Cardiac rehabilitation after myocardial infarction. The costs and benefits of technology-enabled, home-based cardiac rehabilitation measured in a randomised controlled trial Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol Comprehensive cardiac rehabilitation improves the control of dyslipidemia in secondary prevention. The effect of a smartphone-based coronary heart disease prevention (SBCHDP) programme on awareness and knowledge of CHD, stress, and cardiac-related lifestyle behaviours among the working population in Singapore: a pilot randomised controlled trial The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease A Web-Based Program Improves Physical Activity Outcomes in a Primary Care Angina Population: Randomized Controlled Trial Women’s hearts need special treatment Mortality reductions in patients receiving exercise-based cardiac rehabilitation: how much can be attributed to cardiovascular risk factor improvements? A Behavior Change Intervention for Women in Cardiac Rehabilitation Reconciling systematic reviews of exercise-based cardiac rehabilitation and secondary prevention programmes for coronary heart disease High-intensity interval training versus moderate-intensity steady-state training in UK cardiac rehabilitation programmes (HIIT or MISS UK): study protocol for a multicentre randomised controlled trial and economic evaluation The effect of problem-based learning in patient education after an event of CORONARY heart disease – a randomised study in PRIMARY health care: design and methodology of the COR-PRIM study The CHOICE (Choice of Health Options In prevention of Cardiovascular Events) replication trial: study protocol Epidemiology and genetics of sudden cardiac death. A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial Inpatient psychotherapeutic treatment for cardiac patients with depression in Germany - short term results Patterns, predictors and effects of texting intervention on physical activity in CHD – insights from the TEXT ME randomized clinical trial Cost-effectiveness of a coronary heart disease secondary prevention program in patients with myocardial infarction: results from a randomised controlled trial (ProActive Heart) Aerobic exercise-based cardiac rehabilitation in Chinese patients with coronary heart disease: study protocol for a pilot randomized controlled trial Implementing cardiac risk-factor case management: lessons learned in a county health system.
Cardiac rehabilitation/ secondary prevention programs are recognized as integral to the comprehensive care of patients with coronary heart disease ( CHD ) , and as such are recommended as useful and effective ( Class I ) by the American Heart Association and the American College of Cardiology in the treatment of patients with CHD . The term cardiac rehabilitation refers to coordinated , multifaceted interventions design ed to optimize a cardiac patient 's physical , psychological , and social functioning , in addition to stabilizing , slowing , or even reversing the progression of the underlying atherosclerotic processes , thereby reducing morbidity and mortality . Cardiac rehabilitation , aims at returning the patient back to normal functioning in a safe and effective manner and to enhance the psychosocial and vocational state of the patient . The program involves education , exercise , risk factor modification and counselling . A meta- analysis based on a review of 48 r and omized trials that compared outcomes of exercise-based rehabilitation with usual medical care , showed a reduction of 20 % in total mortality and 26 % in cardiac mortality rates , with exercise-based rehabilitation compared with usual medical care . Risk stratification helps identify patients who are at increased risk for exercise-related cardiovascular events and who may require more intensive cardiac monitoring in addition to the medical supervision provided for all cardiac rehabilitation program participants . During exercise , the patients ' ECG is continuously monitored through telemetry , which serves to optimize the exercise prescription and enhance safety . The safety of cardiac rehabilitation exercise programs is well established , and the occurrence of major cardiovascular events during supervised exercise is extremely low . As hospital stays decrease , cardiac rehabilitation is assuming an increasingly important role in secondary prevention . In contrast with its growing importance internationally , there are very few cardiac rehabilitation centers in India at the present moment We conducted a cost benefit analysis of a home telehealth-based cardiac rehabilitation programme compared to the st and ard hospital-based programme .  A total of 120 participants were enrolled in a trial , with 60 r and omised to the telehealth group and 60 r and omised to usual care .  Participants in the telehealth group received a mobile phone , Wellness Diary and a Wellness web portal , with daily text messaging . Participants in the usual care group received the st and ard 6-week hospital-based outpatient cardiac rehabilitation programme , including gym sessions . The cost of delivery by telehealth was slightly lower than for patients attending a rehabilitation service in person . From the provider 's perspective , the telehealth intervention could be delivered for $ 1633 per patient , compared to $ 1845 for the usual care group . From the participant 's perspective , patient travel costs for home rehabilitation were substantially less than for hospital attendance ( $ 80 vs $ 400 ) . Cardiac rehabilitation by telehealth offers obvious advantages and the option should be available to all patients who are eligible for cardiac rehabilitation Background Cardiac rehabilitation ( CR ) is a secondary prevention program that offers education and support to assist patients with coronary heart disease ( CHD ) make lifestyle changes . Despite the benefits of CR , attendance at centre-based sessions remains low . Mobile technology ( mHealth ) has potential to reach more patients by delivering CR directly to mobile phones , thus providing an alternative to centre-based CR . The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours ( for example , physically active , fruit and vegetable intake , not smoking , low alcohol consumption ) over and above usual CR services in New Zeal and adults diagnosed with CHD . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted at two Auckl and hospitals in New Zeal and . One hundred twenty participants will be r and omised to receive a 24-week evidence - and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone ( control ) . The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months , measured using a composite health behaviour score . Secondary outcomes include overall cardiovascular disease risk , body composition , illness perceptions , self-efficacy , hospital anxiety/depression and medication adherence . Discussion This study is one of the first to examine an mHealth-delivered comprehensive CR program . Strengths of the trial include quality research design and in-depth description of the intervention to aid replication . If effective , the trial has potential to augment st and ard CR practice s and to be used as a model for other disease prevention or self-management programs . Trial registryAustralian New Zeal and Clinical Trials Registry : BACKGROUND Secondary prevention is an important goal of cardiac rehabilitation in patients with coronary heart disease ( CHD ) . Dyslipidemia is one of the major risk factors that is important to control to reduce the incidence of future ischemic coronary events . The aim of the present study was to assess whether control of dyslipidemia , in secondary prevention , could be improved by a comprehensive cardiac rehabilitation program . METHODS Fifty-two newly diagnosed hyperlipidemic men , who had experienced a recent CHD event , were separated in two equal groups of 26 patients : group CR+ , in which patients were included in a 2-month cardiac rehabilitation program including an extensive educational program on cardiovascular risk factors , lipids , and diet , and group CR-without any cardiac rehabilitation . Mean age , body mass index , initial levels of total cholesterol , triglycerides , high-density lipoprotein ( HDL ) cholesterol , low-density lipoprotein ( LDL ) cholesterol , and LDL/HDL ratio were not significantly different between the 2 groups . In both groups , each patient was referred to a dietitian and to the same lipidologist to start an appropriate hypolipidemic treatment . Treatment of coronary event , type of hyperlipidemia , and hypolipidemic treatment were not different between the two groups . RESULTS Lipid measurements , performed 3 months after the beginning of the hypolipidemic treatment , showed that patients from the CR+ group , compared with those from the CR-group , had a significantly greater reduction of total cholesterol ( 23 % versus 13 % ; P < 0.001 ) , of LDL cholesterol ( 28 % versus 12 % ; P < 0.001 ) , of LDL/HDL ratio ( 34 % versus 13 % ; P < 0.01 ) and of triglycerides ( 33 % versus 21 % ; P = 0.05 ) . CONCLUSIONS Patients with CHD included in a comprehensive cardiac rehabilitation program showed a significantly better response to the hypolipidemic treatment than patients without cardiac rehabilitation . These results could be attributable to the extensive educational program on secondary prevention performed during cardiac rehabilitation , leading to optimized knowledge on lipid-lowering diet and to improved diet and drug adherence . A secondary prevention educational program must be an important part of any comprehensive cardiac rehabilitation program in patients with CHD Abstract Background Coronary heart disease ( CHD ) is the most prevalent type of cardiac disease among adults worldwide , including those in Singapore . Most of its risk factors , such as smoking , physical inactivity and high blood pressure , are preventable . mHealth has improved in the last decade , showing promising results in chronic disease prevention and health promotion worldwide . Our aim was to develop and examine the effect of a 4-week Smartphone-Based Coronary Heart Disease Prevention ( SBCHDP ) programme in improving awareness and knowledge of CHD , perceived stress as well as cardiac-related lifestyle behaviours in the working population of Singapore . Methods The smartphone app “ Care4Heart ” was developed as the main component of the programme . App content was review ed and vali date d by a panel of experts , including two cardiologists and two experienced cardiology-trained nurses . A pilot r and omised controlled trial was conducted . Eighty working people were recruited and r and omised to either the intervention group ( n = 40 ) or the control group ( n = 40 ) . The intervention group underwent a 4-week SBCHDP programme , whereas the control group were offered health promotion websites only . The participants ’ CHD knowledge , perceived stress and behavioural risk factors were measured at baseline and on the 4th week using the Heart Disease Fact Question naire-2 , Perceived Stress Scale , and Behavioural Risk Factor Surveillance System . Results After the SBCHDP programme , participants in the intervention group had a better awareness of CHD being the second leading cause of death in Singapore ( X2 = 6.486 , p = 0.039 ) , a better overall CHD knowledge level ( t = 3.171 , p = 0.002 ) , and better behaviour concerning blood cholesterol control ( X2 = 4.54 , p = 0.033 ) than participants in the control group . Conclusion This pilot study