Access remains the most serious barrier to cardiac rehabilitation

Noted experts in cardiovascular rehabilitation attending the Third Jim Pattison-Mazankowski Alberta Heart Institute Cardiac Rehabilitation Symposium (Banff, April 21-23, 2023) observed that although cardiac rehabilitation benefits diverse groups of patients and affords the most cost-effective prevention for recurrent events, it is grossly underutilized globally. They concluded that access is the hardest obstacle for patients to overcome. Contributions from the symposium are included in the new supplement opens in new tab/window to the Canadian Journal of Cardiology opens in new tab/window, published today by Elsevier.

Guest Editor Paolo Raggi, MD, PhD, FACC, FAHA, FACP, FASNC, FSCCT, Professor of Medicine/Cardiology, University of Alberta, explained: “During the symposium it became amply clear that despite the well-known benefits of rehabilitation, we still face several obstacles for a more universal uptake of it, and physicians often hesitate or delay offering this therapeutic and preventive solution to patients in need. Symposia such as this one organized by the Mazankowski Heart Institute and the University Hospital Foundation are designed to increase our awareness of the extraordinary benefits of rehabilitation that extend well beyond increasing physical activity.”

Participants stressed that providing social support, especially in poorer countries, is essential for reducing barriers to accessing cardiac rehabilitation. They proposed that home-based rehabilitation may reach individuals who may not otherwise be able to avail themselves of these services.

Other key topics explored during the symposium included:

• The many barriers that women encounter to participate in cardiac rehabilitation sessions (some universal, others cultural). Recommendations on how to mitigate these obstacles were presented, particularly for unemployed women.

• The benefits of exercise for patients with dialysis-dependent kidney failure, in part to maintain cardiovascular health. Despite over 30 years of research in people with chronic kidney disease on the benefit of exercise, rehabilitation programs are rare in kidney care and are not incorporated into routine management at any stage.

• The emerging field of cardio-oncology rehabilitation in cancer patients. A successful cardio-oncology team requires the strict collaboration of cardiology and oncology specialists as well as clinical pharmacologists and nurses.

• The possible benefits of time-restricted eating. This nutrition strategy could result in improved glucose and blood pressure control and provision of efficient fuel (ketones) for a failing heart.

• Sarcopenia, or loss of muscle mass and strength, with or without obesity and nonalcoholic fatty disease in patients living with HIV. These conditions predispose to developing cardiovascular disease and may prevent patients from participating in cardiac rehabilitation.

• The benefits of lifelong exercise prior to a heart transplant. Highly trained athletes demonstrate better and faster recovery of function following a heart transplant. This suggests that a lifelong exposure to exercise may aid at the time of development of heart failure in delaying symptoms and improving the overall outcome.

• The role of telemedicine in facilitating home-based interventions for adolescents with congenital heart disease.

In addition, two highlighted contributions focused on:

Among the topics discussed was heart failure with preserved ejection fraction (HFpEF), which occurs when the muscle in the left ventricle stiffens and does not relax properly. This results in increased pressure in the lungs. A group of investigators explored the relationship between physical activity, cardiac remodeling, and cardiorespiratory fitness across the exercise spectrum, from elite athletes to sedentary individuals, emphasizing the critical role of cardiac size in determining exercise capacity. They found that exercise rehabilitation improves outcomes for patients with reduced and preserved ejection fraction.

Senior author Andre La Gerche, MBBS, PhD, FRACP, Baker Heart and Diabetes Institute, St. Vincent’s Hospital Melbourne, and The University of Melbourne, said, “In contrast to the large compliant left ventricle of the endurance athlete, an individual with a lifetime of physical inactivity is likely to have a small, stiff heart with reduced cardiac reserve. We propose that this may contribute to the development of HFpEF in certain individuals and is key to understanding the link between low cardiorespiratory fitness and increased risk of heart failure.”

Another featured presentation focused on secondary prevention strategies for patients with spontaneous coronary artery dissection (SCAD), a serious, noniatrogenic and nontraumatic cardiac event that predominantly affects women and has a high risk of recurrence. The authors’ research concludes that cardiac rehabilitation, as a part of a secondary prevention program, may decrease recurrent events and improve quality of life.

Senior author Collen Norris, PhD, Faculty of Nursing, University of Alberta, explained: “The psychosocial burden among SCAD survivors is high, and rates of anxiety and depression are higher than what is seen in other cardiac patient populations. Therefore, tailored secondary prevention strategies including medical therapy, cardiac rehabilitation, and psychosocial intervention have the potential to decrease recurrent events.”

Looking towards the future, Dr. Raggi elaborated, “The burden for society could be lessened by health promotion programs in early childhood that address all aspects of cardiovascular and oncological care such as dietary habits, physical activity, body weight, smoking avoidance, and blood pressure, glucose, and cholesterol control. However, we face the usual conundrum: with limited resources where should we focus our efforts and spend our money? It has long been known that one ounce of prevention is far superior to a pound of cure. Yet we keep failing to implement such knowledge. If unable to prevent the first event, we should at least make sure to focus our best efforts and in the most economical way on the next phase of care for the patients who suffered an event: comprehensive rehabilitation efforts, since they do work!”

