PURPOSE:To identify and prioritize key considerations for culturally adapting the Mediterranean diet for diverse populations participating in cardiac rehabilitation (CR) programs outside the Mediterranean region. METHODS:This modified, 2-round Delphi consensus study (September to December 2025) included 3 phases. Phase 1 involved online focus groups with dietitians from Canada and Brazil. Phase 2 comprised in-person and virtual focus groups with adults enrolled in a Canadian CR program. Data from Phases 1 and 2 were analyzed using thematic analysis to generate candidate recommendations. Phase 3 consisted of a 2-round Delphi process with CR health care professionals and patients from 31 countries across all 6 World Health Organization regions, who rated recommendation importance using a 5-point Likert scale. Consensus was assessed using descriptive statistics. RESULTS:Focus groups with dietitians (n = 27) and CR participants (n = 15) generated 26 recommendations across 7 thematic categories. In the 2-round Delphi process (N = 102), 15 recommendations reached consensus in round 1 and were refined, while 11 were excluded or merged. Twelve recommendations progressed to round 2, yielding a final set of 11 consensus-based recommendations. Key priorities included flexibility, cultural and religious relevance, affordability, local food availability, individualized counseling, and emphasis on heart-healthy behaviors over weight loss. Alcohol was considered nonessential, with support for excluding it from educational materials. CONCLUSIONS:This international, stakeholder-informed study established 11 consensus recommendations to guide culturally responsive adaptation of the Mediterranean diet in CR. Findings support flexible, patient-centered dietary approaches that maintain cardioprotective principles while enhancing feasibility and relevance across diverse global settings.
Purpose: To identify and prioritize key considerations for culturally adapting the Mediterranean diet for diverse populations participating in cardiac rehabilitation (CR) programs outside the Mediterranean region. Methods: This modified, 2-round Delphi consensus study (September to December 2025) included 3 phases. Phase 1 involved online focus groups with dietitians from Canada and Brazil. Phase 2 comprised in-person and virtual focus groups with adults enrolled in a Canadian CR program. Data from Phases 1 and 2 were analyzed using thematic analysis to generate candidate recommendations. Phase 3 consisted of a 2-round Delphi process with CR health care professionals and patients from 31 countries across all 6 World Health Organization regions, who rated recommendation importance using a 5-point Likert scale. Consensus was assessed using descriptive statistics. Results: Focus groups with dietitians (n = 27) and CR participants (n = 15) generated 26 recommendations across 7 thematic categories. In the 2-round Delphi process (N = 102), 15 recommendations reached consensus in round 1 and were refined, while 11 were excluded or merged. Twelve recommendations progressed to round 2, yielding a final set of 11 consensus-based recommendations. Key priorities included flexibility, cultural and religious relevance, affordability, local food availability, individualized counseling, and emphasis on heart-healthy behaviors over weight loss. Alcohol was considered nonessential, with support for excluding it from educational materials. Conclusions: This international, stakeholder-informed study established 11 consensus recommendations to guide culturally responsive adaptation of the Mediterranean diet in CR. Findings support flexible, patient-centered dietary approaches that maintain cardioprotective principles while enhancing feasibility and relevance across diverse global settings.
