Social support needed to reduce the barriers in accessing 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 to the Canadian Journal of Cardiology, 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!"