Treadmill stress testing before starting a home-based online cardiac rehabilitation programme: is it necessary?
Authors: Vila Garcia J , Torremocha Lopez A , Hernandez D , Araujo A , Arranz H , Albadalejo A , Lara Garcia A , Canales Munoz L , Moreno Gomez J R , Castro Conde A 
Published: June 2024

Abstract

Introduction
Cardiac rehabilitation (CR) is one of the most important interventions to reduce mortality after a myocardial infarction and is also beneficial in other cardiovascular (CV) diseases, such as atrial fibrillation (AF) or heart failure (HF). Treadmill exercise testing (TET) before starting a CR programme (CRP) is still considered a standard of care in many centres and plays a role in exercise prescription, especially for those individuals undergoing home-based (HB) CRP, but also constitutes a barrier that limits access to many patients. In particular in March 2020 a lockdown was implemented in most EU countries due to COVID-19, which limited the possibility of performing such TET in our centre.

Purpose
The aim of this research is to prove whether accomplishing an virtual CRP without a prior TET can be considered as safe as an HB CRP in low-risk patients.

Methods
This retrospective observational study included patients who attended a virtual CRP of a tertiary-level hospital between June 1st 2020 and September 22nd 2023 and those who attended a HB CRP from January 1st 2019 and December 31st 2019. Exclusion criteria for HB online CR were left ventricle ejection fraction (LVEF) under 40%, lack of Internet connection and dementia or cognitive impairment.
The virtual CRP included a total of 8 online classes on CV disease, risk factors and lifestyle, as well as a 2-week online exercise programme supervised by a physiotherapist. The on-site CRP had a duration of 6 weeks.
Participants were included in the virtual CRP without a TET or a cardiopulmonary exercise test (CPET).
The primary end point of our study is the incidence of exercise-related adverse events (ERAE) during the duration of the CRP in both groups.

Results
742 patients were included in the virtual CRP. 33 individuals (4.4%) abandoned follow up. 572 individuals (77.1%) were men. The mean age was 60.3 ± 10.6 years. The most frequent indication (84.2%) for CR was ischemic heart disease (IHD). The mean rate of assistance to virtual classes (from those who did not abandon) was 94.2 ± 17%. The mean rate of assistance to training sessions was 96.4 ± 40%. During the CRP follow-up only 1 individual underwent minor complications.
277 patients were included in the HB CRP, from which 21 (7.5%) abandoned. 199 individuals (77.7%) were men. The mean age was 60.87 ± 11.5 years. The most frequent indication (74.2%) for CR IHD. The mean rate of assistance to training sessions was 93.8 ± 11%. 4 individuals underwent minor complications during the CRP follow-up.
No patients underwent ERAE in any of both groups and there were no cases of exercise-related deaths or hospitalizations.

Conclusions
The incidence of ERAE in low-risk patients undergoing HB online CRP seems insignificant. Treadmill tests and CPET are useful in those patients with exercise related CV symptoms but performing them to all patients before the enrolment in a CRP doesn’t seem to be necessary in terms of safety. Basal characteristics of subjects.