Faculty Bibliography

BACKGROUND:Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults' uptake, and efficacy data are currently lacking. OBJECTIVE:This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. METHODS:RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). RESULTS:As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. CONCLUSIONS:The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/32163.

Background: Mobile health cardiac rehabilitation (mHealth-CR) may improve outcomes among older adults with ischemic heart disease, but variable engagement is not yet understood. We therefore analyzed preliminary data from the RESILIENT trial, an ongoing randomized trial of mHealth-CR vs. usual care in patients age >= 65.
Method(s): Data from the first 50 intervention participants were analyzed. Weekly engagement was scored from 0-11 based on exercise completion, therapist communication, video viewing, and BP self-measurement. Participants were classified as high or low engagement based on median engagement scores. Groups were compared by age, sex, social support (living alone), depression (PHQ-8), and Charlson Comorbidity Index (CCI).
Result(s): There was widely varying engagement with mHealth-CR that ranged from nearly zero to nearly perfect engagement (Figure). There were no significant differences between high and low engagement groups based on mean age (72.6 vs. 72.8, P=0.8), sex (76% male vs. 80%, P=0.7), living alone (28% vs. 44%, P=0.2), depression (mean 3.9 vs. 4.6, P=0.5), or comorbidity burden (mean 4.4 vs. 4.8, P=0.3), although the sample size was small.
Conclusion(s): Our early findings show wide variation in mHealth-CR engagement among older adults

Dyspnoea self-management is often suboptimal for patients with COPD. Many patients with COPD experience chronic dyspnoea as distressing and disabling, especially during physical activities. Breathing therapy is a behavioural intervention that targets reducing the distress and impact of dyspnoea on exertion in daily living. Using a qualitative design, we conducted interviews with 14 patients after they participated in a novel mind-body breathing therapy intervention adjunct, capnography-assisted respiratory therapy (CART), combined with outpatient pulmonary rehabilitation. Comprehensive CART consisted of patient-centred biofeedback, tailored breathing exercises, a home exercise programme and motivational interviewing counselling. We assessed participants' perceptions and reported experiences to gauge the acceptability of CART and refine CART based on feedback. Constant comparative analysis was used to identify commonalities and themes. We identified three main themes relating to the acceptability and reported benefits of CART: (1) self-regulating breathing; (2) impact on health; and (3) patient satisfaction. Our findings were used to refine and optimise CART (i.e. its intensity, timing and format) for COPD. By addressing dysfunctional breathing behaviours and dysregulated interoception, CART offers a promising new paradigm for relieving dyspnoea and related anxiety in patients with COPD.

Background Cardiac rehabilitation (CR) is increasingly being prescribed for adult congenital heart disease (ACHD) patients after cardiac procedures or for reduced exercise tolerance. We aim to describe the functional capacity improvements of ACHD patients in CR. Methods This retrospective study included ACHD patients at NYU Rusk Cardiac Rehabilitation from 2013-2019. We collected data on patient characteristics, number of sessions attended, and exercise testing results. Paired sample t-tests were used to assess for changes between pre- and post-CR exercise time and metabolic equivalents (METs). Results In total, 76 ACHD patients (mean age 38.2 years, 56.6% female, 89.5% moderate or complex conditions by anatomic classification) participated in CR. Referral indication was reduced exercise tolerance for 43.4% and was post-cardiac procedure (transcatheter or surgical) for the remainder. Among 37 patients (48.7%) who finished all 36 CR sessions, complete exercise testing data was available for 29 of them. Exercise time increased by 83.8 seconds (95% CI, 43.9 - 123.8; baseline mean 520.7), METs increased by 1.2 (95% CI, 0.6 - 1.8; baseline mean 8.1), and both parameters increased for 72.4% of these patients. These statistically significant improvements were observed across referral indications. Conclusion On average, CR benefits ACHD patients who complete the program, regardless of referral indication. Efforts to increase CR referral and retention would allow more patients to benefit. [Formula presented]
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PURPOSE/OBJECTIVE:Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS:We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS:Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS:Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

With the ubiquity of mobile devices, the availability of mobile health (mHealth) applications for cardiovascular disease (CVD) has markedly increased in recent years. Older adults represent a population with a high CVD burden and therefore have the potential to benefit considerably from interventions that utilize mHealth. Traditional facility-based cardiac rehabilitation represents one intervention that is currently underutilized for CVD patients and, because of the unique barriers that older adults face, represents an attractive target for mHealth interventions. Despite potential barriers to mHealth adoption in older populations, there is also evidence that older patients may be willing to adopt these technologies. In this review, we highlight the potential for mHealth uptake for older adults with CVD, with a particular focus on mHealth cardiac rehabilitation (mHealth-CR) and evidence being generated in this field.