NIHR Signal Telehealth may help some people be more active after a heart attack

Published on 21 June 2016

A variety of “telehealth” approaches may be worth considering for encouraging physical activity after a heart attack or heart surgery, suggests a review of published research. Cardiac rehabilitation and exercise programmes are well known to be effective in improving survival following a heart attack.

Typical cardiac rehabilitation programmes offer exercise classes, education about heart disease and healthier lifestyle, and approaches to reduce stress. Although rehabilitation is usually provided as group sessions in hospital settings, in the UK only about 45% of those eligible join schemes and many drop out. This review looked at 11 studies of telehealth from around the developed world that included telephone contact, text messages, email reminders or exercise-related phone apps for use at home compared with rehabilitation delivered at a centre.

Overall, the review found few studies comparing telehealth delivered programmes directly with centre-based rehabilitation, and the evidence was not strong enough to be confident of any difference on exercise levels or fitness outcomes. There was a modest benefit over usual care. People using telehealth delivered programmes appear to complete more sessions. There was no evidence to compare costs.

The study population, at an average age of 58, was young. Whether telehealth works for people who are older or less likely to use technology is yet to be tested.

Telehealth may help some people be more active after a heart attack

Why was this study needed?

Cardiac rehabilitation reduces the risk of death from heart disease by 26 to 36% and reduces readmissions by 28 to 56%. However, uptake in the UK is low. Of the 134,525 people who had a heart attack or bypass graft in 2013, just 45% attended cardiac rehabilitation. Rates were highest following bypass surgery at 86% but as low as 33% after a heart attack.

Commonly cited reasons for non-attendance include work commitments, travel difficulty, or disliking group activities.

This systematic review and meta-analysis examined if telehealth routes are an effective method for providing the exercise element of cardiac rehabilitation programmes as this may be more convenient and improve uptake.

What did this study do?

Results from 11 randomised controlled trials were pooled which compared telehealth with centre-based exercise cardiac rehabilitation or usual care. There were 1,189 participants, aged 53 to 63 years, from trials conducted in Western countries with comparable approaches to cardiac rehabilitation, though none included were undertaken in the UK.

Telehealth approaches included phones, apps, email, and other online communication to deliver prescriptive exercise instructions and receive biosensor data for review by specialists. Activity in these approaches occurred at home. Centre-based cardiac rehabilitation included two to three supervised exercise sessions per week. Usual care could include advice to be more active at home, but not prescribed exercise training.

Reliability in the results is limited as most trials had a high risk of selection bias, meaning that the characteristics of two groups being tested might have been different. Some studies were small (15 people) and there were other differences between them in terms of frequency and type of telehealth intervention and length of follow-up.

What did it find?

The studies used a wide variety of technologies and approaches. The use of older approaches (such as landline phone calls) was more common than use of newer apps or biosensors.

  • Physical activity levels, such as step counts, were slightly better for telehealth participants compared to usual care in four studies (standardised mean difference [SMD] 0.29, 95% confidence interval [CI] 0.07 to 0.50).
  • Levels were significantly higher in a single follow-on study of 66 people who had already completed cardiac rehabilitation. In this study, wearing a motion sensor and receiving telehealth weekly goals increased the daily step-count by 10,000 steps (about five miles) (SMD 9.84, 95% CI 8.05 to 11.64) and greatly improved oxygen uptake capacity compared to no intervention.
  • Exercise programme adherence was better for telehealth compared with centre-based programmes, in the three studies that reported number of sessions completed (SMD 0.75, 95% CI 0.52 to 0.98).
  • Maximum aerobic fitness did not differ significantly between telehealth and centre-based or usual care approaches, as reported in seven studies.
  • Overall, cardiovascular risk factors (body composition, blood pressure, blood lipids and blood glucose) did not differ significantly between telehealth and centre-based approaches, but there was wide variation in the values. This means we cannot be confident of a true change in values for different approaches.

What does current guidance say on this issue?

