Cardiopulmonary Rehabilitation and Prevention

Influence of High-Intensity Interval Training Versus Continuous Training on Functional Capacity in Individuals With Heart Failure: A SYSTEMATIC REVIEW AND META-ANALYSIS Introduction: Cardiac rehabilitation programs reduce the risk of death and acute events related to the disease through the association of various modalities of exercise. When implemented in high-intensity interval training (HIIT) programs, it may allow for gradual adaptation of the skeletal muscles to greater exercise intensities. The present systematic review aimed to determine whether HIIT promoted a greater increase in exercise tolerance in comparison with continuous aerobic training in individuals with heart failure. Methods: A systematic search for articles indexed in the PubMed/MEDLINE, LILACS, SciELO, PEDro, Scopus, and Web of Science databases was carried out. The descriptors used for the search followed the description of the MeSH/DeCS terms with no language or year of publication restrictions. When possible, a meta-analysis was performed and the quality of the evidence was evaluated using the GRADE scale. Results: The broad search strategy resulted in 5258 titles, and a total of 7 articles were included in the qualitative synthesis. A low quality of evidence was observed demonstrating that interval training is superior to continuous aerobic training for improving peak oxygen uptake, which reflects an increase in functional capacity of these individuals and moderate quality of evidence regarding improved quality of life and left ventricular ejection fraction. Conclusion: High-intensity interval training and continuous training provide benefits for patients, however, the quality of evidence still does not allow us to indicate whether there is a superiority of HIIT over conventional continuous exercise training using the variables analyzed. Correspondence: Daniella Cunha Brandão, PhD, Av Jornalista Anibal Fernandes, s/n, Cidade Universitária—CEP: 50740-560, Recife, Brazil (daniellacunha@hotmail.com). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Interventions in Patients With Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy: A SYSTEMATIC REVIEW AND META-ANALYSIS Purpose: Physical activity improves outcomes across a broad spectrum of cardiovascular disease. The safety and effectiveness of exercise-based interventions in patients with implantable cardioverter-defibrillators (ICDs) including cardiac resynchronization therapy defibrillators (CRT-Ds) remain poorly understood. Methods: We identified clinical studies using the following search terms: "implantable cardioverter-defibrillators"; "ICD"; "cardiac resynchronization therapy"; "CRT"; and any one of the following: "activity"; "exercise"; "training"; or "rehabilitation"; from January 1, 2000 to October 1, 2015. Eligible studies were evaluated for design and clinical endpoints. Results: A total of 16 studies were included: 8 randomized controlled trials, 5 single-arm trials, 2 observational cohort trials, and 1 randomized crossover trial. A total of 2547 patients were included (intervention groups = 1215 patients, control groups = 1332 patients). Exercise interventions varied widely in character, duration (median 84 d, range: 23-168 d), and follow-up time (median 109 d, range: 23 d to 48 mo). Exercise performance measures were the most common primary endpoints (87.5%), with most studies (81%) demonstrating significant improvement. Implantable cardioverter-defibrillator shocks were uncommon during active exercise intervention, with 6 shocks in 635 patients (0.9%). Implantable cardioverter-defibrillator shocks in follow-up were less common in patients receiving any exercise intervention (15.6% vs 23%, OR = 0.68; 95% CI, 0.48-0.80, P < .001). Vo2 peak improved significantly in patients receiving exercise intervention (1.98 vs 0.36 mL/kg/min, P < .001). Conclusion: In conclusion, exercise interventions in patients with ICDs and CRT-Ds appear safe and effective. Lack of consensus on design and endpoints remains a barrier to broader application to this important patient population. Correspondence: Daniel A. Steinhaus, MD, Saint Luke's Mid America Heart Institute, 4330 Wornall Rd, Ste 2000, Kansas City, MO 64111 (dsteinhaus@saint-lukes.org). Dr Steinhaus has consulted for Abbott Laboratories and Boston Scientific and has a family member who is an executive for Medtronic. Dr Lubitz receives sponsored research support from Bayer HealthCare, Biotronik, and Boehringer Ingelheim, and has consulted for St Jude Medical and Quest Diagnostics. Dr Noseworthy has no disclosures to report regarding this publication. Dr Kramer has consulted to the Baim Institute for Clinical Research for clinical trials of medical devices. