Up to one-third of patients with atrial fibrillation (AF) live with obesity and stand to experience improvements in AF symptom burden through moderate weight loss. Cardiac rehabilitation (CR) programs are ideal settings to manage AF risk factors, however few programs offer targeted behavioral weight loss treatment (BWLT). The aim of this study was to investigate perceived barriers and facilitators of participating in BWLT + CR to inform the development of a BWLT for patients with AF and obesity using a qualitative descriptive approach. Purposive sampling was used to recruit patients with AF and BMI ≥ 30 kg/m2 from an AF specialty clinic in Canada. Patients participated in semi-structured interviews regarding perceived barriers, facilitators, and preferences to a proposed BWLT+ CR program consisting of 12 wk of supervised CR exercise with weekly, virtual, group-based BWLT sessions followed by bi-weekly follow up support for 12 wk. Interviews were recorded and transcribed verbatim. Conventional content analysis was used to analyze the qualitative data. Twenty patients (9 women; 100% white) participated in the interviews. Data were categorized to describe barriers (e.g., time constraints), facilitators (e.g., accountability) and preferences (e.g., virtual participation options). Four overarching themes emerged: 1) gender differences in prior weight loss attempts; 2) AF symptoms are manageable; 3) need for more AF patient education; and 4) a desire for flexibility. In conclusion, patients unanimously reported that a BWLT+ CR program was desirable and had few barriers to participating. Results informed modifications to a BWLT+ CR program which is currently being tested in a randomized clinical trial.

BACKGROUND:Short sleep duration (<7 h/day) affects one-third of the population, is implicated in morbidity and mortality from coronary heart disease (CHD), and is driven by an interplay of individual, social, and societal factors. OBJECTIVE:To review observational and experimental studies that have tested interventions to address short sleep in various clinical presentations (sleep disorders, behaviorally induced short sleep, lack of sleep opportunity) and describe considerations needed for CHD populations. CONCLUSIONS:Few existing interventions have a primary aim to increase sleep duration in individuals with insufficient sleep, and none specifically target individuals with established CHD. Short sleep duration may be modifiable via treatment of insomnia, behavioral sleep extension, and system-level changes to healthcare settings, workplace policies, and communities. With further research on interventions that address diverse phenotypes of short sleep-while assessing long-term cardiometabolic outcomes, patient preferences, and mechanisms-of-action-sleep health could become an important component of CHD secondary prevention.

PURPOSE:Cardiac rehabilitation (CR) is an effective treatment to reduce the burden of cardiovascular disease (CVD) but is underutilized. This study characterized CR enrollment barriers and perceived physician endorsement of CR in patient subgroups at increased risk of poor outcomes. MATERIALS AND METHODS:The association between sociodemographic and clinical characteristics and Cardiac Rehabilitation Barriers Scale (CRBS) item and subscale scores were examined using secondary data analysis of patients with acute coronary syndrome referred to, but not yet enrolled in, a 12-week CR program. Participants rated perceived strength of recommendation to attend CR on 1-5 scale. RESULTS:The three most endorsed CRBS items were inclement weather, travel, and work responsibilities. Additional barriers (e.g. time constraints, already exercising, family responsibilities) emerged in certain patient subgroups. Perceived strength of physician endorsement was high in the overall sample. After statistical adjustment for confounds, depressed mood was positively associated with logistical (b = 0.05, p = 0.002), and comorbidity-related barriers (b = 0.02, p < 0.001). Female sex (b = 0.62, p = 0.004), higher body mass index (b = 0.05, p = 0.009), and diabetes (b = 1.08, p < 0.001), were associated with logistical barriers. CONCLUSIONS:Patients require individualized support to address CR enrollment barriers. Given their crucial role in supporting patients to access CR, nurses are well-positioned to identify and address CR barriers.

Despite its relevance to cardiovascular health, obesity is rarely targeted during cardiac rehabilitation (CR). The objective of this paper was to review evidence regarding whether measures to address excess body fat should be offered as a standard component of CR for patients with obesity. We organize the paper around three themes: 1) outcomes of obesity management, 2) the complexity of obesity management, and 3) patient attitudes, experiences, and preferences. Our discussion of each theme was informed by a narrative literature review and a survey of Canadian CR healthcare providers (n=80). We consider literature regarding available approaches to obesity management including behavioural weight loss, pharmacological, and surgical treatments. We go on to assess concerns relating to the complexity of obesity intervention, and the importance of CR patients' lived experiences and goals. Finally, we summarize obesity management considerations in the context of the goals and interventions of CR. Although most (71%) CR providers support integrating obesity management into CR, there are concerns about training, weight bias, and unrealistic expectations for weight loss within time-limited programs. Efforts to incorporate obesity management into CR must address these barriers while considering evidence-based strategies to optimize treatment outcomes (e.g., adjunctive pharmacotherapy; long-term follow-up). Whether CR should offer obesity management depends on provider competency and program resources. More research is needed to clarify patient preferences and to establish the feasibility, long-term efficacy, and cost-effectiveness of obesity management approaches in CR.

