Treadmills, elliptical machines, and tennis shoes; objects commonly associated with leisure time and fitness training are abundant on the 16th floor of the NYU Ambulatory Care Center, home to the NYU Cardiac Rehabilitation Program. Cardiac rehabilitation (CR) programs involve regimented, structured physical activity and are typically employed over the course of many weeks; at NYU, the standard schedule involves supervised activity three times per week for three months.
Evidence suggests that participation in CR programs after hospitalization for a variety of cardiac conditions and procedures (including stable ischemic heart disease, heart failure, and following coronary revascularization) imparts real benefits including decreased cardiovascular-related mortality, reduced hospital admissions, and improvement in health-related quality of life. ACC/AHA guidelines accordingly assign a Class I recommendation for the prescription of CR programs to patients after hospitalization for acute coronary syndrome, post-revascularization, or heart failure.
Despite these recommendations, CR programs are underutilized. Studies (here and here) have noted that many patients who could benefit from participation in a CR program are not referred upon discharge, and under-referral is even more pronounced in older patients. Given that adults over the age of 65 have the highest rates of mortality related to acute myocardial infarction and heart failure, lack of referral for these patients may represent a glaring missed opportunity for significant impact.
Notably, in a recent observational study by Flint et. al. of patients aged ≥65 with acute myocardial infarction, those with slow gait speed – a marker of frailty – were less frequently referred to CR programs. While reasons for this phenomenon are likely multifactorial (e.g. transportation, lack of available facilities, physical limitations), an important and addressable factor is referral bias; clinicians may feel that a patient who is “too frail” may be unlikely to benefit from a program that includes frequent structured exercise. Notably, in the study by Flint et al., patients with slow gait speed who participated in a CR program garnered similar benefits in outcomes (mortality, maintenance of activities of daily living) when compared their less frail counterparts. These data (which build on previous observations) suggest that even older adults who are considered frail or have significant medical comorbidities benefit from standardized referral to CR.
Initial referral is just one of many potential barriers to participation in CR programs: economic and social factors contribute to reduced rates of participation and adherence. Time commitment, including distance from home to a CR program, has also been mentioned as a barrier to utilization. In this context, mobile health (mHealth) companies are rapidly moving to develop home-based CR programs that leverage existing technologies (smartphones, tablet devices, wearable monitors) with the promise that they can serve as either a substitute or adjunctive therapy to traditional ambulatory CR programs. If successful, they may fill a significant gap in our current care paradigms for older adults by reducing a number of barriers to participation in CR programs; but rigorous trials will be ultimately required to evaluate their efficacy.
By: John Bostrom, MD