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Aerobic Exercise Effects on Quality of Life and Psychological Distress After an Implantable Cardioverter Defibrillator Purpose: The purpose of this study was to evaluate quality of life (QOL), psychological function, and self-efficacy outcomes in the Anti-Arrhythmic Effects of Exercise After an ICD Trial. Methods: In the Anti-Arrhythmic Effects of Exercise After an ICD Trial, 160 patients (124 men and 36 women) who had an implantable cardioverter defibrillator for primary (43%) or secondary (57%) prevention were randomized to exercise (EX, n = 84) or usual care (UC, n = 76). The EX consisted of 8 wk of home walking 1 hr/d 5 d/wk, followed by 16 wk of maintenance home walking for 150 min/wk. Adherence was determined from exercise logs, ambulatory HR recordings, and phone calls. Assessments were conducted at baseline, 8, and 24 wk for QOL: Patient Concerns Assessment and Short Form-36; anxiety: State Trait Anxiety Inventory; depression: Physician Health Questionnaire-Depression; and self-efficacy: Self-Efficacy for Walking Scale. Results: Participants averaged 55 ± 12 yr of age with ejection fraction = 40.6 ± 15.7%. The EX significantly decreased depression severity (EX: 1.33 ± 0.64; UC: 1.51 ± 0.86, P = .05) and improved self-efficacy (EX: 7.65 ± 1.97; UC: 6.85 ± 2.40, P = .05) at 8 wk. There were no significant effects at 24 wk. Adherent exercisers had significant improvements in QOL, psychological, and self-efficacy outcomes at 8 and 24 wk compared with those who were nonadherent. There were no implantable cardioverter defibrillator shocks associated with exercise. Conclusions: The EX conferred significant effects on depression and self-efficacy at 8 wk, without effects on QOL. Adherent exercisers experienced significant improvements in outcomes over those who were nonadherent or received UC. Correspondence: Cynthia M. Dougherty, ARNP, PhD, University of Washington, School of Nursing, Box 357266, 1959 NE Pacific St, HSB T615A, Seattle, WA 98195 (cindyd@uw.edu). The authors declare no conflicts of interest. Clinical Trial Registration Information: ClinicalTrials.gov number: NCT 00522340, https://trialbulletin.com/lib/entry/ct-00522340 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Rehabilitation Improves Cardiac Volumes and Functional Capacity in Patients With Endomyocardial Fibrosis: A RANDOMIZED CONTROLLED TRIAL Purpose: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy associated with low functional capacity and high mortality rates. Exercise training has been proved to be a nonpharmacological treatment of cardiovascular diseases. Therefore, the purpose of this study was to determine the effects of exercise rehabilitation in EMF patients. Methods: Twenty-two EMF patients, functional classes II and III (New York Heart Association [NYHA]), were randomized to the control (C-EMF) or exercise rehabilitation (Rehab-EMF) group. Patients in the Rehab-EMF group underwent 4 mo of exercise rehabilitation, whereas patients in the C-EMF group were instructed to maintain their usual daily routine. Peak oxygen uptake (Vo2), cardiac function, and quality of life were evaluated. All assessments were performed at baseline and after 4 mo. Results: After 4 mo of rehabilitation, peak Vo2 increased in the Rehab-EMF group (17.4 ± 3.0 to 19.7 ± 4.4 mL/kg/min, P < .001), whereas the C-EMF group showed no difference (15.3 ± 3.0 to 15.0 ± 2.0 mL/kg/min, P = .87). Also, post-intervention, peak Vo2 in the Rehab-EMF group was greater than that in the C-EMF group (P < .001). Furthermore, the Rehab-EMF group, when compared to the C-EMF group, showed an increase in left ventricular end-diastolic volume (102.1 ± 64.6 to 136.2 ± 75.8 mL vs 114.4 ± 55.0 to 100.4 ± 49.9 mL, P < .001, respectively) and decrease in left atrial diastolic volume (69.0 ± 33.0 to 34.9 ± 15.0 mL vs 44.6 ± 21.0 to 45.6 ± 23.0 mL, P < .001, respectively). Quality-of-life scores also improved in the Rehab-EMF group, whereas the C-EMF group showed no change (45 ± 23 to 27 ± 15 vs 47 ± 15 to 45 ± 17, P < .001, respectively). Conclusion: Exercise rehabilitation is a nonpharmacological intervention that improves functional capacity, cardiac volumes, and quality of life in EMF patients after endocardial resection surgery. In addition, exercise rehabilitation should be prescribed to EMF patients to improve their clinical condition. Correspondence: Ana Luiza Carrari Sayegh, PhD, Clinical Unit of Cardiomyopathy, Heart Institute, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44 Cerqueira Cesar, Sao Paulo, SP 05403-000, Brazil (ana_luizas@hotmail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Cardiac Rehabilitation on Sexual Satisfaction Among Patients After Coronary Artery Bypass Graft Surgery Purpose: After coronary artery bypass graft (CABG) surgery, many patients experience diminished sexual function and satisfaction. The present study aimed to investigate the effect of outpatient cardiac rehabilitation (OCR) on the level of sexual satisfaction among post-CABG patients. Methods: A clinical trial was performed at the Al-Zahra Hospital, Shiraz, Iran, from July 2017 to January 2018. Based on the inclusion criteria, 104 post-CABG patients were recruited into the study. The participants were randomly assigned to the intervention (OCR) group (n = 52) or the usual care group (n = 52). The intervention group received 20 sessions of OCR, whereas the usual care group received the routine hospital care and education. Data were collected using the Index of Sexual Satisfaction and a demographic data sheet. The data were analyzed using the SPSS