Taking cardiac rehabilitation to the doctor's office: a rule-based exercise prescription tool using cdss for phase iii cardiac rehabilitation
Authors: Sestayo Fernandez M , Chondromatidou L , Notas G , Gatsios D , Tsakanikas V , Marias K , Fotiadis D I , Pena Gil C , Gonzalez-Juanatey J R , Mooren F C , Schmitz B 
Published: June 2024

Abstract

Background/Introduction
Exercise-based cardiac rehabilitation (CR) is an integral component in the management of coronary artery disease (CAD). While the efficacy of CR in reducing cardiovascular mortality and hospitalizations is well-established, challenges persist in the individualization of guideline-based exercise (re-)prescriptions. Decision Support Systems (DSS) may assist cardiologists and general practitioners (GPs), in particular during phase III CR maintenance, to prescribe effective exercise programs to CAD patients.

Purpose
To develop a tool that enables GPs and other healthcare professionals (HPs) to generate informed, safe, and personalized exercise prescriptions based on current ESC guidelines for CAD patients in phase III CR.

Methods
Within the scope of the EU-funded project "TIMELY", we have developed the Rule-Based Exercise Prescription Tool (REPT), a DSS aligned with the ESC Guidelines on Exercise Prescription. A Knowledge Base (KB) was generated based on extracted rules from textual guidelines. The system integrated 112 rules, encoded, and organized to be both human-readable and machine-interpretable to facilitate active participation, extensibility, and error-proofing by HPs involved in the system's design using a Delphi approach. Since various medical conditions, comorbidities and medication need to be considered, REPT was split into two functionalities: the Permissibility Report (PR), generating a report with patient-specific exercise limitations based on medical history, and the Exercise Prescription (EP) which formulates weekly exercise plans tailored to these limitations. The programmed REPT algorithm includes a compilation of activated rules, the tabulation of PRs, and the parameter-level comparison. A representative sample of 12 patients was used to generate PRs and EPs, which were evaluated by HPs from four different countries.

Results
Upon input of patient data, the PR automatically generates permissible exercise volume, cautionary insights, suitable sports disciplines, and proficiency levels. The EP functionality suggests an initial exercise program and weekly progressions, considering limitations from the PR. Activity calories are used to define weekly goals. The output is a comprehensive report for endurance and resistance exercise according to the FITT criteria, encompassing minimum/maximum values for weekly frequency, intensity, and duration. The REPT was implemented in a remotely operated integrative care platform to produce a PR to health care professionals. HPs completely/mostly agreed with generated PRs and EPs in terms of safety and guideline consistency (95%) and indicated usability in real life (84%).

Conclusion
REPT is a safe and useful DSS to assist cardiologists and GPs to bring guideline-based and individualized exercise prescription to CAD patients during phase III CR. Its implementation could help to improve secondary prevention in CAD patients across Europe.