partially confirmed the positive effects of the SBCHDP programme in improving awareness and knowledge of CHD among the working population . Due to the small sample size and short follow-up period , this study was underpowered to detect significant differences between groups . A full-scale longitudinal study is required in the future to confirm the effectiveness of the SBCHDP programme Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components Background : The CardioFit internet-based expert system was design ed to promote physical activity in patients with coronary heart disease ( CHD ) who were not participating in cardiac rehabilitation . Design : This r and omized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes . Methods : A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and r and omly assigned to either  CardioFit  ( n = 115 ) or  usual care ( n = 108 ) . The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking . They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist . Usual care consisted of physical activity guidance from an attending cardiologist .  Physical activity was measured by pedometer and self-reported over a 7-day period , 6 and 12 months after r and omization . Results : The CardioFit internet-based physical activity expert system significantly increased objective ly measured ( p = 0.023 ) and self-reported physical activity ( p = 0.047 ) compared to usual care . Emotional ( p = 0.038 ) and physical ( p = 0.031 ) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care . Conclusions : Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care . Use of the CardioFit program could extend the reach of rehabilitation and secondary -prevention services Background Angina affects more than 50 million people worldwide . Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population . An Internet-based version could offer a feasible alternative . Objective Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina . Methods We conducted a r and omized controlled trial , recruiting those diagnosed with angina from general practitioners ( GPs ) in primary care to an intervention or control group . Intervention group participants were offered a 6-week Web-based rehabilitation program ( “ ActivateYourHeart ” ) . The program was introduced during a face-to-face appointment and then delivered via the Internet ( no further face-to-face contact ) . The program contained information about the secondary prevention of coronary heart disease ( CHD ) and set each user goals around physical activity , diet , managing emotions , and smoking . Performance against goals was review ed throughout the program and goals were then reset/modified . Participants completed an online  exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room . Participants in the control group continued with GP treatment as usual , which consisted of being placed on a CHD register and attending an annual review . Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessment s. The primary outcome measure was change in daily steps at 6 weeks , measured using an accelerometer . Secondary outcome measures were energy expenditure ( EE ) , duration of sedentary activity ( DSA ) , duration of moderate activity ( DMA ) , weight , diastolic/systolic blood pressure , and body fat percentage . Self-assessed question naire outcomes included fat/fiber intake , anxiety/depression , self-efficacy , and quality of life ( QOL ) . Results A total of 94 participants were recruited and r and omized to the intervention ( n=48 ) or the usual care  ( n=46 ) group ; 84 and 73 participants completed the 6-week and 6-month follow-ups , respectively . The mean number of log-ins to the program was 18.68 ( SD 13.13 , range 1 - 51 ) , an average of 3 log-ins per week per participant . Change in daily steps walked at the 6-week follow-up was + 497 ( SD 2171 ) in the intervention group and –861 ( SD 2534 ) in the control group ( 95 % CI 263 - 2451 , P=.02 ) . Significant intervention effects were observed at the 6-week follow-up in EE ( + 43.94 kcal , 95 % CI 43.93 - 309.98 , P=.01 ) , DSA ( –7.79 minutes , 95 % CI –55.01 to –7.01 , P=.01 ) , DMA ( + 6.31 minutes , 95 % CI 6.01 - 51.20 , P=.01 ) , weight ( –0.56 kg , 95 % CI –1.78 to –0.15 , P=.02 ) , self-efficacy ( 95 % CI 0.30 - 4.79 , P=.03 ) , emotional QOL score ( 95 % CI 0.01 - 0.54 , P=.04 ) , and angina frequency ( 95 % CI 8.57 - 35.05 , P=.002 ) . Significant benefits in angina frequency ( 95 % CI 1.89 - 29.41 , P=.02 ) and social QOL score ( 95 % CI 0.05 - 0.54 , P=.02 ) were also observed at the 6-month follow-up . Conclusions An Internet-based secondary prevention intervention could be offered to those with angina . A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness . Trial Registration International St and ard R and omized Controlled Trial Number ( IS RCT N ) : 90110503 ; http://www.controlled-trials.com/IS RCT N90110503/IS RCT N90110503 ( Archived by WebCite at http://www.webcitation.org/6RYVOQFKM ) Coronary heart disease ( CHD ) is the leading cause of death for both men and women in the Western world . Some studies show that the observed decline in cardiovascular mortality is not as pronounced among women as among men . There is a growing awareness that most earlier studies both on primary and secondary risk factors , diagnosis , prognosis , and rehabilitation have focused mainly on men . Thus , there is a need to develop knowledge about women with CHD and to address gender issues in treatment and rehabilitation strategies . Negative affect and emotions increase risk and may interfere with effective cardiac rehabilitation . Therefore , methods for coping with emotional stress need to be included in treatment regimens after a coronary event . The feasibility of a stress