software, v23.0 (IBM) and the independent sample t test, paired-samples t test, and χ2 test. Results: There was no statistically significant difference in the mean pre-intervention score for sexual satisfaction between the groups. However, a statistically significant difference in the mean post-intervention score for sexual satisfaction was observed between the groups (P < .001). The difference in the mean pre- and post-intervention scores for sexual satisfaction in the intervention group was statistically significant (P < .001), whereas there was no significant difference in the usual care group. Conclusion: Post-CABG patients who completed the OCR program experienced an increased level of sexual satisfaction. It is, therefore, recommended to include an OCR program as part of the patient treatment and aftercare following CABG surgery. Correspondence: Mahnaz Rakhshan, PhD, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz 71936-13119, Iran (mzrakhshan@ymail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-Being in Patients With Heart Failure Purpose: To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms. Methods: Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU. Results: Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to −345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to −127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, −35 to −374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, −1 to 3, P = .27). Conclusions: Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU. Correspondence: Laura S. Redwine, PhD, College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC22, Tampa, FL 33612 (lredwine@health.usf.edu). This research was supported by R01HL096784. The protocol for the parent study can be found at clinicaltrial.gov. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Clinical Trial number: NCT01625819. ORCID#: 0000-0001-7633-2034. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

People With COPD Who Respond to Ground-Based Walking Training Are Characterized by Lower Pre-training Exercise Capacity and Better Lung Function and Have Greater Progression in Walking Training Distance Purpose: To investigate the characteristics that distinguish responders from nonresponders to ground-based walking training (GBWT) in people with chronic obstructive pulmonary disease (COPD). Methods: An analysis was undertaken of data collected during a trial of GBWT in people with COPD. Responders to GBWT were defined in 2 ways: (1) improved time on the endurance shuttle walk test of ≥190 sec (criterion A); or (2) improved ability to walk, perceived by the participant to be at least "moderate" (criterion B). Differences in participant characteristics, pre-training exercise capacity, health-related quality of life, and the improvement in the distance walked during the training program were examined between responders and nonresponders. Results: Of the 95 participants randomized to GBWT (age 69 ± 8 yr, forced expiratory volume in 1 sec [FEV1] % predicted = 43% ± 15%), data were available for analysis on 78 and 73 patients by criterion A and criterion B, respectively. According to criterion A, 32 (41%) participants were responders. The odds of being a responder increased with increasing FEV1 % predicted (OR = 1.2; 95% CI, 1.0-1.5, for every 5% increase) and increased with decreasing pre-training incremental shuttle walk distance (OR = 1.4; 95% CI, 1.0-1.8, for every 50-m decrement). According to criterion B, 42 (58%) participants were responders. There were no differences in characteristics or pre-training measures between the responders and nonresponders. For both criteria, responders demonstrated greater change in the distance walked during the training program (P < .05). Conclusion: Responders to GBWT had lower pre-training exercise capacity, had better lung function, and demonstrated greater change in the distance walked during the training program. Correspondence: Jennifer A. Alison, PhD, Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, 75 East St, Lidcombe, NSW 2141, Australia (jennifer.alison@sydney.edu.au). All authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: COMPARISON BETWEEN MEN AND WOMEN Purpose: To compare functional and cardiovascular variables of men and women with peripheral artery disease (PAD). Methods: This observational, cross-sectional study included 67 women and 144 men (age 66 ± 9 and 67 ± 10 yr, respectively) with PAD. Patients were submitted to a clinical evaluation, 6-min walk test (6MWT) and cardiovascular evaluation, including blood pressure, arterial stiffness variables, and heart rate variability. Results: Women had lower claudication onset distance (P = .033) and 6MWT distance (P < .001), and similar percentage of the predicted 6MWT distance (P > .05). Women had higher pulse pressure (P = .002), augmentation index (P < .001), augmentation index corrected by 75 bpm (P < .001), and brachial and central systolic blood pressure (P = .041 and P = .029). Diastolic blood pressure, pulse wave velocity, and heart rate variability were similar between sexes (P > .05). Conclusion: Although predicted 6MWT performance was similar between sexes, women had