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Coronavirus Disease (COVID-19) Pandemic: An Opportunity Window to Implement Home-Based Cardiac Rehabilitation

Coronavirus/isolation & purification; Coronavirus Infections/prevention and control; Syndrome Acute Respiratory; Cardiovascular Diseases; Hypertension; Diabetes; Comorbidity; Physical Activity; Exercise; Cardiac Rehabilitation; Public Health Services

The World Health Organization declared that the new coronavirus outbreak is a public health emergency of pandemic proportions. The outbreak has caused various governments to take protective measures such as lockdown of cities, travel bans, prohibition of group gatherings and public events, and social distancing. Many health and exercise training facilities were closed, as well as cardiac rehabilitation services. These restrictions are disrupting people’s daily activities.

Although staying at home can contain virus spread, it will certainly reduce regular physical activity and increase sedentary behavior, which can increase the risk of development and worsening of chronic conditions.11. Chen P, Mao L, Nassis GP, Harmer P, Ainsworth BE, Li F. Coronavirus disease (COVID-19): The need to maintain regular physical activity while taking precautions. J Sport Health Sci. 2020;9(2):103-4.

2. Owen N, Sparling PB, Healy GN, Dunstan DW, Matthews CE. Sedentary behavior: emerging evidence for a new health risk. Mayo Clin Proc. 2010;85(12):1138-41.

3. Henson J, Dunstan DW, Davies MJ, Yates T. Sedentary behaviour as a new behavioural target in the prevention and treatment of type 2 diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1):213-20.

4. Hamilton MT, Healy GN, Dunstan DW, Zderic TW, Owen N. Too Little Exercise and Too Much Sitting: Inactivity Physiology and the Need for New Recommendations on Sedentary Behavior. Curr Cardiovasc Risk Rep. 2008;2(4):292-8.

5. Eanes L. CE: Too Much Sitting: A Newly Recognized Health Risk. Am J Nurs. 2018;118(9):26-34.

6. Ding D, Rogers K, van der Ploeg H, Stamatakis E, Bauman AE. Traditional and Emerging Lifestyle Risk Behaviors and All-Cause Mortality in Middle-Aged and Older Adults: Evidence from a Large Population-Based Australian Cohort. PLoS Med. 2015;12(12):e1001917.
- 77. Simpson RJ, Kunz H, Agha N, Graff R. Exercise and the Regulation of Immune Functions. Prog Mol Biol Transl Sci. 2015;135:355-80. Therefore, there is a strong evidence for continuing physical activity at home even during the pandemic situation.

Cardiac rehabilitation should be an integral component in the continuum of care for patients with cardiovascular disease.88. Taylor RS, Walker S, Smart NA, Piepoli MF, Warren FC, Ciani O,et al. et al. Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis. J Am Coll Cardiol. 2019;73(12):1430-43.

9. Servey JT, Stephens M. Cardiac Rehabilitation: Improving Function and Reducing Risk. Am Fam Physician. 2016;94(1):37-43.

10. Piepoli MF, Corra U, Benzer W, Biarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17(1):1-17.

11. Herdy AH, López-Jiménez F, Terzic CP, Milani M, Stein R, Carvalho T, et al. et al. South American guidelines for cardiovascular disease prevention and rehabilitation. Arq Bras Cardiol. 2014;103(2 Suppl 1):1-31.
- 1212. Benzer W, Rauch B, Schmid JP, Bonner G, Ouarrak T, McGee H, et al. Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry. Int J Cardiol. 2017;228:58-67. Nevertheless, only a small number of patients that would benefit from cardiac rehabilitation is referred to the program. In the United Kingdom less than 20% of patients discharged with a diagnosis of heart failure are referred to cardiac rehabilitation.1313. Dalal HM, Taylor RS, Doherty P. Home-based rehabilitation for heart failure: we need to act now. Eur J Prev Cardiol. 2019;26(12):1343-4. In the United States, patient participation in cardiac rehabilitation is also low, with only 16.3% of Medicare patients and 10.3% of veterans after hospital discharge for myocardial infarction, percutaneous coronary intervention or coronary artery bypass graft surgery.1414. Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement. Circulation. 2018;137(18):1899-908. In Brazil, access to cardiac rehabilitation programs is also suboptimal.1515. Britto RR, Supervia M, Turk-Adawi K, Chaves GS, Pesah E, Lopez-Jimenez F, et al. Cardiac rehabilitation availability and delivery in Brazil: a comparison to other upper middle-income countries. Braz J Phys Ther. 2020;24(2):167-76.

There is an urgent need for new cardiac rehabilitation strategies that overcome current geographical, logistical, cost-related and access-related barrier.1313. Dalal HM, Taylor RS, Doherty P. Home-based rehabilitation for heart failure: we need to act now. Eur J Prev Cardiol. 2019;26(12):1343-4. , 1616. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Am Coll Cardiol. 2019;74(1):133-53. Although training at home is usually recommended when training at cardiac rehabilitation facility is not possible, few physicians feel confident prescribing stand-alone exercises to cardiac patients. Nevertheless, the European Guidelines on Cardiovascular disease prevention states that “home-based rehabilitation with and without telemonitoring holds promise for increasing participation and supporting behavioral change”.1717. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al.. [2016 European guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation]. G Ital Cardiol (Rome). 2017;18(7):547-612. Noteworthy, Cochrane reviews1818. Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6:CD007130.

19. Buckingham SA, Taylor RS, Jolly K, Zawada A, Dean SG, et al. Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis. Open Heart. 2016;3(2):e000463.
- 2020. Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015(8):CD007130. concluded that home-based cardiac rehabilitation and traditional cardiac rehabilitation programs have similar effects on quality of life of patients with recent myocardial infarction or coronary revascularization.