PURPOSE:This study examined the effects of smoking status upon pulmonary rehabilitation (PR) entry (current vs never/former) on clinical outcomes of PR using the American Association of Cardiovascular and Pulmonary Rehabilitation PR Registry. METHODS:Participants with chronic obstructive pulmonary disease (N = 41,087) were from 319 PR programs in the US contributing data between 2013 and 2021. Baseline characteristics included demographics (age, sex, race, education, insurance), body mass index, and smoking status (current vs former/never). Outcomes included the number of PR sessions attended, functional capacity (6-minute walk distance [6MWD]), depression and anxiety symptoms, and dyspnea. RESULTS:Current smoking was reported by 14% of participants. Compared to those who never or formerly smoked, those currently smoking were younger (64.1 ± 8.8 vs 70.8 ± 8.9 years), more likely to have Medicaid (17% vs 7%), had lower body mass index (28.3 ± 8.2 vs 30.0 ± 7.9 kg/m2), greater 6MWD (906.9 ± 343.0 vs 841.3 ± 350.6 ft), and higher depression (8.5 ± 6.1 vs 6.3 ± 5.3) and anxiety (6.9 ± 4.6 vs 5.5 ± 4.3) symptoms. At PR completion, those who smoke attended fewer sessions (14.9 ± 10.8 vs 18.7 ± 10.8 sessions), yet had similar improvements in 6MWD, anxiety symptoms, and dyspnea, but less improvement in depression symptoms (+0.52 [95% CI, 0.35-0.69]) compared to those who never or formerly smoked. CONCLUSION:Despite attending fewer PR sessions, patients with chronic obstructive pulmonary disease who currently smoke have clinically significant improvements in functional capacity, anxiety symptoms, and dyspnea comparable to patients who never or formerly smoked, yet their depression symptoms remain higher at program completion. Thus, PR programs should not restrict entry based on smoking status.
PURPOSE:To quantify facility-level variation in cardiac rehabilitation (CR) completion among Medicare beneficiaries after major cardiovascular procedures. METHODS:We analyzed Medicare fee-for-service claims for beneficiaries discharged alive after common cardiovascular procedures between July 2016 and December 2018. Beneficiaries were attributed to CR facilities via the national provider identifier on CR claims. Facilities with <20 patients were excluded. CR completion was defined as finishing 36 sessions within 1 year of hospital discharge. Hierarchical logistic regression estimated risk-adjusted facility completion rates, adjusting for demographics, procedure, clinical complexity, and clustering between facilities. The model cluster-level variance informed the median OR to quantify the between-facility variation in CR completion. Bivariate analyses compared risk-adjusted completion across urbanicity, facility-volume quartiles, US census region, and local community distress. RESULTS:Among 183 888 beneficiaries who attended ≥1 CR session across 2194 facilities, the mean ± SD number of sessions attended was 25.6 ± 12.4, with 53 558 (29%) completing CR. Risk-adjusted facility-level completion rates ranged from 0% to 90.9% (median: 32.9%; IQR: 18.7%, 44.9%). After adjusting for patient factors, the median OR for CR adherence between facilities was 2.34 (95% CI, 2.26-2.43), indicating a facility-level difference in completion independent of patient mix. Completion did not differ significantly by urbanicity or facility volume but varied by region and level of community distress (P < .001). CONCLUSIONS:Completion of CR varies widely across facilities and is highly facility-dependent, indicating opportunities for quality improvement.
PURPOSE:This study aimed to investigate the relationships between the dose of post-lung transplantation (LTx) pulmonary rehabilitation (PR) and exercise capacity, rehospitalization, and survival in LTx recipients. METHODS:Demographic and clinical data of LTx recipients from January 2020 to April 2023 were extracted and reviewed. The association between PR and the pre- to post-PR change in 6-minute walk test distance (6MWTd) was determined using lasso regression for variable selection followed by multiple linear regression. The association between the number of PR sessions completed and rehospitalization and survival after LTx was determined using negative binomial regression and Cox proportional hazards models. RESULTS:Aerobic training volume was a significant independent predictor of 6MWTd improvement from pre- to post-PR (β = .318, P < .001). Each additional PR session was associated with a 4.7-m greater 6MWTd (P = .010), a 3.8% lower rate of rehospitalization within 1 year of transplantation (IRR = 0.962, P = .078), and a 9.0% lower mortality risk (HR = 0.910, P = .052). Completing 16 to 27 PR sessions was associated with a 48% lower rehospitalization rate (IRR = 0.518, P =.037) and a 73% lower mortality risk (HR = 0.266, P = .071) compared with completing 1 to 11 sessions. CONCLUSIONS:Greater aerobic training volume was an independent predictor of improved exercise capacity, while a greater number of PR sessions was associated with fewer total rehospitalizations within 1 year of LTx and a trend toward improved survival.