Atrial fibrillation (AF) represents a global epidemic. Although international AF practice guidelines indicate weight loss for patients with AF and comorbid obesity (BMI ≥ 30 kg/m2) to alleviate symptom burden and improve prognosis, few cardiac rehabilitation (CR) programs include targeted weight loss treatment. This RCT protocol will evaluate the efficacy of a “Small Changes” behavioral weight loss treatment (BWLT) to produce clinically relevant (≥ 10

BACKGROUND:Pharmacoepidemiology has emerged as a crucial field in evaluating the use and effects of medications in large populations to ensure their safe and effective use. This study aimed to assess the agreement of cardiac medication use between a provincial medication database, the Pharmaceutical Information Network (PIN), and reconciled medication data from confirmation through patient interviews for patients referred to cardiac rehabilitation. METHODS:The study included data from patients referred to the TotalCardiology Rehabilitation CR program, and medication data was available in both TotalCardiology Rehabilitation charts and PIN. The accuracy of medication data obtained from patient interviews was compared to that obtained from PIN with proportions and kappa statistics to evaluate the reliability of PIN data in assessing medication use. RESULTS:Patient-reported usage was higher for statins (41.6 %) vs. 38.4 %), ACE/ARB, beta-blockers (75.7 %) vs. 73.7 %), DOAC (3.5 %) vs. 2.6 %), and ADP-receptor antagonists (71.0 %) vs. 68.1 %) than if PIN was used. Patient-reported usage data was lower for Ezetimibe (4.7 vs. 4.8 %), Aldosterone antagonists (5.4 %) vs. 5.5 %), digoxin (0.9 %) vs. 1.0 %), calcium channel blockers (19.2 vs. 19.9 %) and warfarin (7.2 %) vs. 8.1 %). The results indicated that the differences between the two sources were very small, with an average agreement of 95.3 % and a kappa of 0.70. CONCLUSION:The study's results, which show a high level of agreement between PIN and patient self-reporting, affirm the reliability of PIN data as a source for obtaining an accurate assessment of medication use. This finding is crucial in the context of pharmacoepidemiology research, where the accuracy of data is paramount. Further research to explore the complementary use of both data sources will be valuable.

Background Cardiac rehabilitation (CR) is a multicomponent intervention to reduce adverse outcomes from coronary artery disease, but its mechanisms are not fully understood. The aims of this study were to examine the impact of CR on survival and cardiovascular risk factors, and to determine potential mediators between CR attendance and reduced mortality. Methods and Results A retrospective mediation analysis was conducted among 11 196 patients referred to a 12‐week CR program following an acute coronary syndrome event between 2009 and 2019. A panel of cardiovascular risk factors was assessed at a CR intake visit and repeated on CR completion. All‐cause and cardiovascular mortality were ascertained via health care administrative data sets at mean 4.2‐year follow‐up (SD, 2.81 years). CR completion was associated with reduced all‐cause (adjusted hazard ratio [HR], 0.67 [95% CI, 0.54–0.83]) and cardiovascular (adjusted HR, 0.57 [95% CI, 0.40–0.81]) mortality, as well as improved cardiorespiratory fitness, lipid profile, body composition, psychological distress, and smoking rates ( P <0.001). CR attendance had an indirect effect on all‐cause mortality via improved cardiorespiratory fitness ( ab =−0.006 [95% CI, −0.008 to −0.003]) and via low‐density lipoprotein cholesterol ( ab =−0.002 [95% CI, −0.003 to −0.0003]) and had an indirect effect on cardiovascular mortality via cardiorespiratory fitness ( ab =−0.007 [95% CI, −0.012 to −0.003]). Conclusions Cardiorespiratory fitness and lipid control partly explain the mortality benefits of CR and represent important secondary prevention targets.

