The evolving mHealth-based cardiac rehabilitation
Authors: Wenru Wang, Ying Jiang
Journal: The Lancet Digital Health (2019)

Coronary heart disease is the most common type of cardiovascular disease and, despite efforts in primary and secondary prevention, it remains the main cause of death and disability in many countries. Cardiac rehabilitation is a comprehensive intervention that uses a multidisciplinary approach with a variety of components, including medical and lifestyle risk-factor management, patient education, exercise training, psychosocial support, and behavioural change counselling.1Anderson L Sharp GA Norton RJ et al.Home-based versus centre-based cardiac rehabilitation.Cochrane Database Syst Rev. 2017; 1CD007130Google Scholar, 2Rawstorn JC Gant N Direito A Beckmann C Maddison R Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis.Heart. 2016; 102: 1183-1192Crossref PubMed Scopus (172) Google Scholar Cardiac rehabilitation is an essential part of coronary heart disease management3Smith Jr, SC Benjamin EJ Bonow RO et al.AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association.J Am Coll Cardiol. 2011; 58: 2432-2446Crossref PubMed Scopus (625) Google Scholar and is recommended by the American Heart Association and the American College of Cardiology for patients who have had a cardiac event or who have undergone percutaneous coronary intervention or coronary artery bypass surgery.2Rawstorn JC Gant N Direito A Beckmann C Maddison R Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis.Heart. 2016; 102: 1183-1192Crossref PubMed Scopus (172) Google Scholar, 3Smith Jr, SC Benjamin EJ Bonow RO et al.AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association.J Am Coll Cardiol. 2011; 58: 2432-2446Crossref PubMed Scopus (625) Google Scholar, 4Intarakamhang P Intarakamhang U Effects of the comprehensive cardiac rehabilitation program on psychological factors and quality of life among coronary heart disease patients.Glob J Health Sci. 2012; 5: 145-152Crossref PubMed Google Scholar Despite the benefits of cardiac rehabilitation in coronary heart disease management, its low uptake has been a pervasive problem. Earlier research5McKee G Biddle M O' Donnell S Mooney M O' Brien F Moser DK Cardiac rehabilitation after myocardial infarction: what influences patients' intentions to attend?.Eur J Cardiovasc Nurs. 2014; 13: 329-337Crossref PubMed Scopus (34) Google Scholar, 6Sutton EJ Rolfe DE Landry M Sternberg L Price JAD Cardiac rehabilitation and the therapeutic environment: the importance of physical, social, and symbolic safety for programme participation among women.J Adv Nurs. 2012; 68: 1834-1846Crossref PubMed Scopus (16) Google Scholar has shown that uptake of centre-based cardiac-rehabilitation was between 10% and 40%. Therefore, a re-engineering of cardiac rehabilitation programmes is needed to improve access, uptake, and adherence.7Balady GJ Ades PA Bittner VA et al.Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association.Circulation. 2011; 124: 2951-2960Crossref PubMed Scopus (422) Google Scholar The emergence of home-based cardiac rehabilitation has overcome some participation barriers and achieved similar effects to centre-based cardiac rehabilitation for mortality, recurrent cardiac event risk, and modifiable cardiovascular risk factors.8Dalal HM Zawada A Jolly K Moxham T Taylor RS Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis.BMJ. 2010; 340b5631Crossref PubMed Scopus (284) Google Scholar In the past decade, with the rapid advancement in mobile technology, wearable devices, and wireless sensors and the growing coverage of mobile cellular network, mobile health (mHealth) and smartphone applications (apps) have been increasingly used in promoting physical activity and lifestyle modifications among patients with coronary heart disease.9Beatty AL Fukuoka Y Whooley MA Using mobile technology for cardiac rehabilitation: a review and framework for development and evaluation.J Am Heart Assoc. 2013; 2e000568Crossref PubMed Scopus (123) Google Scholar However, the effects of smartphone-delivered cardiac rehabilitation are unclear. The randomised controlled trial done by Tashi Dorje and colleagues10Dorje T Zhao G Tso K et al.Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial.Lancet Digital Health. 2019; (published online Oct 10)https://doi.org/10.1016/S2589-7500(19)30151-7Summary Full Text Full Text PDF Scopus (45) Google Scholar on the effectiveness of the smartphone-based and social media-based cardiac-rehabilitation and secondary-prevention programme has provided us with much-needed evidence in this area. In their study, Dorje and collagues10Dorje T Zhao G Tso K et al.Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial.Lancet Digital Health. 2019; (published online Oct 10)https://doi.org/10.1016/S2589-7500(19)30151-7Summary Full Text Full Text PDF Scopus (45) Google Scholar have developed a novel cardiac-rehabilitation and secondary-prevention programme that is exclusively delivered via the social media platform WeChat. The team used the advanced features of current smartphones, as well as WeChat's powerful functions in social media, communication, online education, physical activity tracking, blood-pressure and heart-rate monitoring, wireless data transfer, and multimedia to support the delivery of a comprehensive home-based cardiac-rehabilitation programme (SMART-CR/SP). The components of SMART-CR/SP included culturally sensitive education content, physical activity prescription, healthy nutrition advice, and support on medication adherence, psychological wellbeing, and coronary heart disease risk-factor modification delivered by the cardiac-rehabilitation and secondary-prevention coach via WeChat-based consultations. The study found significant between-group differences in functional capacity (measured by 6-min walk test), with greater improvements in the intervention group than in the control group, who received only standard care, at 2 months (mean between-group difference in change of 6-min walk distance from baseline 20·6 m [95% CI 7·5–33·8]) and at 6 months (22·3 m [8·2–36·4]). Participants in the intervention group also showed significantly greater knowledge and awareness of coronary heart disease and improved cardiac rehabilitation and secondary-prevention needs, as well as lower systolic blood pressure and resting heart rate, than the control group 6 months after discharge, and higher adherence to core cardioprotective medications and lower lipid concentrations 12 months after discharge. In addition, the usability and acceptability of SMART-CR/SP were reported to be high. Dorje and collagues' study10Dorje T Zhao G Tso K et al.Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial.Lancet Digital Health. 2019; (published online Oct 10)https://doi.org/10.1016/S2589-7500(19)30151-7Summary Full Text Full Text PDF Scopus (45) Google Scholar is the first of its kind to use a social media platform to deliver cardiac rehabilitation. It substantially advances the evidence to support mHealth-based chronic disease management. With the rapid increase in smartphone penetration and popularity of social media, patients now seem more prepared to accept telemedicine and mHealth than just a few years ago. If an app or a wearable device could persuade people to walk a few more steps every day or modify lifestyle risk factors, it would be much cheaper than years of doctor appointments in the hospital. The current wave of digital disruption in health care has increased the accessibility and affordability of health care. In countries where regulations on health data are not very stringent, telemedicine and digital health are growing and innovating at an increased pace. The use of WeChat—one of the most widespread apps in China—as the delivery platform for the home-based cardiac-rehabilitation programme in Dorje and colleague' study,10Dorje T Zhao G Tso K et al.Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trial.Lancet Digital Health. 2019; (published online Oct 10)https://doi.org/10.1016/S2589-7500(19)30151-7Summary Full Text Full Text PDF Scopus (45) Google Scholar is an example of such innovation. To date, few studies similar to the SMART-CR/SP trial have been published; therefore, replications of study interventions are needed before solid evidence can be formed. In addition, future studies will need to include cost-effectiveness analyses and directly compare the effectiveness of mHealth-based cardiac rehabilitation to that of centre-based cardiac rehabilitation. We declare no competing interests. Smartphone and social media-based cardiac rehabilitation and secondary prevention in China (SMART-CR/SP): a parallel-group, single-blind, randomised controlled trialSMART-CR/SP was found to be a cardiac rehabilitation and secondary prevention service model with high efficacy and accessibility and to be easy to use. These results justify the implementation of similar models of care on a broader scale. Full-Text PDF Open Access