PURPOSE:Cardiac rehabilitation (CR) is a promising treatment for patients with stable angina pectoris (SAP) and has been postulated as a safe and effective alternative to revascularization in low-risk patients. We assessed the barriers and facilitators for the implementation of CR for patients with SAP. METHODS:We interviewed 12 clinicians (cardiologists and CR case managers) and 6 patients to assess perceived and expected barriers and facilitators in choosing CR as first-choice treatment for SAP in the Netherlands. The interviews were analyzed both inductively and deductively using the theoretical domains framework. RESULTS:We found a total of 44 barriers and 28 facilitators across 8 themes. Clinicians reported the following key barriers: lack of evidence and clarity in guidelines; knowledge gaps about the outcomes, treatment indication, and content of CR; higher perceived effort to discuss CR compared with a revascularization; a lack of support from colleagues and authorities; suboptimal treatment decision-making conditions; beliefs that affect openness to CR; and the organization/funding of care. Clinicians indicated these facilitators: their belief in CR and motivation to provide the best and affordable care. Patients reported no major barriers. As facilitators, patients indicated openness to CR and trust in the clinician advice. CONCLUSION:Clinicians experience barriers to propose CR as an initial treatment strategy rather than revascularization in patients with SAP despite their motivation and belief in CR. Clinicians require more evidence, awareness of the existing evidence, clarity in guidelines, and support from their professional association.
PURPOSE:The 6-minute walk test is a powerful prognostic tool to predict mortality in heart failure (HF). We sought to assess whether the use of percent predicted 6-minute walk test distance (%6MWD) allows for enhancing the prognostic performance of the test versus actual 6MWD. METHODS:We studied 1425 patients with HF. The primary outcome was all-cause mortality within 1 and 3 years. Predicted 6MWD were determined using the Enright, Duncan, and Morbach equations. RESULTS:The area under the curve of actual and %6MWD in predicting mortality ranged from 0.713 to 0.737 at 1 year and from 0.646 to 0.692 at 3 years. In multivariable analyses, actual 6MWD and each %6MWD were independently associated with mortality risk both at 1 year and 3 years; the odds ratios ranged from 1.29 to 1.36 at 1 year and from 1.19 to 1.24 at 3 years. When added to the baseline risk model for 1-year mortality prediction, actual 6MWD and each %6MWD yielded a statistically significant, similar improvement in discriminative ability, the proportion of survivors reclassified as lower risk, and, except for %6MWDEnright, the proportion of patients with events reclassified as higher risk. Similar results were observed at 3 years. CONCLUSIONS:Our data indicate that %6MWD, regardless of the equation used to estimate predicted values, is independently associated with mortality risk in HF and provides incremental prognostic information over well-established predictors of death. Its prognostic performance, however, is not superior to that of actual 6MWD.
PURPOSE:Post-traumatic stress disorder (PTSD) is associated with poor health behaviors and risk for cardiovascular disease, and PTSD may impair cardiovascular disease recovery. Whether PTSD severity is a barrier to cardiac rehabilitation (CR) use following a new myocardial infarction (MI) or revascularization (percutaneous coronary intervention or coronary artery bypass grafting) is uncertain. METHODS:Eligible patients were identified from Veterans Health Administration historical medical record data. Patients (N = 5170) had 1 or more PTSD diagnoses and ≥1 PTSD Checklist score between October 1, 2011, and September 30, 2022. Modified Poisson models with robust error variance were computed before and after adjusting for covariates to measure the association between PTSD severity and any CR use in the 12 months after MI/revascularization. Among those who used CR, we determined if PTSD severity was linked to receiving 9 or more sessions. RESULTS:The sample was an average 62.1 ± 11.0 years of age, 95% male, and 77% identified as White race. During the 12-month follow-up period, 8% of the sample had any CR, and among those who did, 66% had ≥9 visits. The severity of PTSD was not significantly associated with any CR use nor with receipt of 9 or more encounters. CONCLUSIONS:Participation in CR was low regardless of PTSD severity. Although it is encouraging that higher PTSD severity is not a barrier to CR participation, increasing engagement of veterans in CR after MI/revascularization will be important for reducing their risk of recurrent events and mortality.