Patient consent This study was approved by the IRB as a retrospective study using de-identified data; therefore, the IRB did not require consent from the patients. The authors confirm that patient consent is not applicable to this article. Background Improving women’s cardiovascular outcomes requires optimizing cardiorespiratory fitness (CRF), as higher CRF predicts improves mortality in people with cardiovascular disease (CVD). As such, increasing CRF is a key goal of cardiac rehabilitation (CR). This study assesses the potential influence of body habitus, assessed by body mass index (BMI), on improvements in CRF in women with CVD. Methods Women (18+ years) diagnosed with CVD who completed a 12-week exercise-based CR program between 1996-2016 were included in this retrospective analysis. Women completed a symptom-limited graded exercise test before CR and at CR completion to determine CRF via peak metabolic equivalents (METs). Women were categorized by baseline BMI: normal =18.5-24.9 kg/m2, overweight =25.0-29.9 kg/m2 and obese ≥30 kg/m2. Mixed ANCOVA was performed to evaluate the impact of BMI classification on ΔMETs at 12-weeks. Results Data from 1,313 women (mean age = 62 ± 11 years) were analyzed. Results from mixed ANCOVA indicated a significant time (pre-CR, 12-weeks) by BMI category interaction [F (2,1307) =3.20, p =.041, ƞ2=.005]. Follow-up ANOVAs showed significant improvements in ΔMETs in women with normal and overweight BMI categories (standard mean difference =1.03, n=454 and 0.92, n=461 respectively, p’s<.001). However, ΔMETs among women classified as obese was non-significant using a Bonferroni-adjusted alpha of 0.017 (SMD =0.79, p=.028; n=398). Conclusions A 12-week exercise-based CR program increased CRF in women classified as normal or overweight by BMI, while those with obesity did not realize similar improvements. Women with obesity may need tailored strategies to increase their improvements in CRF in CR.

Background: To retrospectively characterize and compare the dose of exercise training (ET) within a large cohort of patients demonstrating different levels of improvement in exercise capacity following a cardiac rehabilitation (CR) program. Methods: A total of 2310 patients who completed a 12-week, center-based, guidelines-informed CR program between January 2018 and December 2019 were included in the analysis. Peak metabolic equivalents (METpeak) were determined pre- and post-CR during which total duration (ET time) and intensity [percent of heart rate peak (%HRpeak)] of supervised ET were also obtained. Training responsiveness was quantified on the basis of changes in METpeak from pre- to post-CR. A cluster analysis was performed to identity clusters demonstrating discrete levels of responsiveness (i.e., negative, low, moderate, high, and very-high). These were compared for several baseline and ET-derived variables which were also included in a multivariable linear regression model. Results: At pre-CR, baseline METpeak was progressively lower with greater training responsiveness (F(4,2305) = 44.2, P < 0.01, eta 2p = 0.71). Likewise, average training duration (F(4,2305) = 10.7 P < 0.01, eta 2p = 0.02) and % HRpeak (F(4,2305) = 25.1 P < 0.01, eta 2p = 0.042) quantified during onsite ET sessions were progressively greater with greater training responsiveness. The multivariable linear regression model confirmed that baseline METpeak, training duration and intensity during ET, BMI, and age (P < 0.001) were significant predictors of METpeak postCR. Conclusions: Along with baseline METpeak, delta BMI, and age, the dose of ET (i.e., training duration and intensity) predicts METpeak at the conclusion of CR. A re-evaluation of current approaches for exercise intensity prescription is recommended to extend the benefits of completing CR to all patients.

PURPOSE:The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR).METHODS:This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade.RESULTS:Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different ( P < .001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors ( P < .001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates.CONCLUSION:Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.

The purpose of this study is to characterize contemporary Canadian health psychology through an environmental scan by identifying faculty, research productivity and strengths, and collaborator interconnectivity. Profiles at Canadian universities were reviewed for faculty with psychology doctorates and health psychology research programs. Publications were obtained through Google Scholar and PubMed (Jan/18-Mar/21). A total of 284 faculty were identified. Cancer, pain, and sleep were key research topics. The collaborator network analysis revealed that most were linked through a common network, with clusters organized around geography, topic, and trainee relationships. Canada is a unique and productive contributor to health psychology.

