Abstract Background Coronary artery calcification (CAC) scoring can be measured as a by-product of computed tomography (CT). CAC scoring reflects the general cardiovascular risk profile of patients. The aim of the present study was to determine the prognostic role of CAC on overall survival (OS) in patients with different hematological diseases undergoing allogeneic stem cell transplantation. Methods A retrospective analysis was conducted on all patients undergoing peripheral blood stem cell transplantation between January 2015 and October 2021. A total of 121 patients (68 male patients, 56.1%) with a mean age of 53.1 ± 13.6 years were identified in the data base and included into the present study. The clinical CT scan to rule out infectious foci was used to assess the CAC score for each patient. The semiquantitative Weston score was measured to quantify CAC. Results A total of 67 patients (54.9%) died during the course of the study. A total of 52 patients (42.6%) had visible calcifications on CT images, whereas 70 patients (57.4%) had no calcifications (CAC score 0). There was no association between the CAC score with OS, with an HR of 1.14 (95% CI 0.89; 1.45), p = 0.28) as a metric variable and HR of 1.33 (95% CI 0.82; 2.15) as a dichotomized variable (CAC score 0 versus positive CAC score). There was no association between CAC score and occurrence of sepsis or graft-versus host disease after transplantation. Conclusions The presence of CT-defined coronary calcifications has no prognostic relevance in patients undergoing allogeneic stem cell therapy. The impact of CT-defined cardiovascular risk factors appears to be relatively modest in this heterogeneous patient sample.
Cardiovascular disease remains the leading cause of morbidity and mortality among cancer survivors. Multiple cardiovascular risk prediction models exist to provide risk stratification for patients who are about to undergo cancer treatment. Current risk models have limited guidance on how to prevent, modify, and monitor for heart failure (HF) particularly heart failure with preserved ejection fraction (HFpEF). Cancer survivors are at an elevated risk for HFpEF due to the development of cardiometabolic syndrome associated with aging and long-term survival. Future efforts should focus on novel biomarkers in assessing HF, development of large, multicenter databases that can be used to validate models across diverse populations, and defining clear treatment pathways once risk is identified. A more comprehensive and inclusive risk stratification model with pragmatic approaches to clinical care will allow for more widespread use among cardiologists and oncologists.
Abstract Background Chimeric antigen receptor (CAR) T-cell therapy has substantially improved outcomes in refractory hematologic malignancies but may cause cardiovascular complications, particularly in the context of cytokine release syndrome (CRS). Real-world data on incidence, severity, and prognostic relevance of cancer therapy–related cardiovascular toxicity (CTR-CVT) defined by the 2022 ESC cardio-oncology guidelines remain in the context of CAR-T cell therapy limited. Methods This retrospective single-center study includes 104 patients treated with CAR T-cells between 09/2019 and 02/2024 for acute lymphoblastic leukemia, non-Hodgkin lymphoma and multiple myeloma. The primary endpoint was new-onset CTR-CVT during hospital stay, defined as cancer therapy–related cardiac dysfunction (CTRCD), arrhythmia, myocardial infarction, cardiogenic shock, or cardiovascular death. Clinical characteristics, biomarkers, echocardiographic parameters, CRS/ICANS severity, and survival outcomes were analyzed. Results Fifty-two patients (50%) met criteria for CTR-CVT, predominantly due to asymptomatic biomarker elevation. CTRCD occurred in 48.1%, whereas clinically significant events were rare: three patients developed symptomatic CTRCD, one experienced cardiogenic shock, and no myocardial infarctions or cardiovascular deaths were observed. Cardiovascular events occurred early and were associated with higher-grade CRS and ICANS, as well as elevated inflammatory markers. Reduced baseline left ventricular ejection fraction, elevated systolic pulmonary artery pressure, impaired performance status, and beta-blocker use were associated with increased CTR-CVT risk. Survival was numerically lower in patients with CTR-CVT but did not reach statistical significance. Conclusion Although half of patients fulfilled ESC criteria for CTR-CVT, clinically relevant cardiac events after CAR T-cell therapy were uncommon. These findings suggest potential overclassification driven by biomarker elevations and underscore the importance of emphasizing clinical relevance when assessing cardiotoxicity in CAR T-cell recipients.