management program for women with CHD was assessed in a pilot study . The program consisted of twenty 2-hr group sessions during 1 year , with 5 to 9 participants per group . The pilot study showed that this treatment program had a low dropout rate and result ed in improvement in quality of life and reduction in stress and symptoms . Further work to optimize psychosocial interventions for women with CHD is needed Background It is unclear how much of the reduction in cardiac mortality in coronary heart disease ( CHD ) patients with exercise training  is the result of direct effects on the heart and coronary vasculature , or to indirect effects , via primary risk factors . Objective The aim of this article was to quantify the cardiac mortality benefits of exercise-based rehabilitation attributable to risk factor reductions versus the direct effects on the heart and vasculature . Methods The IMPACT coronary heart disease model was used to examine the reduction in cardiac mortality attributable to changes in risk factors from a meta- analysis of cardiac rehabilitation r and omized , controlled trials . Patients were receiving rehabilitation following an acute myocardial infa rct ion , angina pectoris or revascularization . Outcomes considered were primary risk factors ( total cholesterol , systolic blood pressure and smoking behaviour ) and cardiac mortality . Results Nineteen exercise-only cardiac rehabilitation trials ( including 2984 patients ) were identified . Across these trials , exercise training reduced pooled cardiac mortality by 28 % ( relative risk , 0.72 , 95 % confidence interval 0.55–0.95 ) , with 30 fewer deaths than in the control group . Applying the CHD model , approximately 17 ( 58 % ) of these 30 fewer deaths were attributable to reductions in major cardiovascular risk factors : 7.1 deaths ( minimum estimate 6.2 , maximum estimate 9.5 ) attributable to an 18 % reduction in smoking prevalence ; 5.9 deaths ( minimum −0.6 , maximum 12.6 ) to a 0.11 mmol/l reduction in cholesterol , and 4.4 deaths ( −1.0 minimum , 6.7 maximum ) to a 2.0 mmHg reduction in systolic blood pressure . Conclusions Approximately half of the 28 % reduction in cardiac mortality achieved with exercise-based cardiac rehabilitation may be attributed to reductions in major risk factors , particularly smoking . Eur J Cardiovasc Prev Rehabil 13:369–374 © 2006 The European Society of There is undeniable evidence for physical and psychosocial benefits of cardiac rehabilitation programs for individuals suffering from coronary heart disease . Yet , fewer women than men are referred to , begin , or complete cardiac rehabilitation programs . The numerous logistical , economic , and motivational barriers to healthy behavior change place women at risk for subsequent CHD events . To close this gender gap and improve outcomes , novel , efficacious , and individualized rehabilitative approaches for women with coronary heart disease are needed . The purpose of this article is to describe a theory-driven behavioral intervention design ed exclusively for women with coronary heart disease . The 12-week intervention is being tested in a r and omized controlled trial involving women referred to a cardiac rehabilitation program .  The tenets of the Transtheoretical Model of behavior change and motivational interviewing guided the development and implementation of the stage-matched , individualized intervention to promote healthy behavior change for women with coronary heart disease . The ongoing trial will examine the efficacy of the intervention on physiological and psychosocial outcomes Findings of systematic review s incorporating meta analysis are by nature hypothesis generating and should be carefully and judiciously interpreted . This need is epitomized by two of the largest review s of interventions to support risk factor reduction after a diagnosis of coronary heart disease ( Table 1 ) . These review s both included r and omized trials published in a similar timeframe ( up to 2003 or 2004 ) that compared the effects of various risk factor reduction programmes for patients with confirmed coronary heart disease to usual care . In 2004 , a Cochrane review found that supervised and unsupervised exercise-based cardiac rehabilitation provided to patients with different forms of coronary heart disease lowered all cause total mortality by 20 % and cardiac mortality by 26 % in 48 trials of 8940 patients . The review ers concluded that there was ‘ no difference in mortality effect between exercise-only cardiac rehabilitation and comprehensive cardiac rehabilitation , or by exercise dose or duration of followup ’ . Also , the exercise-based programmes did not reduce recurrent myocardial infa rct ion and the need for repeat coronary revascularization to statistically significant levels . Around the same time , a second review of 63 trials involving 21,295 patients who had undergone secondary cardiac prevention programmes found reductions of total mortality of 15 % and of acute myocardial infa rct ion of 17 % . However , in contrast to the previous review , the secondary prevention programmes significantly reduced the rate of recurrent heart attacks . Also , benefits did not differ between programmes ‘ that incorporated education and counselling about coronary risk factors with a supervised exercise programme , those that included risk factor education or counselling but no exercise component , and those that consisted of only a structured exercise programme ’ . On first reading , these review s appear to offer different conclusions on effects on cardiovascular morbidity and regarding the benefits of supervised exercise . Either could be cited selectively to support or refute the benefits of exercise programmes for morbidity or to support or refute