higher blood pressure and wave reflection variables compared with men. Interventions to reduce blood pressure and wave reflection should be emphasized in women with PAD. Correspondence: Raphael M. Ritti-Dias, PhD, Universidade Nove de Julho, São Paulo, SP, Brazil (raphaelritti@gmail.com) The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Adherence to Pulmonary Rehabilitation in COPD: A QUALITATIVE EXPLORATION OF PATIENT PERSPECTIVES ON BARRIERS AND FACILITATORS Purpose: Adherence to pulmonary rehabilitation (PR) is low. This qualitative study used the PRECEDE model to identify predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors acting as barriers or facilitators of adherence to PR, and elicit recommendations for solutions from patients with chronic obstructive pulmonary disease (COPD). Methods: Focus groups with COPD patients who had attended PR in the past year were conducted. Sessions were recorded, transcribed verbatim, and coded independently by 2 coders, who then jointly decided on the final coding scheme. Data were summarized across groups, and analysis was used a thematic approach with constant comparative method to generate categories. Results: Five focus groups with 24 participants each were conducted. Participants (mean age 62 yr) were 54% male, and 67% black. More than half had annual income less than $20 000, 17% were current smokers, and 54% had low adherence (less than 35% of prescribed PR sessions). The most prominent barriers included physical ailments and lack of motivation (intrapersonal), no support system (interpersonal), transportation difficulties, and financial burden (structural). The most prominent facilitators included health improvement, personal determination (intrapersonal), support from peers, family, and friends (interpersonal), and program features such as friendly staff and educational component of sessions (structural). Proposed solutions included incentives to maintain motivation, tobacco cessation support (intrapersonal), educating the entire family (interpersonal), transportation assistance, flexible program scheduling, and financial assistance (structural). Conclusion: Health limitations, social support, transportation and financial difficulties, and program features impact ability of patients to attend PR. Interventions addressing these interpersonal, intrapersonal, and structural barriers are needed to facilitate adherence to PR. Correspondence: Gabriela R. Oates, PhD, 1600 7th Ave South, ACC 620, Birmingham, AL 35233 (goates@uab.edu). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Motivational Telephone Intervention to Reduce Early Dropouts in Cardiac Rehabilitation: A FEASIBILITY PILOT STUDY Purpose: Cardiac rehabilitation (CR) improves outcomes, yet early dropout is common. The purpose of the study was to determine whether a motivational telephone intervention among patients at risk for nonadherence would reduce early dropouts. Methods: We performed a randomized double-blind pilot study with the intervention group receiving the telephone intervention 1 to 3 d after outpatient CR orientation. The control group received the standard of care, which did not routinely monitor attendance until 2 wk after orientation. The primary outcome was the percentage of patients who attended their second exercise session as scheduled. Secondary outcomes included attendance at the second CR session at any point and total number of sessions attended. Because not everyone randomized to the intervention was able to be contacted, we also conducted a per-protocol analysis. Results: One hundred patients were randomized to 2 groups (age 62 ± 15 yr, 46% male, 40% with myocardial infarction) with 49 in the intervention group. Patients who received the intervention were more likely to attend their second session as scheduled compared with the standard of care (80% vs 49%; relative risk = 1.62; 95% CI, 1.18-2.22). Although there was no difference in total number of sessions between groups, there was a statistically significant improvement in overall return rate among the per-protocol group (87% vs 66%; relative risk = 1.31; 95% CI, 1.05-1.63). Conclusions: A nursing-based telephone intervention targeted to patients at risk for early dropout shortly after their CR orientation improved both on-time and eventual return rates. This straightforward strategy represents an attractive adjunct to improve adherence to outpatient CR. Correspondence: Grace LaValley, DNP, AGACNP-BC, Baystate Health Systems, 759 Chestnut Street, Springfield, MA 01199 (grace.lavalley@baystatehealth.org). The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, participation in speakers' bureaus, memberships, employment, stock ownership, or other equity interest) or nonfinancial interest (such as personal or professional relationships affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript. Dr Quinn R. Pack was partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (award number: KL2TR001063). The content is solely the responsibility of the authors and does not represent the official views of the NIH. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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