NICE guidance from 2013 on cardiac rehabilitation recommends a preventative approach against future heart attacks, including lifestyle changes, regular physical activity and attending and completing a cardiac rehabilitation programme.

It recommends cardiac rehabilitation should be offered in a choice of settings including the person’s home or a centre. However, it does not mention telehealth.

The British Association for Cardiovascular Prevention and Rehabilitation guidance from 2012 gives more detail on the components and delivery of cardiac rehabilitation programmes, but does not mention telehealth either.

What are the implications?

Despite limitations in the underlying research, there is some evidence that telehealth could be an effective option for people who are unable or unwilling to participate in centre-based cardiac rehabilitation exercise programmes.

There was no information on the costs of cardiac rehabilitation exercise delivered by telehealth, compared with centre-based rehabilitation. However, cardiac rehabilitation programmes in centres are known to be very cost effective relative to the cost of cardiac-related hospital admission. It is reasonable to assume that telehealth approaches may also offer savings compared with no rehabilitation.

Before any implementation of these technologies it would be useful to know more about the reasons for success in some programmes and further research is needed in the UK context, involving older participants and/or using newer technologies.

Citation and Funding

Rawstorn JC, Gant N, Direito A, et al. Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis. Heart. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

BHF. Cardiac rehabilitation. London: British Heart Foundation; accessed 2016.

Dalal HM, Taylor RS. Telehealth technologies could improve suboptimal rates of participation in cardiac rehabilitation. Heart. 2016. [Epub ahead of print].

Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ. 2015;351:h5000.

JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart. 2014;100(suppl 2):ii1-67.

MINAP. Myocardial Ischaemia National Audit Project. Annual public report April 2013 – March 2014. London: MINAP; 2014.

NICE. Secondary prevention in primary and secondary care for patients following a myocardial infarction. CG172. London: National Institute for Health and Care Excellence; 2013.

UKBACPR. BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012. 2nd ed. London: British Association for Cardiovascular Prevention and Rehabilitation; 2012.

Why was this study needed?

Cardiac rehabilitation reduces the risk of death from heart disease by 26 to 36% and reduces readmissions by 28 to 56%. However, uptake in the UK is low. Of the 134,525 people who had a heart attack or bypass graft in 2013, just 45% attended cardiac rehabilitation. Rates were highest following bypass surgery at 86% but as low as 33% after a heart attack.

Commonly cited reasons for non-attendance include work commitments, travel difficulty, or disliking group activities.

This systematic review and meta-analysis examined if telehealth routes are an effective method for providing the exercise element of cardiac rehabilitation programmes as this may be more convenient and improve uptake.

What did this study do?

Results from 11 randomised controlled trials were pooled which compared telehealth with centre-based exercise cardiac rehabilitation or usual care. There were 1,189 participants, aged 53 to 63 years, from trials conducted in Western countries with comparable approaches to cardiac rehabilitation, though none included were undertaken in the UK.

Telehealth approaches included phones, apps, email, and other online communication to deliver prescriptive exercise instructions and receive biosensor data for review by specialists. Activity in these approaches occurred at home. Centre-based cardiac rehabilitation included two to three supervised exercise sessions per week. Usual care could include advice to be more active at home, but not prescribed exercise training.

Reliability in the results is limited as most trials had a high risk of selection bias, meaning that the characteristics of two groups being tested might have been different. Some studies were small (15 people) and there were other differences between them in terms of frequency and type of telehealth intervention and length of follow-up.

What did it find?

The studies used a wide variety of technologies and approaches. The use of older approaches (such as landline phone calls) was more common than use of newer apps or biosensors.