Cardiovascular disease (CVD) is a major concern among cancer survivors. However, the intersection of cancer and CVD has only recently gained broader attention, and substantial evidence gaps remain. This study aimed to identify risk factors associated with incident CVD in cancer survivors and to develop a machine learning model for CVD risk prediction. In this retrospective study, we included 2,500 patients receiving systemic antitumor therapy at Jilin Cancer Hospital; 188 incident CVD events were observed. Variables spanning demographic, clinical, tumor- and treatment-related, and laboratory domains were collected. The dataset was randomly split into a training set (75
Myocardial infarction and ischemic stroke are common causes of morbidity after major cancer surgery. Understanding the risks associated with both open and laparoscopic surgery is crucial in reducing postoperative morbidity and mortality. This nationwide cohort study included patients who underwent major cancer surgery in the pelvis from 2000 to 2015. The primary outcome was the incidence of myocardial infarction and ischemic stroke within 90 days postoperatively. Adjusted odds ratios (OR) were estimated using logistic regression adjusted for propensity score and risks by regression standardization. A total of 22,619 patients operated with laparoscopic and 70,896 patients operated with open approach were included in the analysis. The crude 90-day cumulative risks of myocardial infarction and ischemic stroke were 0.66
Early radiation-induced cardiac injury in patients receiving thoracic radiotherapy (RT) remains insufficiently characterized. Global longitudinal strain (GLS) and circulating biomarkers such as high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro–B-type natriuretic peptide (NT-proBNP) may detect subclinical myocardialdamage. This prospective single-center cohort study enrolled 47 adults with thoracic malignancies treated with curative-intent RT. Cardiac assessments were performed at baseline, 1 week, and 12 weeks post-RT. GLS was measured by two-dimensional speckle-tracking echocardiography, and hs-cTnT and NT-proBNP were quantified using high-sensitivity immunoassays. Mean heart dose (MHD) was categorized as < 10 Gy or ≥ 10 Gy to explore dose-stratified differences within this predominantly low-dose exposure cohort. Temporal changes and dose-stratified differences were analyzed using non-parametric tests. GLS remained stable across timepoints (median − 18.06
The coexistence of cancer and aortic stenosis is increasingly common in elderly patients, presenting unique challenges for management. Transcatheter aortic valve implantation (TAVI) offers a less invasive alternative to surgical valve replacement, but the impact of various clinical factors on post-TAVI mortality in cancer patients remains unclear. To systematically review and meta-analyze the predictors of mortality in cancer patients undergoing TAVI for aortic stenosis. A comprehensive literature search was conducted in Scopus, PubMed, Web of Science, and Embase up to May 2025. Studies assessing mortality predictors in cancer patients post-TAVI were included. Data extraction and quality assessment were performed independently by two reviewers. Pooled hazard ratios (HRs) and 95
Cyclin-dependent kinase (CDK) 4/6 inhibitors improve outcomes in hormone receptor–positive, HER2-negative breast cancer, but real-world data on cardiovascular (CV) toxicity are limited. In this single-centre retrospective matched cohort study, women with breast cancer treated with a CDK4/6 inhibitor at University Hospitals Leuven between 2016 and 2022 constituted the index cohort. Age- and BMI-matched women without active cancer, selected from the population-based FLEMENGHO study, constituted the reference cohort. CV events were identified from medical records, and follow-up in the reference cohort was truncated to the maximum follow-up duration of the index cohort to improve comparability. Among 536 matched pairs, the index cohort had a significantly higher observed incidence of CV events than the reference cohort (67.7 vs 17.2 per 1,000 person-years; P < 0.0001), including the cardiac composite (28.0 vs 9.6 per 1,000 person-years; P < 0.0001). Venous thromboembolism (11.6