BACKGROUND:Training physicians to provide effective behavior change counseling using approaches such as motivational communication (MC) is an important aspect of noncommunicable chronic disease prevention and management. However, existing evaluation tools for MC skills are complex, invasive, time consuming, and impractical for use within the medical context. OBJECTIVE:The objective of this study is to develop and validate a short web-based tool for evaluating health care provider (HCP) skills in MC-the Motivational Communication Competency Assessment Test (MC-CAT). METHODS:Between 2016 and 2021, starting with a set of 11 previously identified core MC competencies and using a 5-step, mixed methods, integrated knowledge translation approach, the MC-CAT was created by developing a series of 4 base cases and a scoring scheme, validating the base cases and scoring scheme with international experts, creating 3 alternative versions of the 4 base cases (to create a bank of 16 cases, 4 of each type of base case) and translating the cases into French, integrating the cases into the web-based MC-CAT platform, and conducting initial internal validity assessments with university health students. RESULTS:The MC-CAT assesses MC competency in 20 minutes by presenting HCPs with 4 out of a possible 16 cases (randomly selected and ordered) addressing various behavioral targets (eg, smoking, physical activity, diet, and medication adherence). Individual and global competency scores were calculated automatically for the 11 competency items across the 4 cases, providing automatic scores out of 100. From the factorial analysis of variance for the difference in competency and ranking scores, no significant differences were identified between the different case versions across individual and global competency (P=.26 to P=.97) and ranking scores (P=.24 to P=.89). The initial tests of internal consistency for rank order among the 24 student participants were in the acceptable range (α=.78). CONCLUSIONS:The results suggest that MC-CAT is an internally valid tool to facilitate the evaluation of MC competencies among HCPs and is ready to undergo comprehensive psychometric property analyses with a national sample of health care providers. Once psychometric property assessments have been completed, this tool is expected to facilitate the assessment of MC skills among HCPs, skills that will better support patients in adopting healthier lifestyles, which will significantly reduce the personal, social, and economic burdens of noncommunicable chronic diseases.

Background: To retrospectively characterize and compare the dose of exercise training (ET) within a large cohort of patients demonstrating different levels of improvement in cardiorespiratory fitness (CRF) following a comprehensive cardiovascular rehabilitation (CR) program.Methods: A total of 2310 patients who completed a 12-week, centre-based, guidelines-informed CR program between January 2018 and December 2019 were included in the analysis. Peak metabolic equivalents (METpeak) were determined pre- and post-CR during which volume (total exercise time) and intensity [percent of heart rate peak (%HRpeak)] of supervised ET were also obtained. Training responsiveness was quantified on the basis of changes in METpeak from pre- to post-CR. A cluster analysis was performed to identity clusters demonstrating discrete levels of responsiveness (i.e., negative, low, moderate, high, and very-high). These were compared for several baseline and ET-derived variables which were also included in a multivariable linear regression model.Results: At pre-CR, baseline CRF was progressively lower with greater training responsiveness (P<0.001). Likewise, average training volume and %HRpeak quantified during onsite ET sessions were progressively greater with greater training responsiveness (P<0.001). The multivariable linear regression model confirmed that baseline CRF, training volume and intensity during ET, BMI, and age (P<0.001) were significant predictors of CRF post-CR.Conclusions: Along with baseline CRF, delta BMI, and age, the dose of ET (i.e., training volume and intensity) predicts CRF at the conclusion of CR. From a CRF standpoint, a re-evaluation of current approaches for exercise intensity prescription is recommended to extend the benefits of completing CR to all patients.

Objective: To develop a prediction model for survival of patients with coronary artery disease (CAD) using health conditions beyond cardiovascular risk factors, including maximal exercise capacity, through the application of machine learning (ML) techniques. Methods: Analysis of data from a retrospective cohort linking clinical, administrative, and vital status databases from 1995 to 2016 was performed. Inclusion criteria were age 18 years or older, diagnosis of CAD, referral to a cardiac rehabilitation program, and available baseline exercise test results. Primary outcome was death from any cause. Feature selection was performed using supervised and unsu-pervised ML techniques. The final prognostic model used the survival tree (ST) algorithm. Results: From the cohort of 13,362 patients (60 & PLUSMN;11 years; 2400 [18%] women), 1577 died during a median follow-up of 8 years (interquartile range, 4 to 13 years), with an estimated survival of 67% up to 21 years. Feature selection revealed age and peak metabolic equivalents (METs) as the features with the greatest importance for mortality prediction. Using these 2 features, the ST generated a long-term prediction with a C-index of 0.729 by splitting patients in 8 clusters with different survival proba-bilities (P <.001). The ST root node was split by peak METs of 6.15 or less or more than 6.15, and each patient's subgroup was further split by age or other peak METs cut points. Conclusion: Applying ML techniques, age and maximal exercise capacity accurately predict mortality in patients with CAD and outperform variables commonly used for decision-making in clinical practice. A novel and simple prognostic model was established, and maximal exercise capacity was further suggested to be one of the most powerful predictors of mortality in CAD. (c) 2022 Mayo Foundation for Medical Education and Research & BULL; Mayo Clin Proc. 2022;97(8):1472-1482