---

Notes for editors

Supplement: Implementation of Comprehensive Lifelong Healthy Behavioral Programs to Improve Outcome: The Third Jim Pattison-Mazankowski Alberta Heart Institute Cardiac Rehabilitation Symposium

Guest Editor: Paolo Raggi, MD, PhD, FACC, FAHA, FACP, FASNC, FSCCT, Professor of Medicine/Cardiology, University of Alberta

Canadian Journal of Cardiology, volume 39, supplement – issue 11 (November 2023) published by Elsevier. The supplement is openly available at https://onlinecjc.ca/issue/S0828-282X(23)X0014-2 opens in new tab/window.

The symposium was funded with a donation by the Jim Pattison Foundation to the University Hospital Foundation in support of the Mazankowski Alberta Heart Institute.

Featured articles

“Understanding Exercise Capacity: From Elite Athlete to HFpEF,” by Stephanie J. Rowe, BBiomed MD, FRACP, Elizabeth D. Paratz, MBBS, PhD, FRACP, Stephen J. Foulkes, PhD, Kristel Janssens, BNurs, Luke W. Spencer, BBiomed(Hons), Louise Fahey, MB BCh, BAO, Paolo D’Ambrosio, MBBS, FRACP, Mark J. Haykowsky, PhD, and Andre La Gerche, MBBS, PhD, FRACP (https://doi.org/10.1016/j.cjca.2023.08.007 opens in new tab/window)

“Secondary Prevention and Rehabilitation for Spontaneous Coronary Artery Dissection: A Systematic Review,” by Andrea Van Damme, BN, MN, Susanna McDermott, BScN, Sean McMurtry MD, PhD, Janice Y. Kung, MLIS, Gabor Gyenes, MD, PhD, and Colleen Norris, PhD (https://doi.org/10.1016/j.cjca.2023.08.013 opens in new tab/window)

Full text of the articles in this supplement is also available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628or [email protected] opens in new tab/window to obtain copies. Journalists wishing to speak to Guest Editor Dr. Paolo Raggi or individual authors should contact Mikiko Van Horn, University Hospital Foundation, at +1 825 901 0614 or [email protected] opens in new tab/window.

About the Canadian Journal of Cardiology

The Canadian Journal of Cardiology opens in new tab/window is the official journal of the Canadian Cardiovascular Society opens in new tab/window. It is a vehicle for the international dissemination of new knowledge in cardiology and cardiovascular science, particularly serving as a major venue for the results of Canadian cardiovascular research and Society guidelines. The journal publishes original reports of clinical and basic research relevant to cardiovascular medicine as well as editorials, review articles, case reports, and papers on health outcomes, policy research, ethics, medical history, and political issues affecting practice. www.onlinecjc.ca opens in new tab/window

About the Editor-in-Chief

Editor-in-Chief Stanley Nattel, MD, is Paul-David Chair in Cardiovascular Electrophysiology and Professor of Medicine at the University of Montreal and Director of the Electrophysiology Research Program at the Montreal Heart Institute Research Center.

About the Canadian Cardiovascular Society (CCS)

The CCS opens in new tab/window is the national voice for cardiovascular clinicians and scientists, representing more than 2,300 cardiologists, cardiac surgeons and other heart health specialists across Canada. We advance heart health for all by setting standards for excellence in heart health and care, building the knowledge and expertise of the heart team, and influencing policy and advocating for the heart health of all Canadians. For further information on the CCS visit https://www.ccs.ca/ opens in new tab/window.

About the University Hospital Foundation

The University Hospital Foundation opens in new tab/window raises funds to advance patient care, research, and innovation at the University of Alberta Hospital, the Mazankowski Alberta Heart Institute, and the Kaye Edmonton Clinic, as well as research at the University of Alberta and care in the community through Alberta Health Services (AHS). Using innovative approaches to philanthropy, including new partnerships and bold ideas to bring the right people, resources, and solutions together, we are improving health, reducing the devastating impact of disease, and addressing the inequitable health challenges faced by members of diverse cultures. https://givetouhf.ca opens in new tab/window

About Elsevier

As a global leader in scientific information and analytics, Elsevier helps researchers and healthcare professionals advance science and improve health outcomes for the benefit of society. We do this by facilitating insights and critical decision-making with innovative solutions based on trusted, evidence-based content and advanced AI-enabled digital technologies.

We have supported the work of our research and healthcare communities for more than 140 years. Our 9,500 employees around the world, including 2,500 technologists, are dedicated to supporting researchers, librarians, academic leaders, funders, governments, R&D-intensive companies, doctors, nurses, future healthcare professionals and educators in their critical work. Our 2,900 scientific journals and iconic reference books include the foremost titles in their fields, including Cell Press, The Lancet and Gray’s Anatomy.

Together with the Elsevier Foundation opens in new tab/window, we work in partnership with the communities we serve to advance inclusion and diversity in science, research and healthcare in developing countries and around the world.

Elsevier is part of RELX opens in new tab/window, a global provider of information-based analytics and decision tools for professional and business customers. For more information on our work, digital solutions and content, visit www.elsevier.com.