the incorporation of supervised exercise into services . Why might these different conclusions have come about and how should they be interpreted ? Firstly , it is unlikely that the different conclusions arise from differences in quality as both review s were of high quality as defined by PRISMA criteria and included many of the same trials : 37 of the 48 ( 77 % ) exercise-based trials were included in the 63 ( 59 % ) secondary prevention trials . Rather , issues of statistical power can explain the differences noted in morbidity . The forest plot analyses showed that , although exercise-based programmes in the Cochrane review did not reach statistically significant headline ‘ effect sizes ’ , there was a tendency towards reduced recurrent myocardial infa rct ion and the need for repeat coronary revascularization . The larger review of secondary prevention programmes considered over twice the number of events in the analysis of recurrent myocardial infa rct ion and found that secondary prevention programmes significantly reduced the rate of recurrent heart attacks . Hence , focusing only on the presence or absence of Introduction Current international guidelines for cardiac rehabilitation ( CR ) advocate moderate-intensity exercise training ( MISS , moderate-intensity steady state ) . This recommendation pre date s significant advances in medical therapy for coronary heart disease ( CHD ) and may not be the most appropriate strategy for the ‘ modern ’ patient with CHD .  High-intensity interval training ( HIIT ) appears to be a safe and effective alternative , result ing in greater improvements in peak oxygen uptake ( VO2 peak ) . To date , HIIT trials have predominantly been proof-of-concept studies in the laboratory setting and conducted outside the UK . The purpose of this multicentre r and omised controlled trial is to compare the effects of HIIT and MISS training in patients with CHD attending UK CR programmes . Methods and analysis This pragmatic study will r and omly allocate 510 patients with CHD to 8 weeks of twice weekly HIIT or MISS training at 3 centres in the UK .  HIIT will consist of 10 high-intensity ( 85–90 % peak power output ( PPO ) ) and 10 low-intensity ( 20–25 % PPO ) intervals , each lasting 1 min . MISS training will follow usual care recommendations , adhering to currently accepted UK guidelines ( ie , > 20 min continuous exercise at 40–70 % heart rate reserve ) . Outcome measures will be assessed at baseline , 8 weeks and 12 months . The primary outcome for the trial will be change in VO2 peak as determined by maximal cardiopulmonary exercise testing . Secondary measures will assess physiological , psychosocial and economic outcomes . Ethics and dissemination The study protocol V.1.0 , date d 1 February 2016 , was approved by the NHS Health Research Authority , East Midl and s — Leicester South Research Ethics Committee ( 16/EM/0079 ) . Recruitment will start in August 2016 and will be completed in June 2018 . Results will be published in peer- review ed journals , presented at national and international scientific meetings and are expected to inform future national guidelines for exercise training in UK CR . Trial registration number NCT02784873 ; pre- results Background Even though there is convincing evidence that self-care , such as regular exercise and /or stopping smoking , alters the outcomes after an event of coronary heart disease ( CHD ) , risk factors remain . Outcomes can improve if core components of secondary prevention programmes are structurally and pedagogically applied using adult learning principles e.g. problem-based learning ( PBL ) . Until now , most education programs for patients with CHD have not been based on such principles . The basic aim is to discover whether PBL provided in primary health care ( PHC ) has long-term effects on empowerment and self-care after an event of CHD . Methods / Design A r and omised controlled study is planned for patients with CHD . The primary outcome is empowerment to reach self-care goals . Data collection will be performed at baseline at hospital and after one , three and five years in PHC using quantitative and qualitative method ologies involving question naires , medical assessment s , interviews , diaries and observations . R and omisation of 165 patients will take place when they are stable in their cardiac condition and have optimised cardiac medication that has not substantially changed during the last month . All patients will receive conventional care from their general practitioner and other care providers . The intervention consists of a patient education program in PHC by trained district nurses ( tutors ) who will apply PBL to groups of 6–9 patients meeting on 13 occasions for two hours over one year . Patients in the control group will not attend a PBL group but will receive home-sent patient information on 11 occasions during the year . Discussion We expect that the 1-year PBL-patient education will improve patients ’ beliefs , self-efficacy and empowerment to achieve self-care goals significantly more than one year of st and ardised home-sent patient information . The assumption is that PBL will reduce cardiovascular events in the long-term and will also be cost-effective compared to controls . Further , the knowledge obtained from this study may contribute to improving patients ’ ability to h and le self-care , and furthermore , may reduce the number of patients having subsequent CHD events in Sweden . Trial registration Background Although morbidity and mortality from coronary heart disease ( CHD ) are high , only a minority of acute coronary syndrome ( ACS ) survivors accesses an effective secondary prevention program . We aim to determine whether the previously proven CHOICE program can be replicated at multiple sites and whether ongoing reinforcement further improves risk factor modification . Methods / design Participants eligible for but not accessing st and ard cardiac rehabilitation will be r and omly allocated to either a previously tested 3-month CHOICE program or a 30-month CHOICE program ( CHOICE-plus ) .  