  • Physical activity levels, such as step counts, were slightly better for telehealth participants compared to usual care in four studies (standardised mean difference [SMD] 0.29, 95% confidence interval [CI] 0.07 to 0.50).
  • Levels were significantly higher in a single follow-on study of 66 people who had already completed cardiac rehabilitation. In this study, wearing a motion sensor and receiving telehealth weekly goals increased the daily step-count by 10,000 steps (about five miles) (SMD 9.84, 95% CI 8.05 to 11.64) and greatly improved oxygen uptake capacity compared to no intervention.
  • Exercise programme adherence was better for telehealth compared with centre-based programmes, in the three studies that reported number of sessions completed (SMD 0.75, 95% CI 0.52 to 0.98).
  • Maximum aerobic fitness did not differ significantly between telehealth and centre-based or usual care approaches, as reported in seven studies.
  • Overall, cardiovascular risk factors (body composition, blood pressure, blood lipids and blood glucose) did not differ significantly between telehealth and centre-based approaches, but there was wide variation in the values. This means we cannot be confident of a true change in values for different approaches.

What does current guidance say on this issue?

NICE guidance from 2013 on cardiac rehabilitation recommends a preventative approach against future heart attacks, including lifestyle changes, regular physical activity and attending and completing a cardiac rehabilitation programme.

It recommends cardiac rehabilitation should be offered in a choice of settings including the person’s home or a centre. However, it does not mention telehealth.

The British Association for Cardiovascular Prevention and Rehabilitation guidance from 2012 gives more detail on the components and delivery of cardiac rehabilitation programmes, but does not mention telehealth either.

What are the implications?

Despite limitations in the underlying research, there is some evidence that telehealth could be an effective option for people who are unable or unwilling to participate in centre-based cardiac rehabilitation exercise programmes.

There was no information on the costs of cardiac rehabilitation exercise delivered by telehealth, compared with centre-based rehabilitation. However, cardiac rehabilitation programmes in centres are known to be very cost effective relative to the cost of cardiac-related hospital admission. It is reasonable to assume that telehealth approaches may also offer savings compared with no rehabilitation.

Before any implementation of these technologies it would be useful to know more about the reasons for success in some programmes and further research is needed in the UK context, involving older participants and/or using newer technologies.

Citation and Funding

Rawstorn JC, Gant N, Direito A, et al. Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis. Heart. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

BHF. Cardiac rehabilitation. London: British Heart Foundation; accessed 2016.

Dalal HM, Taylor RS. Telehealth technologies could improve suboptimal rates of participation in cardiac rehabilitation. Heart. 2016. [Epub ahead of print].

Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ. 2015;351:h5000.

JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart. 2014;100(suppl 2):ii1-67.

MINAP. Myocardial Ischaemia National Audit Project. Annual public report April 2013 – March 2014. London: MINAP; 2014.

NICE. Secondary prevention in primary and secondary care for patients following a myocardial infarction. CG172. London: National Institute for Health and Care Excellence; 2013.

UKBACPR. BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012. 2nd ed. London: British Association for Cardiovascular Prevention and Rehabilitation; 2012.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

Published on 5 March 2016

Rawstorn, J. C.,Gant, N.,Direito, A.,Beckmann, C.,Maddison, R.

Heart , 2016

OBJECTIVE: Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD). METHODS: CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence. RESULTS: 11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors. CONCLUSIONS: Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

Cardiac rehabilitation is recommended within two weeks of diagnosis or discharge from hospital for conditions such as stable angina, stable heart failure and following a heart attack and heart operations. It involves help to modify lifestyle risk factors such as smoking and diet, and support to achieve individualised physical activity goals. Other elements include addressing any psychosocial problems and measures to reduce medical risk factors including high blood pressure and cholesterol.

Expert commentary

The traditional, ‘one size fits all’ model of centre-based cardiac rehabilitation programs has many limitations, which compromise easy access. There have been suggestions that alternatives are needed, such as home-based, internet and community options, if we are to improve historically low participation rates. We also should investigate further the potential of smartphones to help deliver and monitor cardiac rehabilitation interventions (e.g. via personal tracking devices such as accelerometers or pedometers) for both younger and older people.

Rod S Taylor, Professor of Health Services Research, University of Exeter Medical School

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  •   Cardiovascular system disorders, Physical therapy