The American College of Cardiology, the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation have recently published a scientific statement on home-based cardiac rehabilitation.1616. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Am Coll Cardiol. 2019;74(1):133-53. In this document, cardiac rehabilitation interventions should include exercise training, dietary education, medication management, tobacco counseling and psychosocial assessment.

It is important to note that proper patient evaluation at baseline is critical to correctly prescribe these interventions. Although cardiopulmonary exercise testing and physical examination cannot be performed remotely, telemedicine may offer the possibility of history taking.2121. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-92. We must consider that, for patients already participating in formal cardiac rehabilitation programs, exercise prescriptions will probably not need to be changed during the social distancing period.

Despite the fact that severe cardiovascular events are rare during cardiac rehabilitation trainings,2222. Haskell WL. The efficacy and safety of exercise programs in cardiac rehabilitation. Med Sci Sports Exerc. 1994;26(7):815-23. safety is a major concern in cardiac rehabilitation facilities and this should not be different in remote rehabilitation programs. Thus, in cases where social distance prevented proper patient evaluation and risk assessment, light-intensity exercise should be preferred and cardiac rehabilitation should focus on dietary education, medication management, tobacco counseling and psychosocial assessment that can be delivered remotely.

Therefore, current evidence suggests that remote cardiac rehabilitation programs must be implemented during the pandemic, since the risks of sedentary behavior outweigh the risks of well-planned programs.

References

  • 1
    Chen P, Mao L, Nassis GP, Harmer P, Ainsworth BE, Li F. Coronavirus disease (COVID-19): The need to maintain regular physical activity while taking precautions. J Sport Health Sci. 2020;9(2):103-4.
  • 2
    Owen N, Sparling PB, Healy GN, Dunstan DW, Matthews CE. Sedentary behavior: emerging evidence for a new health risk. Mayo Clin Proc. 2010;85(12):1138-41.
  • 3
    Henson J, Dunstan DW, Davies MJ, Yates T. Sedentary behaviour as a new behavioural target in the prevention and treatment of type 2 diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1):213-20.
  • 4
    Hamilton MT, Healy GN, Dunstan DW, Zderic TW, Owen N. Too Little Exercise and Too Much Sitting: Inactivity Physiology and the Need for New Recommendations on Sedentary Behavior. Curr Cardiovasc Risk Rep. 2008;2(4):292-8.
  • 5
    Eanes L. CE: Too Much Sitting: A Newly Recognized Health Risk. Am J Nurs. 2018;118(9):26-34.
  • 6
    Ding D, Rogers K, van der Ploeg H, Stamatakis E, Bauman AE. Traditional and Emerging Lifestyle Risk Behaviors and All-Cause Mortality in Middle-Aged and Older Adults: Evidence from a Large Population-Based Australian Cohort. PLoS Med. 2015;12(12):e1001917.
  • 7
    Simpson RJ, Kunz H, Agha N, Graff R. Exercise and the Regulation of Immune Functions. Prog Mol Biol Transl Sci. 2015;135:355-80.
  • 8
    Taylor RS, Walker S, Smart NA, Piepoli MF, Warren FC, Ciani O,et al. et al. Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis. J Am Coll Cardiol. 2019;73(12):1430-43.
  • 9
    Servey JT, Stephens M. Cardiac Rehabilitation: Improving Function and Reducing Risk. Am Fam Physician. 2016;94(1):37-43.
  • 10
    Piepoli MF, Corra U, Benzer W, Biarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17(1):1-17.
  • 11
    Herdy AH, López-Jiménez F, Terzic CP, Milani M, Stein R, Carvalho T, et al. et al. South American guidelines for cardiovascular disease prevention and rehabilitation. Arq Bras Cardiol. 2014;103(2 Suppl 1):1-31.
  • 12
    Benzer W, Rauch B, Schmid JP, Bonner G, Ouarrak T, McGee H, et al. Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry. Int J Cardiol. 2017;228:58-67.
  • 13
    Dalal HM, Taylor RS, Doherty P. Home-based rehabilitation for heart failure: we need to act now. Eur J Prev Cardiol. 2019;26(12):1343-4.
  • 14
    Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement. Circulation. 2018;137(18):1899-908.
  • 15
    Britto RR, Supervia M, Turk-Adawi K, Chaves GS, Pesah E, Lopez-Jimenez F, et al. Cardiac rehabilitation availability and delivery in Brazil: a comparison to other upper middle-income countries. Braz J Phys Ther. 2020;24(2):167-76.
  • 16
    Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Am Coll Cardiol. 2019;74(1):133-53.
  • 17
    Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al.. [2016 European guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation]. G Ital Cardiol (Rome). 2017;18(7):547-612.
  • 18
    Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6:CD007130.
  • 19
    Buckingham SA, Taylor RS, Jolly K, Zawada A, Dean SG, et al. Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis. Open Heart. 2016;3(2):e000463.
  • 20
    Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015(8):CD007130.
  • 21
    Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-92.
  • 22
    Haskell WL. The efficacy and safety of exercise programs in cardiac rehabilitation. Med Sci Sports Exerc. 1994;26(7):815-23.
  • Study Association
    This study is not associated with any graduation program.
  • Sources of Funding
    There were no external funding sources for this study.

Publication Dates

  • Publication in this collection
    29 May 2020
  • Date of issue
    May-Jun 2020

History

  • Received
    04 Apr 2020
  • Reviewed
    07 Apr 2020
  • Accepted
    07 Apr 2020
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