Both groups will participate in individualised risk factor modules of differing duration that involve choice , goal setting and telephone follow-up for three months . CHOICE-plus will also receive additional face-to-face and telephone reinforcement between three and 30 months . At one site we will recruit a r and omised control group , receiving conventional care . Primary outcomes are lipid levels , blood pressure , physical activity levels and smoking rates . Secondary outcomes include readmission rates , death , the number of risk factors , other modifiable risk factors , quality of life and process evaluation measures over three years . Discussion We present the rationale and design of a multi-centre , replication study testing a modular approach for the secondary prevention of CHD following an ACS.Trial Registration [ Clinical Trial Registration Number , ACTRN12608000182392 Sudden cardiac death ( SCD ) generally refers to an unexpected death from a cardiovascular cause in a person with or without preexisting heart disease . The specificity of this definition varies depending on whether the event was witnessed ; however , most studies include cases that are associated with a witnessed collapse , death occurring within 1 hour of an acute change in clinical status , or an unexpected death that occurred within the previous 24 hours.1–3 Further , sudden cardiac arrest describes SCD cases with resuscitation records or aborted SCD cases in which the individual survived the cardiac arrest . The incidence of SCD in the United States ranges between 180 000 and 450 000 cases annually.4 These estimates vary owing to differences in SCD definitions and surveillance methods for case ascertainment.4,5 In recent prospect i ve studies using multiple sources in the United States,6,7 Netherl and s,8 Irel and , 9 and China,10 SCD rates range from 50 to 100 per 100 000 in the general population .3 Despite the need for multiple sources of surveillance to provide a more accurate estimate of SCD incidence , it is clear that the overall burden in the population remains high . Although improvements in primary and secondary prevention have result ed in substantial declines in overall coronary heart disease ( CHD ) mortality over the past 30 years,11,12 SCD rates specifically have declined to a lesser extent.13–16 SCD still accounts for > 50 % of all CHD deaths and 15 % to 20 % of all deaths.17,18 For some segments of the population , rates are not decreasing19 and may actually be increasing.14,19 As a result , SCD prevention represents a major opportunity to further reduce mortality from CHD . Despite major advances in cardiopulmonary resuscitation20 and postresuscitation care , survival Background Coronary heart disease ( CHD ) and depression are leading causes of disease burden globally and the two often co-exist . Depression is common after Myocardial Infa rct ion ( MI ) and it has been estimated that 15 - 35 % of patients experience depressive symptoms . Co-morbid depression can impair health related quality of life ( HRQOL ) , decrease medication adherence and appropriate utilisation of health services , lead to increased morbidity and suicide risk , and is associated with poorer CHD risk factor profiles and reduced survival . We aim to determine the feasibility of conducting a r and omised , multi-centre trial design ed to compare a tele-health program ( MoodCare ) for depression and CHD secondary prevention , with Usual Care ( UC ) . Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome ( ACS ) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensl and . Consenting participants are then contacted at two weeks post-discharge for baseline assessment . One hundred eligible participants are to be r and omised to an intervention or a usual medical care control group ( 50 per group ) . The intervention consists of up to 10 × 30 - 40 minute structured telephone sessions , delivered by registered psychologists , commencing within two weeks of baseline screening . The intervention focuses on depression management , lifestyle factors ( physical activity , healthy eating , smoking cessation , alcohol intake ) , medication adherence and managing co-morbidities . Data collection occurs at baseline ( Time 1 ) , 6 months ( post-intervention ) ( Time 2 ) , 12 months ( Time 3 ) and 24 months follow-up for longer term effects ( Time 4 ) . We are comparing depression ( Cardiac Depression Scale [ CDS ] ) and HRQOL ( Short Form-12 [ SF-12 ] ) scores between treatment and UC groups , assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects . A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion This manuscript presents the protocol for a r and omised , multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients . The results of this trial will provide valuable new information about potential psychological and wellbeing benefits , cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression . Trial Registration NumberAustralia and New Zeal and Clinical Trials Register ( ANZCTR ) : Background Cardiac rehabilitation improves health-related quality of life ( HRQoL ) and reduces hospitalizations in patients with heart failure , but international uptake of cardiac rehabilitation for heart failure remains low . Design and methods The aim of this multicentre r and omized trial was to compare the REACH-HF ( Rehabilitation EnAblement in CHronicHeart Failure ) intervention , a facilitated self-care and home-based cardiac