PURPOSE:The surge in e-cigarette use among young people worldwide has become a major public health issue. However, its impact on outcomes important to young people, such as cardiorespiratory fitness, is still not fully understood. This review aims to determine the effects of e-cigarette use on cardiorespiratory fitness in young people. REVIEW METHODS:A systematic search was conducted across PubMed and Embase to identify relevant studies. Original articles assessing the effects of e-cigarettes on cardiorespiratory fitness and lung function in young adults were considered. Data were extracted regarding the study design, participant characteristics, exposure conditions (eg, chronic or acute e-cigarette use), key findings, and study limitations. A narrative synthesis approach was used to present a descriptive summary of study characteristics, results, and limitations. Eighteen studies met the inclusion criteria. Chronic e-cigarette users demonstrated lower cardiorespiratory fitness compared with nonusers, while acute vaping currently shows no association with cardiorespiratory fitness, although conclusions are limited by the small number of available studies. Chronic vaping is associated with subtle small-airway and pulmonary physiological alterations, although evidence for long-term lung function impairment remains inconclusive, whereas acute vaping causes transient lung function changes. SUMMARY:Future research should adopt prospective study designs, realistic vaping sessions, and validated abstinence periods in primarily e-cigarette users. Addressing these methodological gaps is critical for guiding public health efforts to mitigate potential risks associated with e-cigarette use among young people.
Purpose: To describe the prevalence of clinical exercise physiologists (CEPs), hiring criteria, and job tasks in early outpatient cardiac and pulmonary rehabilitation (CR/PR) programs in the United States. Methods: In this cross-sectional study, a survey was sent by the American Association of Cardiovascular and Pulmonary Rehabilitation to CR/PR program leaders. Data were analyzed using descriptive statistics. Results: Among 311 programs, 96% (n = 297) offered CR, 71% (n = 222) offered PR, and CEPs were the most frequently reported staff in both CR (86%; n = 256) and PR (83%; n = 185). Staff were exclusively CEPs in 10% (n = 30) of CR and 5% (n = 12) of PR. Hiring criteria for CEPs were a bachelor’s degree in 92% (n = 240) and a master’s in the remaining programs. Advanced Cardiac Life Support certification was required before or within 1 year of hire in 70% (n = 183) of programs. The American College of Sports Medicine Clinical Exercise Physiologist (ACSM-CEP) credential was required before or within 1 year of hire in 24% (n = 62) of programs. In 75% (n = 196) of programs, CEPs were responsible for the majority (≥23 of 29) of job tasks that are common to CR/PR. Conclusions: Clinical exercise physiologists serve integral roles in CR/PR programs in the United States with job responsibilities that allow them to work at the top of their scope of practice in many programs. Underutilization of CEPs at some institutions might be improved by better understanding the variability in academic preparation and the importance of the ACSM-CEP credential.
PURPOSE:Thoracic aortic disease (TAD), including type A acute aortic dissection and Marfan Syndrome, requires lifelong management. Exercise may offer benefits, but the impact of exercise on quality of life (QoL), cardiovascular outcomes, and safety remains unclear. This scoping review synthesizes evidence on exercise effects in patients with TAD. REVIEW METHODS:A comprehensive search was conducted in PubMed, Embase, and CINAHL for studies published up to June 30, 2025. Eligibility criteria included original studies evaluating exercise interventions in patients with TAD or related genetic conditions. Studies reporting outcomes on QoL and cardiovascular status or safety were included. Two reviewers independently screened titles and abstracts, followed by a full-text review; discrepancies were resolved by a third. Data extraction covered population, intervention, and outcomes related to QoL, cardiovascular health, and adverse events. SUMMARY:Nine studies were included, comprising randomized controlled trials, cohort studies, and observational designs. Exercise interventions varied from moderate-intensity aerobic training, resistance training, and personalized rehabilitation programs. Most studies reported improved physical function and capacity, particularly in post-surgical patients with type A acute aortic dissection. Mental health outcomes showed mixed results; some studies reported significant reductions in anxiety and depression, while others found no significant changes in the mental component of QoL. No serious adverse events occurred, although systolic blood pressure responses varied greatly. Despite limited evidence, exercise may enhance physical performance in patients with TAD, although the impact on mental health remains uncertain. Future research should focus on optimizing intervention protocols, incorporating psychosocial support, and establishing evidence-based safety thresholds for exercise-induced blood pressure changes.
