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Traditional centre-based cardiac rehabilitation (CR) programmes have been developed and evaluated in various countries for more than four decades.1 The evidence for the effectiveness of CR in coronary heart disease has been accumulating and the benefits in terms of reductions in cardiovascular mortality and unplanned hospital readmissions coupled with an improvement in health-related quality of life.2 Comprehensive CR is now recommended by several international guidelines and all eligible patients with coronary heart disease including heart failure are encouraged to participate in CR.3 ,4 However, the uptake and usage of CR has remained suboptimal—with participation rates of 10%–30% reported in Europe, USA and Australia.5 Reasons given for poor uptake include low referral rates, problems with transport especially in rural locations, work commitments, a dislike of groups and a lack of funding and trained healthcare personnel.3 ,5 To remedy this, there have been calls to make CR interventions more patient centred with policies that support initiatives offering alternatives to centre-based CR.6 Emerging models of alternative CR which may increase participation include home-based and telehealth-based CR delivered to individuals.3 ,5
In their Heart publication, Rawstorn et al report on a systematic review and meta-analysis seeking to determine the benefits of telehealth exercise-based CR compared with traditional centre-based CR or usual care on exercise capacity and other cardiovascular risk factors.7A total of 11 randomised controlled trial (RCTs) in 1189 patients with coronary heart disease met their eligibility criteria and were included in their analysis. Three of the studies were conducted in Canada with single study reports from Australia, Belgium, Brazil, France, Korea, Netherlands, New Zealand and the USA—all the studies were published in this century (2002–2014). Compared with the post 2005 studies included in the latest Cochrane systematic review of CR for coronary heart disease the mean age of patients was slightly younger (mean age 58 vs 61.7 years) although the participants were comparable in terms of gender mix (25% female) and included patients other than post-myocardial infarction (MI) (following admission for acute coronary syndrome or revascularisation).2 ,7
The telehealth technologies used included landline telephones, internet-based websites using computers and mobile/smartphones with some use of applications (apps). The majority of the telehealth CR interventions delivered walking at moderate to vigorous intensity for 30–60 min, 2–5 times a week. Biosensors were used to monitor heart rate and physical activity (eg, accelerometers). Clinical data were reviewed by clinicians and fed back to patients who were also given online ‘education and psychosocial support’ via the telephone or computer, although two telehealth CR interventions also included face-to-face consultations.7
The key outcomes of the studies included exercise capacity, physical activity, adherence to exercise and cardiovascular risk factors—blood pressure, blood lipids, blood glucose and body composition (such as body mass index and waist:hip ratios). Unexpectedly, the authors report that compared with usual care, telehealth CR was more effective in improving physical activity but there were no differences in any other outcomes.7 They acknowledge that this is in contrast with the evidence that demonstrates that exercise-based CR results in improvements in exercise capacity and cardiovascular risk factors.3 ,4 In contrast, and, again surprisingly, outcomes were found to be better when comparisons were made with centre-based CR. Telehealth CR interventions were apparently superior at improving levels of physical activity and patients were more adherent to the prescribed exercise regimes with improvements in diastolic blood pressure and serum low density lipoprotein (LDL) cholesterol levels. These findings probably reflect the differing nature of the telehealth CR interventions across the trials included in this review. In the round of our broader knowledge of the evidence base for CR, a more intuitive conclusion is that telehealth CR interventions offer similar benefits to centre-based CR, both offering outcome advantages for patients over usual care (no CR). In other words this systematic review provides evidence for telehealth CR to offer to patients alongside home-based CR as an alternative to centre-based CR.7
Nevertheless, the claim of review authors that the superior levels of adherence to exercise and higher levels of physical activity in those engaging in telehealth CR has the ‘potential for telehealth CR to transform’ accessibility to CR should be approached with caution.7 Given that western populations are ageing and the mean age of the participants in this review was 58 years the findings may not be generalisable to an elderly population as acknowledged by the authors. The latter group tend to have multiple morbidities including heart failure and may be less willing to embrace telehealth-based technologies. More targeted research is needed in these older populations. Further research in telehealth CR should also attempt to conduct fully powered studies with longer follow-up (at least 12 months). The focus should be on outcomes such as health-related quality of life and unplanned hospital admissions related to cardiovascular events as reported in recent trials.2
However, this is another systematic review which suggests that we could increase the rate of participation in CR by employing alternative models to centre-based CR.5 ,7 In addition to alternatives to centre-based CR there needs to be strong physician/clinician endorsement to CR. Lavie et al have called for a ‘multifaceted endorsement of CR from healthcare professionals- cardiologists, general physicians, nurses, exercise physiologists and primary care physicians’.8
The current model of centre-based CR is limited by many issues which compromise easy access3 ,4 and ‘one size fits all’ is not the answer.8 Recent calls for alternative models that include home-based, internet-based and community-based programmes need to be heeded if we are to improve on participation rates which have remained suboptimal for decades.1 ,8 ,9 Given the global and widespread use of smartphones, we should explore how best to use web-based and mobile applications including personal tracking devices (accelerometers/pedometers) to deliver and monitor tele-based CR interventions for younger and older people with coronary heart disease. Use of telehealth-based CR models will help to augment current centre-based and home-based CR interventions to reach a much larger population with coronary heart disease. It is important to remember that patients can have strong preferences for the model of CR they receive.10 Where possible these choices of centre, home and telehealth (and combinations) need to be considered by providers and commissioners to address our current uptake challenge in CR.
Contributors The editorial was led by HMD and both authors have contributed to the writing and editing of earlier drafts. Tony Mourant, retired consultant cardiologist made comments on an earlier draft of this editorial.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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