rehabilitation programme to usual care for adults with heart failure with reduced ejection fraction ( HFrEF ) . The study primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL ( Minnesota Living with Heart Failure question naire ( MLHFQ ) ) at 12 months compared with usual care alone . Results The study recruited 216 participants , predominantly men ( 78 % ) , with an average age of 70 years and mean left ventricular ejection fraction of 34 % . Overall , 185 ( 86 % ) participants provided data for the primary outcome . At 12 months , there was a significant and clinical ly meaningful between-group difference in the MLHFQ score of –5.7 points ( 95 % confidence interval –10.6 to –0.7 ) in favour of the REACH-HF intervention group ( p = 0.025 ) . With the exception of patient self-care ( p < 0.001 ) there was no significant difference in other secondary outcomes , including clinical events ( p > 0.05 ) at follow-up compared with usual care . The mean cost of the REACH-HF intervention was £ 418 per participant . Conclusions The novel REACH-HF home-based facilitated intervention for HFrEF was clinical ly superior in disease-specific HRQoL at 12 months and offers an affordable alternative to traditional centre-based programmes to address current low cardiac rehabilitation uptake rates for heart failure The purpose of the PROTeCD(Psychotherapeutic Re source -Orientated Treatment for Cardiac Patients with Depression)- study was to develop and to evaluate a brief psychotherapeutic intervention for rehabilitation in- patients with coronary heart disease ( CHD ) and depressive disorders . In three cardiac rehabilitation hospitals all patients were screened for mental distress at admission . Patients generally stay for 3 to 4 weeks before being referred to outpatient care . Method : Those patients with elevated distress were interviewed for mental disorders and took part in the baseline- assessment . Patients diagnosed with a depressive disorder at baseline were r and omised into the intervention or the usual care group .  Efficacy was assessed at discharge from hospital ( short-term ) . 59 subjects with CHD and co-morbid depressive disorder were r and omised into the trial - 27 into the intervention group ( IG ) and 32 into the usual care group ( UC ) . Patients in the intervention group received 4 to 6 individual psychotherapeutic sessions of 50 minutes each , including patient education and cognitive-behavioural treatment of depression . Outcome measures were depressive and anxiety symptoms in self report and interview . Results : There was no significant difference between intervention and usual care group in this short-term reduction of depressive symptoms , mental distress and anxiety . However , at discharge the patients still suffer from an increased level of distress compared to the recommended cut off scores of the assessment scales . Conclusion : Multimodal inpatient rehabilitation reduces depressive and anxiety symptoms in depressed CHD patients in short term independently of an additional psychotherapeutic intervention Background Mobile phone text message interventions are used to support behaviour change including physical activity , but we have less insight into how these interventions work and what factors predict response . Aims To study the effect of TEXT ME ( Tobacco EXercise and dieT Messages ) text message intervention on physical activity domains , consistency of effects across sub-groups and its additive value in patients that received traditional cardiac rehabilitation programme . Methods This is a secondary analysis of the TEXT ME , a r and omized clinical trial of lifestyle-focused text message intervention compared with usual care in patients with coronary heart disease . A quarter of the messages were design ed specifically to encourage physical activity . Sedentary time and physical activity were assessed using the Global Physical Activity Question naire . Results At baseline , 85 % of the 710 participants reported low physical activity levels . At six months , compared with controls , the intervention arm reported higher recreational physical activity ( 471 vs. 307 metabolic equivalent-min/week , p = 0.001 ) and travel physical activity ( 230 vs. 128 MET-min/week , p = 0.002 ) , similar work-related physical activity and lower sedentary times ( 494 vs. 587 min , p < 0.001 ) . Male gender , high baseline physical activity , cardiac rehabilitation participation and text message intervention predicted physically active status at six months . Subjects that received both cardiac rehabilitation and text messaging intervention were more likely to achieve target physical activity levels compared with cardiac rehabilitation alone ( odds ratio 7.07 vs. 1.80 , p < 0.001 ) . Conclusions The TEXT ME intervention improved recreational and travel physical activity , reduced sedentary times but had no effects on work-related physical activity . It had incremental benefits at achieving target physical activity levels even in patients participating in the traditional cardiac rehabilitation programme Background Participation in coronary heart disease ( CHD ) secondary prevention programs is low . Telephone-delivered CHD secondary prevention programs may overcome the treatment gap . The telephone-based health coaching ProActive Heart trial intervention has previously been shown to be effective for improving health-related quality of life , physical activity , body mass index , diet , alcohol intake and anxiety . As a secondary aim , the current study evaluated the cost-effectiveness of the ProActive Heart intervention compared to usual care . Methods 430 adult myocardial infa rct ion patients were r and omised to a six-month  CHD secondary prevention ‘ health coaching ’ intervention or ‘ usual care ’ control group . Primary outcome variables were health-related quality of life ( SF-36 ) and physical activity ( Active Australia Survey ) . Data were collected at baseline , six-months ( post-intervention ) and 12 months ( six-months post-intervention completion ) for longer term effects . Cost-effectiveness data [ health utility ( SF-6D ) and health care utilisation ] were collected using self-reported ( general practitioner , specialist , other health professionals , health services , and medication ) and cl aims data ( hospitalisation rates ) . Intervention effects are presented as mean differences ( 95 % CI ) , p-value . Results Improvements in health status ( SF-6D ) were observed in both groups , with no significant difference between the groups at six [ 0.012 ( -0.016 , 0.041 ) , p = 0.372 ] or 12 months [ 0.011 ( -0.028 , 0.051 ) p = 0.738 ] . Patients in the health coaching group were significantly more likely to be admitted to hospital due to causes unrelated to cardiovascular disease ( p = 0.042 ) . The overall cost for the health coaching group was higher ( $ 10,574 vs. $ 8,534 , p = 0.021 ) , mainly due to higher hospitalisation ( both CHD and non-CHD ) costs ( $ 6,841 vs. $ 4,984 , p = 0.036 ) . The incremental cost-effectiveness ratio was $ 85,423 per QALY . Conclusions There was no intervention effect measured using the SF-36/SF-6D and ProActive Heart result ed in significantly increased costs . The cost per QALY gained from ProActive Heart was high and above acceptable limits compared to usual care Background Cardiovascular disease is the leading cause of morbidity and mortality in the world , including China . Cardiac rehabilitation ( CR ) has been demonstrated to be beneficial in reducing cardiovascular mortality , myocardial infa rct ion , and cerebrovascular events . This pilot study seeks to assess the feasibility of aerobic-exercise-based CR in Chinese patients with coronary heart disease ( CHD ) and outcomes of aerobic metabolism capacity and molecular biomarkers . Methods / design This study is a single-center , pilot , r and omized , controlled study that is currently being carried out at a regional hospital in Shanghai . Forty patients with CHD who underwent percutaneous coronary intervention will be r and omly allocated into either the intervention group or control group . Participants in the intervention group will undergo 8 weeks of aerobic exercise with targeted intensity and participants in the control group will undergo 8 weeks of leisure exercise . The primary measurement is the feasibility of the trial ; the secondary measurement is the capacity of aerobic metabolism and the exploratory measurement includes additional molecular biomarkers underlying cardiovascular function . Discussion This is the first prospect i ve r and omized and controlled clinical study in China that assesses the parameters of aerobic metabolism and comprehensively screens for substantial blood biomarkers to reveal the molecular mechanisms underlying changes in cardiovascular function after aerobic exercise with targeted intensity in participants with CHD . The success of this study will contribute to guide the design of future CR studies in patients with CHD in China . Trial registration Chinese Clinical Trial Registry , ChiCTR-IPR-17010556 . Registered on 1 June 2016 METHODS Case-management ( CM ) can positively influence chronic disease care by facilitating guideline -concordant interventions that improve outcomes through intensive , individualized , longitudinal care . Implementation of CM , however , is difficult . We have identified lessons learned from a cardiovascular risk reduction CM program that may aid future CM implementation . INTRODUCTION Heart to Heart is both a clinical trial and program dissemination project implementing CM for persons at elevated risk of coronary heart disease ( CHD ) events in a multiethnic , low-income population in a county health system . Patients were r and omized to CM plus usual primary care ( N = 212 ) or primary care alone ( N = 207 ) . CM  patients received face-to-face nurse and dietitian visits ( mean of 14 hours ) over 17 months . Visits emphasized behavior change , risk-factor monitoring , and guideline -based pharmacotherapy . A total of 341 patients ( 81 % ) were available for follow-up . This CM model is currently transitioning to a County-run program . RESULTS Findings demonstrated statistically significant reductions in mean Framingham Risk for CM versus usual primary care ( 1.56 % absolute decrease in 10-year CHD risk , P = 0.007 ) . Favorable changes were noted across most major CHD risk factors . Lessons learned are the need for the following : ( 1 ) Strategies for implementing CM in low-income , ethnically-diverse population s , ( 2 ) Methods for developing clinical ly more effective CM , and ( 3 ) Approaches to increase the  efficiency of cardiovascular CM . CONCLUSIONS CM for cardiac risk factors faces notable implementation barriers , particularly in County health systems . Specific implementation solutions recommended may help confront these barriers and improve diffusion of this evidence -based and patient centered model of care
Conclusions : Telehealth interventions with a range of delivery modes could be offered to patients who can not attend cardiac rehabilitation , or as an adjunct to cardiac rehabilitation for effective secondary prevention
Background : Coronary heart disease ( CHD ) is a major cause of death worldwide .
Cardiac rehabilitation , an evidence -based CHD secondary prevention programme , remains underutilized .
Telehealth may offer an innovative solution to overcome barriers to cardiac rehabilitation attendance .
We aim ed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and /or usual care for patients with CHD .