence of, or hospitalization for defibrillator implant
* Hospitalization for pacemaker implantation
* Unresolved unstable angina \&/or hospitalization for angina (without MI or PCI)
* Uncontrolled arrhythmias causing symptoms or hemodynamic compromise
* Neuromuscular, musculoskeletal or rheumatoid disorders that are exacerbated by exercise
* Other uncontrolled metabolic conditions (e.g. diabetes)
* Chronic infectious diseases such as mononucleosis, hepatitis, AIDS
* Acute systematic illness or fever
* Uncontrolled tachycardia (\<120 bpm)
* Uncompensated congestive heart failure (\&/or NYHA Class III, or IV)
* 3rd degree AV block without pacemaker
* Active pericarditis or myocarditis
* Recent embolism
* Suspected or known AAA aneurysm \> 4cm
* Uncontrolled hypertension (SBP \> 200; DBP \> 110)
* Pregnancy
B: Inclusion Criteria:

All of them:

* Age ≤ 80 years.
* Stable Ischemic heart disease, revascularized by angioplasty or underwent surgery by coronary bypass \<= one year from the acute episode.
* Good cognitive level.
* Ability to perform aerobic exercise tape or cycle ergometer.
* Understand the use of a mobile Smartphone or Tablet.
* Signature of informed consent.

And at least one of the following:

* Ventricular dysfunction by Ejection Fraction (FE) 40 - 50%.
* Functional capacity 5-7 metabolic equivalents (METS).
* Raising the blood pressure with the effort.

Exclusion Criteria:

* Presence of malignant arrhythmias such as ventricular fibrillation outside the acute phase of Acute myocardial infarction (AMI) (\> 24 h after AMI), ventricular tachycardia, Atrioventricular block of 2nd degree and 3rd degree, Atrial fibrilation (FA) in patients with Wolf Parkinson White, fibrillation or paroxysmal atrial flutter with response ventricular quickly and hemodynamic deterioration, premature ventricular contractions increases during exertion, paroxysmal supraventricular tachycardia uncontrolled.
* Previous infarcts.
* Hypotensive response to exercise.
* Myocardial Ischemia valued at exercise test.
* Unstable Angina.
* Nonrevascularizable disease.
* Poorly controlled hypertension baseline.
* Killip III and IV Killip.
* No collaborator.
* Valvular heart disease associated.
* Pacemaker or Implantable Cardioverter Defibrillator.
* Pathology of musculoskeletal, neurological or breathing that impair the ability of prolonged ambulation.
C: Inclusion Criteria:

* coronary artery disease
* age over 18
* referred to cardiac rehabilitation
* exercise tolerance demonstrated

Exclusion Criteria:

* severe arrhythmia
* heart failure
* drug abuse
* pregnancy
D: Inclusion Criteria:

1. Men and women admitted for an IHD event (acute coronary syndrome or revascularization procedure) who are at low or moderate risk.91
2. Regular Internet access (home, work or other environment).
3. Over 18 years of age.
4. Permission of the attending physician.
5. Able to read, write and understand English without difficulty.
6. No physical limitations to regular activity.

Exclusion Criteria:

1. Previous experience with a cardiac rehabilitation program.
2. Patients with depression, uncontrolled diabetes and other significant co-morbidities that may interfere with effective IHD management.
3. Those patients, who in the mind of the attending physician, are unsuitable for participation.
4. Those unable to provide informed consent.
5. Pregnant women.
6. High-risk patients for safety considerations (future studies will include high-risk patients).

Answer: D