1. Introduction
1.1. Cardiac Rehabilitation
CR (cardiac rehabilitation) utilizes specific exercises supervised by health care
professionals, such as cycling, swimming, running, and walking, which benefit the
patient’s blood lipid levels and blood pressure. The goal is to help them return to an active
lifestyle post coronary artery disease, myocardial infarction, and atherosclerosis.1
CR comprises three phases: Clinical, out-patient, and post-CR.2 The clinical phase
focuses on post-intervention therapy and assessing the patient’s ability to tolerate
rehabilitation. Out-patient CR focuses on developing a patient-centered therapy plan and
starting physical rehabilitation to prevent recurrent events. Post-CR involves aerobic
training and independence, where the patient can maintain a healthy, active lifestyle at
home with intervention as necessary.3
CR has clear positive effects as it reduces heart disease mortality.4,5 It was also
beneficial in preventing future heart problems in those with a risk factor that is a
precursor to cardiovascular disease.6
1.2. Inequity in Access to Cardiac Rehabilitation
There are several barriers that prevent heart failure patients from accessing cardiac
rehabilitation. These include a lack of awareness about the availability of rehab programs
and transportation issues for those who live in rural or remote areas. In addition, there
are cost concerns due to insurance coverage limitations, time constraints for patients who
work full-time, and physical limitations such as mobility issues.7
Additionally, social barriers such as profiling based on race, gender, and culture
may also be factors that limit access to cardiac rehabilitation services.8 Addressing these
barriers is important because research has shown that participation in cardiac
rehabilitation can improve outcomes such as quality of life, functional capacity, and
mortality rates among people with heart failure. Nonetheless, a randomized program
concluded no correlation between CR and all-cause mortality.7 Howbeit, a gender bias
of mostly males led to a reduction in accuracy. It is important to note that there is a lack
of data on the effects of CR on patient populations from populations due to attrition bias.
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Attrition bias is the process by which the number of participants decreases for multiple
reasons: unwanted side effects, dissatisfaction with treatments, or death from other
causes. This bias further decreases the generalisability, validity, and reliability of the
results.9
1.2.1. Racial Inequity
Even though rates of hypertension prevalence are highest in African Americans.10–
12 They are less likely to be appropriately treated for most of the conditions predisposed
to the development of PAD, including cigarette smoking, diabetes, hypertension, and
hyperlipidemia. Lack of referral and financial resources are among the main barriers to
CR participation globally.13 However, most patients who need this rehabilitation are inpatients
who are referred to the program by their attending doctor, thus minimizing the
number of walk-in CR patients. Studies indicate that CR referral and participation rates
are lower among patients from ethnic minorities. When socioeconomic status and
education access are controlled, ethnic minorities often receive lower-quality health care
than white patients. It is unclear how the quality of health care was measured and it is
difficult to know if ethnicity played a part in the wellbeing of the patients throughout the
trials.14
1.2.2. Gender
Women tend to have a lower referral and enrollment rate than men.15,16 They also
have a higher dropout rate due to social and logistical factors (e.g., family responsibilities
and dependence).16 One study conducted in 2017 with 44 men and 21 women aged 50
to 76 argues that women older than 65 are more prone to disabilities post-cardiac
surgery.15,17 This once again launches a gender bias towards this study, and the sample
size is too small compared to a study with 1,297,204 bypass surgeries, including 317,716
done in females. The latter study established, with and without prejudice, that female
bypass patients had an increased risk of mortality between 28 to 41%. This plays a role
in females not getting the opportunity to participate in cardiac rehabilitation programs.18
1.2.3. Age
Due to the elderly community being more prone to suffer through a heart attack,
stroke, and CAD, there is a lack of evidence attributed to selection bias on the
effectiveness of CR in different age groups.19 Additionally, younger patients who do
experience cardiovascular diseases inevitably have a higher mortality rate making it
difficult to determine the relationship between age and CR due to a phenomenon called
survivorship bias.6
1.3. Comorbidities
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Although comorbidities such as obesity are believed to affect the outcome of cardiac
rehabilitation, a study conducted in 2021 suggests no significant negative correlation
between heart health and measurable results. This includes chronotropic competence
after cardiac rehabilitation between obese and non-obese patients.20
1.4. Telehealth and Telerehabilitation
Telehealth or mHealth21 is a system of providing healthcare remotely through
wireless technology.22,23 This includes video conferencing, remote monitoring, and
mobile apps. It allows patients to receive medical care from their homes, reducing the
need for in-person visits and improving access to healthcare, especially for those who
live in remote areas or have mobility issues. Telehealth has been increasingly used
recently and has become especially relevant during the COVID-19 pandemic.24
Telerehabilitation is a type of telehealth that specifically focuses on providing
rehabilitation services remotely through technology.25 It can include video conferencing
sessions with a physical therapist or other healthcare providers, remote monitoring of
exercises and progress, and using mobile apps to guide patients through their
rehabilitation programs.26
Telerehabilitation has been shown to be effective for various conditions such as
stroke, spinal cord injury, and musculoskeletal disorders. Like telehealth in general, it
can improve access to care for those with difficulty traveling or accessing traditional inperson
rehab services due to socio-economic barriers. However, there is not enough
data to come to a conclusion on the efficacy of telerehabilitation and there were no details
regarding the sample size and exclusion criteria.27
1.5. Availability and Timing of CR Programs
The British Heart Foundation recommends cardiac rehabilitation to commence
within four weeks (28 days) of interventions.1 These interventions include PCI, and postMI-PCI; however, for coronary bypass surgery (CABG), the recommended
commencement period is adjusted for recovery and is therefore increased to 42 days. A
paper from 2015 conducted a data analysis on the NHS National Audit of Cardiac
Rehabilitation (NACR) database. The study noted a strong correlation and concluded that
for each day delayed in the commencement of CR; the patients were 1% less likely to
improve in fitness-related measures. In reference to early rehabilitation, patients
achieved healthy physical activity levels, and normal fitness-related QoL increased by
31% and 36%, respectively. On the contrary, late rehabilitation patients improved their
physical activity levels and QoL by 27% and 29%, respectively.28 More details should
have been provided on the limitations and biases.These include lack of control,
confounding variables and how the participants were selected.