Patients with ischemic heart disease (IHD) or peripheral artery disease (PAD) represent a high-risk cardiovascular phenotype. When cancer is diagnosed in this population, clinical attention may shift toward treatment of the malignancy, potentially leading to under-recognition of pre-existing cardiovascular disease and its associated risks. Real-world data describing early cardiovascular outcomes after cancer diagnosis in this subgroup are however limited. The objective was to describe 1-year risks of cardiovascular death, major adverse cardiovascular events (MACE: ischemic stroke, systemic embolism, myocardial infarction, and hemorrhagic stroke), and venous thromboembolism (VTE: pulmonary embolism, and deep vein thromboembolism) after cancer diagnosis and to compare these risks across cancer sites within this high-risk vascular population. Using nationwide Danish registries, we identified 91,253 patients with IHD and/or PAD who developed a first primary cancer between 2002 and 2022. One-year cumulative incidences of cardiovascular death, MACE, and VTE were estimated using competing-risk methods. Multivariable Cox regression models were used to identify clinical predictors of cardiovascular outcomes. Within one year of cancer diagnosis, 33
Anthracycline-induced cardiotoxicity is a major cause of late heart failure (HF) in cancer survivors. Yet early identification of individuals at risk for accelerated cardiotoxic progression remains a clinical challenge. This study leveraged a rat model of long-latency doxorubicin cardiotoxicity to identify early features associated with progression to a prespecified 7-month HF endpoint and to develop a machine learning risk-stratification framework. Doxorubicin-treated rats (both sexes, n = 32 doxorubicin treated and n = 22 saline) were monitored with monthly echocardiography and monthly plasma concentrations of growth differentiation factor-15 (GDF15) for up to 12 months. We defined the primary HF endpoint as the occurrence of severe systolic dysfunction (fractional shortening (FS) < 30
Cardiotoxicity is a relevant late complication after hematopoietic stem cell transplantation. Early identification of subclinical myocardial injury could allow preventive interventions, yet the optimal diagnostic approach in this setting remains undefined. To evaluate the incidence of subclinical myocardial damage through cardiac biomarkers and echocardiography in adult HSCT recipients, and to determine their association with subsequent clinical cardiotoxicity. This prospective, single-center study enrolled 158 adult patients undergoing HSCT between 2017 and 2020. NT-proBNP, troponins, and CK-MB were measured at baseline, post-infusion, day 14, and day 30. Echocardiography was performed at baseline and day 30. Subclinical myocardial damage was defined as the presence of asymptomatic myocardial injury during chemotherapy, as evidenced by new biomarker elevation and/or a relative decline > 15
Cardiovascular disease and cancer represent the leading causes of mortality worldwide. The coexistence of ischemic heart disease and cancer is increasing due to shared risk factors, improved cancer survival, and cardiovascular toxicity from antineoplastic treatments. This complex relationship poses unique diagnostic and therapeutic challenges requiring multidisciplinary management approaches. This comprehensive review examines the multifaceted relationship between ischemic heart disease and cancer, analyzing firstly shared risk factors including smoking, sedentary lifestyle, obesity, diabetes, dyslipidemia and hypertension. We discuss the pathophysiological mechanisms linking cancer and ischemic heart disease, particularly chronic inflammatory states and prothrombotic conditions. The review systematically evaluates cardiovascular toxicity associated with major cancer therapies, including chemotherapy (fluoropyrimidines, platinum compounds, proteasome inhibitors), targeted therapy (vascular endothelial growth factor inhibitors), radiotherapy, immunotherapy, and hormonal treatments. We address the clinical presentation spectrum from asymptomatic ischemia to acute coronary syndromes, highlighting diagnostic challenges and management particularities in cancer patients. Special attention is given to the management of patients with thrombocytopenia and the specific case of fluoropyrimidine-induced cardiotoxicity. The intersection of ischemic heart disease and cancer requires specialized cardio-oncology expertise to optimize both cancer treatment and cardiovascular outcomes. Early cardiovascular risk stratification, careful selection of cancer therapies, and coordinated multidisciplinary care are essential. As cancer survivorship continues to improve, long-term cardiovascular monitoring and risk factor modification become increasingly important. Future research should focus on developing predictive biomarkers, cardioprotective strategies, and evidence-based guidelines to better manage this complex patient population.