Background: In cardiac rehabilitation programs, cardiorespiratory fitness is commonly estimated (eCRF) from the maximum workload achieved on a graded exercise test. This study compared four well-established eCRF equations in their ability to predict mortality in patients with cardiovascular disease (CVD). Methods: A total of 7269 individuals with CVD were studied (81% male; age 59.4 +/- 10.3yr). eCRF was calculated using equations from the American College of Sports Medicine, Bruce et al., the Fitness Registry and the Importance of Exercise International Database, and McConnell and Clark. The eCRF from each equation was compared with a RMANOVA. Cox proportional hazard models assessed the relationship between the eCRF equations and mortality risk. The predictive ability of the models was compared using the concordance index. Results: There were 284 deaths (85% male) over a follow-up period of 5.8 +/- 2.8yr. Although differences in eCRF were observed between each equation (P < 0.05), the eCRF from each of the four equations was predictive of mortality (P < 0.05). The concordance index values for each of the models were the same (0.77) indicating similar predictive performance. Conclusions: The four well-established eCRF equations did not differ in their ability to predict mortality in patients with CVD, indicating any could be used for this purpose. However, the differences in eCRF from each of the equations suggest potential differences in their ability to guide clinical care and should be the focus of future research.

Background: Cardiac rehabilitation (CR) programs are ideal treatment settings for atrial fibrillation (AF) risk factor management, yet few CR curricula include a behavioral weight loss treatment (BWLT) component for patients with comorbid obesity (BMI ≥ 30 kg/m 2 ). Aim: To identify perceived barriers, facilitators, and preferences regarding CR with added BWLT among patients with AF and obesity using a qualitative descriptive approach. Methods: Patients (18+) with paroxysmal or persistent AF and obesity were recruited from a Canadian AF clinic. Patients completed questionnaires assessing socio-demographic variables and participated in semi-structured interviews to elicit their potential barriers, facilitators, and preferences regarding a proposed 12-week CR+BWLT program (i.e., twice-weekly supervised exercise, risk factor management, and weekly group-based cognitive-behavioral weight management support). Interviews were recorded and transcribed. Conventional content analysis was used to derive themes from qualitative data. Results: Twenty patients (9 women; 63±12 years; BMI=35.50±6.00 kg/m 2 ) participated. Data were categorized to describe patients' barriers, facilitators, and preferences/perspectives (Figure 1). Four overarching themes emerged from the categories: 1) frustration with weight management; 2) AF symptoms are manageable; 3) AF information needs; and 4) desire for program flexibility. Conclusion & Future Directions: The proposal to offer BWLT alongside CR was acceptable to patients with AF and obesity, with most reporting few barriers to participating. The results will inform AF-specific adaptations to an established BWLT (e.g., modules on AF pathophysiology and exercise recommendations). The AF-adapted BWLT will be piloted in the target population prior to testing the full intervention package in a randomized controlled trial. The novel combination of CR+BWLT, tailored to an AF population, has potential to improve AF management and outcomes for patients with comorbid obesity.

BackgroundGrowing evidence supports the use of prehabilitation before coronary artery bypass grafting (CABG) to improve surgical outcomes, but its feasibility and impact on risk factor management in real-world clinical settings remain unknown. This observational study examined prehabilitation utilization and its association with postoperative cardiac rehabilitation (CR) participation and cardiovascular risk profile.MethodsAs standard care in a large Canadian city, eligible patients were referred to prehabilitation upon entering the elective CABG waitlist then were re-referred to CR following surgery. Prehabilitation consisted of medically supervised exercise training and multidisciplinary support with health behavior change until the scheduled surgery. An assessment of cardiorespiratory fitness, blood pressure, body habitus, psychological distress, lipids, glycated hemoglobin, and smoking status was completed during a prehabilitation intake visit then was repeated after surgery prior to starting CR.ResultsAmong 97 prehabilitation referrals over a 20-month period, only 49% attended an intake visit. Most patients who enrolled (n = 39) also completed (n = 37) prehabilitation. Completion of prehabilitation was significantly associated with higher CR referral (OR = 6.92, 95% CI 1.50–32.00), enrollment (OR = 14.08, 95% CI 5.09–38.94) and attendance [t(62) = 4.48, p < .001], and with improvements in cardiorespiratory fitness, body mass index, and symptoms of depression and anxiety (p < .004).ConclusionsPrehabilitation may improve CR participation and risk factors among individuals undergoing elective CABG, but more work is needed to disseminate this service to eligible patients.