1.6. Target audience of CR
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CR programmes are designated for cardiovascular patients. However, it is worth
noting that stroke patients and CAD patients share similar risk factors29,30 which is why it
could benefit them to join the cardiac rehabilitation program.31,32 However, it is
questionable whether or not they should be enrolled in the program as it produces many
ethical issues in relation to their inclusion.33 One of these issues would be occupying the
possibly available spaces for patients recovering from a heart attack. In addition, it is
important to note that stroke and cardiac patients may have different needs to treat their
specific concerns.31 Therefore, the best program for cardiac patients should include
aerobic exercises.34 This also applies to stroke patients as they are likely to suffer from
neurological deficits which can be most effectively treated with resistance exercises and
physiotherapy. It is important to note that both groups can benefit from the reduction in
risk factors, positive lifestyle changes and education but it may be unethical to combine
their treatment as it leads to inadequate care for both groups.29
2. Objectives
Highlight the current literature on the efficacy of hospital-based cardiac
rehabilitation.
Explore barriers to access and adherence to cardiac rehabilitation.
Ascertain the value of remote methods of cardiac rehabilitation in overcoming these
barriers.
Determine if CR can be expanded to include stroke patients.
Summarise and critique studies investigating alternate methods of cardiac
rehabilitation and their effectiveness.
3. Methodology
3.1 Search Strategy
The search was conducted across PubMed, MEDLINE, and PubMedCentral
databases. Two MeSH terms were used in the search: ”Cardiac Rehabilitation” and
”Telerehabilitation”. Additionally, other similar keywords were added to the query.
The query yielded 81 results. Their results were further narrowed by assessing them
through our inclusion criteria.
3.2 Inclusion Criteria
All studies included in this review were published between 2013-2023, measure
quantitative data and have full text available.
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4. Discussion
Currently, two forms of cardiac rehabilitation, center-based and home-based, are
provided to patients. During center-based rehabilitation, patients are supervised, making
it a safer option.35 However, it’s more costly as it runs over a longer course of time and
could be unsuitable for people living in rural areas.36 Home-based CR is only ideal when
the patients are compliant and disciplined enough to do everything independently. Centerbased
cardiac rehabilitation had a higher drop-out rate than home-based cardiac
rehabilitation. Still, both programs positively affected clinical outcomes and quality of
life.37 Home-based cardiac rehabilitation is more convenient but compromises on
improvements in chronotropic measures.38,39,27
In regard to overcoming barriers in minority groups, efforts should be made to
improve accessibility by offering home-based CR to patients struggling with constraints.
Patients should be made aware of CR programs post-discharge to prevent overwhelming
them with information. Furthermore, more equipment and staff should be allocated to CR
programs to increase uptake and decrease waiting times and improve outcomes from
timely interventions.
General solutions to the barriers faced by CR patients would be improving the
accessibility of the affiliated health care departments, making the programs more
individualized rather than doing it in groups, and raising awareness on the importance of
cardiac rehabilitation as an element of full recovery and treatment of certain heart
conditions.
5. Conclusion
In conclusion, the importance of cardiac rehabilitation is usually undermined by
doctors and patients so it is necessary to assess the effectiveness of cardiac rehabilitation
in the methods available of following through with it and how accessible it is when needed.
It is also important to evaluate the different barriers that affect uptake, adherence, and
prognosis of the treatment and draw solutions to such barriers. CR could branch out to
other areas of detrimental diseases such as strokes which adds to the many motives of
uptaking of such programs.