Immune-mediated myocarditis is a rare and potentially fatal complication of oncologic immunotherapy. While most reported cases have been associated with the use of immune checkpoint inhibitors (ICIs), novel immunotherapy agents may also pose cardiac risks that warrant further attention. We report a case of fulminant, steroid-refractory myocarditis following initiation of talquetamab, a bispecific T-cell engager (BiTE) targeting CD3 and GPRC5D used for relapsed or refractory multiple myeloma (MM). A 69-year-old man with MM refractory to multiple lines of treatment presented to his outpatient cardio-oncologist with syncope and intermittent chest pain 4 weeks after starting talquetamab. He was found to have elevated high-sensitivity troponin and new inferior Q waves on EKG. He presented to the hospital, where he was admitted to the cardiac intensive care unit. New ST-segment elevations in the inferior leads were subsequently observed on serial EKGs. Transthoracic echocardiography showed a decreased left ventricular (LV) ejection fraction with new regional wall motion abnormalities. Left and right heart catheterization and endomyocardial biopsy were unremarkable. Cardiac magnetic resonance imaging (MRI) revealed segmental late gadolinium enhancement, myocardial edema, increased T1 time, and increased extracellular volume. Acute myocarditis due to talquetamab was presumed, and intravenous steroid therapy was initiated. His symptoms and biomarkers initially improved but later worsened despite steroid therapy. He received additional immunosuppressive therapies including tocilizumab, mycophenolate mofetil, intravenous immunoglobulin, and ruxolitinib. However, his biomarkers and LV systolic function continued to worsen, ultimately resulting in death. This case underscores the potential for immune-mediated myocarditis associated with talquetamab to follow a fulminant and treatment-refractory course despite guideline-directed escalation of immunosuppression, with important implications for clinical recognition and management. It also illustrates the diagnostic challenge of immune-mediated myocarditis presenting as an ST-segment elevation myocardial infarction (STEMI) mimic with non-obstructive coronary arteries. Finally, it emphasizes the complementary role of cardiac MRI in establishing the diagnosis when endomyocardial biopsy is non-diagnostic.
Abstract Background Lung Cancer (LC) and Hypertension (HTN) frequently co-exist as a significant comorbidity with shared risk factors and pathophysiological mechanisms. We examined national trends and forecast future mortality involving LC co-listed with HTN among US adults from 2000 to 2025, with projections to 2035. Methods Using CDC WONDER MULTIPLE Cause-of-Death, we conducted a retrospective analysis of LC and co-listed HTN mortality from 2000 to 2025 among adults aged ≥ 25 years. Age-adjusted mortality rates (AAMRs) were calculated, and joinpoint regression was utilized to estimate annual average percentage changes (AAPCs) with 95% confidence intervals (CIs). Auto-ARIMA and Prophet time-series models in R (v4.5.0) projected AAMRs through 2035, evaluated by root mean squared error (RMSE). Results There were 305,878 reported deaths due to LC and co-listed HTN. The AAMR rose from 3.55 to 6.00 (AAPC 2.038; p < 0.0001). Men had higher mean AAMRs than women (mean AAMR: men 6.16; women 4.07). Among races, Non-Hispanic (NH) Black adults had the greatest mortality (mean AAMR: 7.38). Geographically, the South had the greatest burden (mean AAMR: 5.67) and non-metropolitan regions had higher mean AAMR than metropolitan regions (5.73 vs. 4.5). Most deaths (42.16%) occurred in decedents’ homes. The overall AAMR was projected to remain persistently elevated through 2035, particularly among men, NH White individuals, and in the Southern region with substantial uncertainty. Conclusion Mortality associated with LC and co-listed HTN is an increasing healthcare burden in the US with marked demographic and regional disparities. Future projections indicate a persistent mortality burden, underscoring the need for targeted prevention strategies.
Abstract Background 5-fluorouracil (5-FU) is a widely used chemotherapy agent in gastrointestinal (GI) malignancies, but it can cause cardiotoxicity, most commonly manifesting as chest pain due to coronary vasospasm, often mimicking acute coronary syndrome. Adequate management of 5-FU-associated vasospasm is critical to ensure the necessary oncological treatment can be safely continued. Objectives The aim of this study was the retrospective analysis of cases of chest pain associated with intravenous 5-FU treatment in GI cancer patients at a single institution, and to report the experiences with antianginal treatment, specifically nitrates and calcium channel blockers, administered in these cases. Methods This was a retrospective, single-center, observational cohort study. We analyzed data of GI cancer patients treated with intravenous 5-FU between March 2024 and August 2025 who experienced chest pain during treatment. Following the institutional protocol, the chemotherapy was transiently suspended, and treatment was re-introduced under combined oral or intravenous nitrate and calcium channel blocker protection. Results Out of 835 patients receiving iv 5-FU, 25 (2.9%) developed chest pain, typically after the second or third cycle of chemotherapy. Three patients presented with ST-elevation on ECG, but none of them showed significant coronary stenosis on imaging. With appropriate cardiological treatment, all 25 patients achieved symptom-free oncological treatment continuation: 19 patients with combined nitrate and calcium channel blocker therapy, 6 with monotherapy, and one of these patients required intravenous treatment under ICU monitoring. Conclusions Coronary vasospasm associated with intravenous 5-FU is a rare but clinically significant complication. Our findings, in line with the literature, suggest that the introduction of antianginal therapy successfully allowed the safe rechallenge and continuation of oncological therapy in all affected patients, which may prevent unnecessary discontinuation of life-prolonging chemotherapy. Trial registration Retrospectively registered (Approval No. OOI/Ált11147-1/2025).