PURPOSE:Fall risk is associated with restricted exercise and increased morbidity and mortality. Outcomes of patients with high fall risk in cardiac rehabilitation (CR) are not well documented. This study describes the prevalence of high fall risk in CR, associated patient characteristics, CR engagement, and outcomes. METHODS:Electronic records were examined from CR patients aged ≥65 years. An 11-variable checklist identified high (≥2 risk factors) versus low fall risk. Groups were compared on demographic, medical, and psychosocial variables, CR sessions completed, and pre-post-CR functional capacity change per maximum effort exercise tolerance test (metabolic equivalent of task) or 6-Minute Walk Test distance. RESULTS:The CR falls incident rate among 384 patients (70% male, mean age 74.2 ± 6.5) was 0.137/1000 visits. One quarter was identified as "high fall risk." Ten percent reported fear of falling. The most common risk factors included visual difficulty (41%), balance disturbance (24%), and gait disturbance (23%). Patients with high fall risk were older (78.03 ± 6.78, P < .001), reported lower physical and mental health-related quality of life ( P ≤ .001), and attended slightly fewer CR sessions (23.80 ± 11.04 vs 26.47 ± 9.91; P = .18). There were no significant differences between groups in functional capacity (metabolic equivalent of task: P = .193; 6-Minute Walk Test: P = .141). CONCLUSIONS:Though patients with high fall risk share characteristics with known associations to lower CR referral (eg, older age and comorbidities), they are as likely to benefit from CR participation as patients with lower risk when supported by tailored exercise prescriptions and safety modifications.
OBJECTIVE:Supervised exercise is currently recognized as the first-line treatment for patients with peripheral artery disease. However, the comparative benefits of treadmill training, arm-ergometry, and leg-ergometry remain unclear. REVIEW METHODS:Medline, Embase, and the Cochrane Library were searched from inception to May 7, 2025, for randomized controlled trials in adults with peripheral artery disease. Eligible studies involved supervised treadmill, arm-ergometry, or leg-ergometry interventions lasting 12 to 24 weeks and compared these interventions with other exercise modalities or nonexercise controls. A frequentist random-effects network meta-analysis was conducted to estimate mean differences (MDs) with 95% CI for peak oxygen uptake, maximal walking distance, and pain-free walking distance. SUMMARY:Eleven trials involving 519 participants were included. Arm-ergometry increased peak oxygen uptake by 1.85 mL/kg/min (95% CI, 0.99-2.71 mL/kg/min, P < .01), and treadmill training increased peak oxygen uptake by 1.46 mL/kg/min (95% CI, 1.12-1.81 mL/kg/min, P < .01) compared with control. Treadmill training increased maximal walking distance (MD = 191.25: 95% CI, 66.84-315.65 m, P < .01), whereas arm-ergometry showed no significant difference (MD = 121.35: 95% CI, -45.61 to 288.32 m, P = .15). In addition, pain-free walking distance improved with treadmill training (MD = 181.88: 95% CI, 154.99-208.76 m, P < .01), arm-ergometry (MD = 78.11: 95% CI, 54.62-101.60 m, P < .01), and leg-ergometry (MD = 51.08: 95% CI, 8.27-93.89 m, P = .02) compared with control.
