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Medium-term effectiveness of a comprehensive internet-based and patient specific tele-rehabilitation program with text messaging support for cardiac patients : randomized controlled trial.Frederik I, Hansen D, Coninx K, et al.
J Med Internet Res 2015, vol 17; 7: e 185
A comprehensive cardiac rehabilitation (CR) is indicated in patients after an acute coronary syndrome, cardiac surgery and chronic heart failure. The short term objective of CR is to improve functional capacity and quality of life, medium term cardiovascular risk factors control, long-term reduced cardiovascular morbility, hospitalisations and mortality. The majority of published studies indicate that a number of patients voluntarily stop CR programs with a drop-out rate ranging from 10% to 40%, vanishing any benefits and increasing health costs. Main factors influencing drop outs and lack of adhesion are distance from CR centre and lack of motivation. Thus, after a first phase of intensive or extensive CR, it is crucial to continue a CR program at home based on regular exercise, correct nutrition and hydration, and smoke cessation. The continuity is the premise of long term benefits, and the real significance of secondary prevention of which CR is the first step to maintain these benefits all life long. Thus, it is important to find methods to convince patients to exercise regularly and eat properly once hospital CR program ends.
Telemonitoring using internet based programmes may be a modern way to continue CR at home and a possible way to maintain supervision far from hospital CR settings. Authors studied 140 patients with coronary artery disease (CAD) and chronic heart failure (CHF) with preserved or reduced ejection fraction randomized to an intervention group (n=70) who received hospital CR and tele-rehabilitation for 6 months, and a control group (n=70) which performed CR as the intervention group, but no tele-rehabilitation. It was demonstrated that functional capacity measured as peak VO2 and quality of life assessed by questionnaire (14-item offline HeartQol) were both improved significantly in patients with coronary artery disease and chronic heart failure with both preserved or reduced ejection fraction, as compared with control group who underwent traditional hospital based CR. In detail, peak VO2 improved from 22.5(6) ml/kg/min to 24.5 (8) ml/kg/min at 6 months in the intervention group (P<0.001 vs controls). Quality of life showed similar improvement in the intervention group (P<0.001 vs controls). These results have been obtained by other groups in a population of chronic heart failure patients. From 13,248 CAD and CHF patients in 37 studies with a mean 9 month follow up, tele-rehabilitation was associated with significantly lower lack of adherence to physical activity guidelines (OR 0.56, 95% CI 0.45-0.69). Drop-out rates were also reduced.
Limitations of the present study may be the use of devices in old people not so familiar with internet usage, and costs. Another limitation may be the lack of an untrained control group, even if, at this point, a lack of CR after cardiovascular events seems to be unethical. A multicenter trial should be performed in order to make tele-rehabilitation a common method of cardiovascular prevention for the next years.
A cost-effectiveness analysis has been performed by the same team (I. Frederik et al.). The results of this analysis are published in the European Journal of Preventive Cardiology.
Read Patrick Doherty’s comment “The benefits of cardiac telerehabilitation: Cost-effectiveness”.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology
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