Abstract Background and aims With the increasing approval of immune checkpoint inhibitors (ICI) for cancer treatment, there is a rising incidence of potentially life-threatening cancer-therapy related cardiac dysfunction (CTRCD). Current 2022 European Society of Cardiology (ESC) guidelines on cardio-oncology recommend a single baseline transthoracic echocardiogram (TTE) for high-risk ICI-treated patients, potentially underestimating the incidence of CTRCD due to lack of follow-up assessments. This study aims to characterize the incidence of CTRCD in cancer patients undergoing ICI therapy using an intensified TTE surveillance approach and to investigate whether extracardiac immune-related adverse events (eirAEs) are associated with CTRCD. Methods We analysed patients scheduled for ICI therapy from the Essen Cardio-Oncology Registry (EcoR). Data were collected during cardio-oncology consultations at baseline, 6 weeks, 6 months, and 12 months. Patients with eirAEs were evaluated compared to patients without eirAEs. Results Among 2,540 cancer patients registered in EcoR until march 2023, 266 (61 ± 14 years, 40.6% female, 86.5% melanoma, 62% metastatic disease) were scheduled for ICI therapy. CTRCD was observed in 35.7% of patients, with 32.7% having asymptomatic mild CTRCD, 0.37% moderate CTRCD, and 2.63% developing heart failure with preserved ejection fraction (HFpEF). Patients with eirAEs had a twofold higher risk of CTRCD (relative risk [RR] 2.05, 95% CI: 1.49–2.83, p < 0.001) and a 66% increased risk of cardiovascular toxicity (RR 1.66, 95% CI 1.30–2.13, p < 0.001). Conclusions ICI therapy is associated with a high prevalence of CTRCD, underscoring the importance of serial echocardiography evaluation, particularly for patients with eirAEs. Enhanced cardio-oncology surveillance is crucial for improving patient outcomes and survival.
Cardiovascular disease (CVD) and cancer share common risk factors, and cancer survivors experience elevated long-term cardiotoxicity. Traditional risk-based metrics require person-time denominators that are unavailable in aggregate public health databases. This study introduces a proportional co-listing framework to detect population-level cardiovascular surveillance signals on death certificates across cancer types and demographic strata. We conducted a national cross-sectional surveillance analysis using CDC WONDER Multiple Cause-of-Death data from 1999 to 2020 for decedents aged ≥ 15 years. Utilizing an “any-mention” framework, we calculated the Proportional Mortality Ratio (PMR), defined as the ratio of CVD co-listing on cancer-related death certificates to CVD listing on non-cancer certificates. Temporal trends were evaluated using joinpoint regression to estimate the average annual percent change (AAPC). Analyses were stratified by age, sex, race/ethnicity, geography, and index cancer subtypes (lung, colon, and leukaemia). Of 56,014,102 death certificates analyzed, 13,917,133 (24.8
Pancreatic cancer and cardiovascular disease are among the leading causes of death in the U.S. and may co-occur with compounding effects. This study assesses trends in mortality rates for comorbid pancreatic cancer and cardiovascular disease, along with sociodemographic disparities to better inform public health and policy efforts. A retrospective cohort study was conducted using CDC WONDER data between 1999 and 2020. Mortality for pancreatic cancer was assessed using ICD-10 code C25 with I00-I99 for any cardiovascular-related death. Joinpoint regression software was used to assess mortality trends overall and across strata of race, sex, and urbanization status. Age-adjusted mortality rate (AAMR) per 1,000,000 was examined on a year-by-year and demographic basis by assessing annual percent change (APC) with confidence intervals and p-values. Between 1999 and 2020, 189,463 deaths were associated with both cardiovascular death and pancreatic cancer. Overall age-adjusted mortality rate (AAMR) per 1,000,000 increased from 26.164 in 1999 to 31.478 in 2020 (APC = 0.85