PURPOSE:Mobile health cardiac rehabilitation may improve access to care among older adults with ischemic heart disease, but engagement remains poorly understood. We analyzed weekly engagement data from the RESILIENT (Rehabilitation Using Mobile Health for Older Adults with Ischemic Heart Disease in the Home Setting) trial, a large, randomized trial of mobile health cardiac rehabilitation in older adults conducted in the United States. METHODS:Data from 298 intervention participants were analyzed. Weekly engagement was scored from 0 to 11 based on exercise entry (7 points), communication with exercise therapist (2 points), video viewing (1 point), and blood pressure measurement (1 point). Latent class analysis identified digital engagement phenotypes. Participant characteristics were compared, and multivariable logistic regression identified factors associated with phenotype membership. RESULTS:Median age was 71.0 years, 28% were women, 23% were non-White, and 62% were enrolled after elective percutaneous coronary intervention. Latent class analysis identified 3 phenotypes: persistently low (n = 81), intermediate declining (n = 93), and persistently high (n = 124). Participants with persistently low engagement were more likely to be non-White (48% vs 12% vs 15%, P < .001), Medicaid enrolled (22% vs 8% vs 7%, P = .001), have less than high school education (16% vs 4% vs 3%, P < .001), have frailty phenotype (28% vs 10% vs 7%, P < .001), and have a greater mean number of comorbidities (3.1 vs 3.0 vs 2.6; P = .012). After adjustment, non-White race and frailty remained independently associated with low engagement. Improvement in 6-minute walk test distance varied: 20.8 m (low), 29.7 m (intermediate), and 54.5 m (high) (P = .003). CONCLUSIONS:Three distinct digital engagement phenotypes emerged. Persistently low engagement was more common among non-White and frail participants, underscoring ongoing disparities despite efforts to overcome the digital divide.
PURPOSE:Access to pulmonary rehabilitation is particularly challenging in rural settings. Tele-pulmonary rehabilitation (tele-PR) is a promising solution, but it is unclear if the supporting evidence includes the populations it is aimed to serve. This review aimed to determine if individuals with chronic obstructive pulmonary disease from rural communities are recruited for tele-PR randomized controlled trials (RCTs). REVIEW METHODS:A systematic review of Medline, CINAHL, Embase, Web of Science, and Compendex was conducted for RCT on tele-PR from 1995 to March 2025. Data were extracted and synthesized to evaluate the inclusiveness of rural populations. SUMMARY:A total of 41 RCTs were included. Most studies (83%) were conducted in urban areas, with only 17% specifying the inclusion of both urban and rural populations. Based on the available data, rural participants represented less than 3% of the total 4142 participants. Furthermore, 78% of the reviewed tele-PR programs required at least 1 mandatory in-person visit for assessment or follow-up, which likely creates a significant barrier to participation for rural residents. Therefore, despite its potential for rural populations, tele-PR research appears to drastically underrepresent these individuals. This limits the generalizability of current findings and hinders the goal of equitable access to care. Researchers must intentionally recruit, report, and design studies considering the principles of equity and diversity.
BACKGROUND:Cardiopulmonary exercise testing (CPX) provides objective assessment of integrative physiological function and is recommended in international guidelines for the investigation of unexplained dyspnea and exercise intolerance. Despite its clinical value, the implementation of CPX is variable worldwide. No previous studies have described CPX practices in Australia and New Zealand. METHODS:A cross-sectional online survey of health professionals involved in CPX delivery was conducted between May 2023 and September 2024. Laboratories were identified using professional society lists and hospital websites. The 29-question survey explored staffing, training, protocols, and test application. Descriptive analyses were used to summarize closed- and open-ended responses. RESULTS:Fifty-five laboratories completed the survey, of 71 approached. Most services were based in public hospital respiratory departments and used cycle ergometry with individualized ramp protocols. Cardiopulmonary exercise testing was most commonly used for unexplained breathlessness, perioperative assessment, and functional evaluation. One-third of services used fixed work rate protocols, and 62% of respondents reported no formal CPX training. Multiple step and ramp protocols were identified across sites, with substantial variation in incremental work rates. The most frequently reported barriers to CPX delivery were inadequate staffing, lack of training, and limited space. CONCLUSION:This is the first survey of CPX practice in Australia and New Zealand. Results highlight substantial variation in training, protocols, and resourcing. These findings can inform professional development strategies and support the generation of standardized practice guidelines. Addressing training gaps, enhancing workforce capacity, and expanding clinical use may increase the quality, consistency, and impact of CPX across the region.