Abstract Heart failure (HF) remains a leading cause of morbidity and mortality worldwide and frequently coexists with Philadelphia-negative myeloproliferative neoplasms (MPNs), which share thrombo-inflammatory pathways that increase cardiovascular risk. HF is often underestimated in this population, and current risk models rarely include variables specific to this complex cardio-hematologic setting. From a cardio-oncology perspective, MPNs represent a prototypical at-risk cancer population in whom chronic inflammation, clonal hematopoiesis, and cancer therapy converge to accelerate cardiovascular damage. This narrative review summarizes current evidence on diagnostic and prognostic biomarkers, imaging parameters, and validated HF and MPNs risk scores, and proposes a pragmatic hybrid framework for integrated HF-MPNs cardiovascular risk assessment. PubMed, Embase, and Web of Science were searched up to December 2025 using combinations of terms related to HF, MPNs, biomarkers, imaging, and risk models. In HF, natriuretic peptides and cardiac troponins remain central for diagnosis and short-term prognosis, whereas emerging biomarkers such as galectin-3, soluble ST2, and GDF-15 refine long-term risk prediction. Advanced imaging tools, including global longitudinal strain, left atrial strain, and cardiac magnetic resonance tissue characterization, provide prognostic value beyond the left ventricular ejection fraction. Multidimensional HF models (e.g., MAGGIC, SHFM, BCN Bio-HF, H2FPEF, 3A3B, GWTG-HF, ADHERE, and EHMRG) combine different variables to estimate mortality and hospitalization risk. In MPNs, blood counts, driver mutations (JAK2, CALR, MPL), inflammatory markers, and scores such as IPSET-thrombosis, DIPSS/DIPSS-plus, and MIPSS stratify thrombotic risk, survival, and leukemic transformation but seldom incorporate HF-specific variables. No single biomarker or score fully captures the bidirectional cardiovascular risk in patients with HF and coexisting MPNs. We propose a simple 0–8-point composite algorithm that combines key HF and MPNs variables (natriuretic peptides or troponins, HF risk scores, driver mutations, leukocytosis/thrombocytosis, LDH) to identify high-risk HF–MPNs phenotypes across ACC/AHA HF Stages A–C, suitable for structured cardio-oncology follow-up. Prospective validation of this hybrid algorithm in dedicated cardio-oncology cohorts and the development of MPNs-adapted HF guidelines are key future priorities.
Cancer is a leading cause of morbidity and mortality worldwide, with millions of survivors facing long-term health complications, particularly cardiovascular diseases (CVD). Treatments such as chemotherapy and radiation therapy can induce cardiotoxicity, resulting in significant cardiovascular morbidity. As cancer survival rates improve, the need for effective management strategies to address the cardiovascular health of cancer survivors has become increasingly critical. This study aimed to develop a smartphone-based application for cardiovascular rehabilitation in cancer survivors. This research was conducted in two phases. In the first phase, users’ requirements were investigated by using a questionnaire. The participants were 31 cardio-oncologists. In the second phase, a prototype of the application was designed and implemented, and its usability was evaluated quantitatively by 27 cancer survivors with cardiovascular complications and eight cardio-oncologists using a QUIS questionnaire (version 5.5). The statistical analysis was conducted using SPSS software, version 28. Most of the proposed educational content, data elements, and application features, including necessary steps to prevent cardiovascular complications in cancer survivors, risk factors for cardiovascular complications in cancer survivors, guidance on quitting smoking and exercise training, the ability to track personal and clinical data, fatigue and anxiety assessments, and communication with physicians, were considered essential items for the application. Ultimately, users evaluated the application’s usability, resulting in an average mean score of 8.19 out of 9 from patients’ perspectives and 8.22 out of 9 from cardio-oncologists, indicating a “good” level of user satisfaction. The development of a smartphone-based application for cardiovascular rehabilitation in cancer survivors represents a significant step toward improving cardiovascular health management in this vulnerable population. However, more research is needed to compare the effects of remote education versus face-to-face rehabilitation on improving health literacy and patient exercise adherence.
