The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence. Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack Rehabilitation Management Study (CHARMS). Benefits and weaknesses of a cardiac rehabilitation programme. Recovery after myocardial infarction. Effects of a caring rehabilitation programme. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Cardiac rehabilitation vs. home exercise after coronary artery bypass graft surgery: a comparison of heart rate recovery. Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. Effects of a problem-based learning rehabilitation programme on quality of life in patients with coronary artery disease.
To evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes. It also sought to explore the reasons for non-adherence to cardiac rehabilitation programmes.
                An individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes.
                Four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands in England, for 2 years from 1 February 2002.
                A total of 525 patients who had experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks.
                All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification. The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education. The home-based programme consisted of an appropriate version of the Heart Manual, home visits and telephone contact. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at 3 weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Where needed, follow-up was made by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English.
                Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire 6, 9 and 12 weeks.
                No clinically or statistically significant differences were found in any of the primary or secondary outcome measures between the home- and centre-based groups. Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both arms between baseline and the 6-month follow-up. Five or more contacts with a cardiac rehabilitation nurse were received by 96% of home-based participants, whereas only 56% of centre-based participants attended this many rehabilitation classes. The direct rehabilitation costs to the health service were significantly higher for the home-based programme (mean cost 198 pounds versus 157 pounds for the centre-based programme), but when patient costs were included the mean cost of the centre-based arm rose to 182 pounds. Patients' reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems limited some patients' ability to exercise. Most non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. The home-based patients' lack of motivation to exercise on their own at home was a major factor in non-adherence. The focus groups revealed little diversity of views among patients from each programme. Patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual.
                A home-based cardiac rehabilitation programme for low- to moderate-risk patients does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes. Different reasons were given by home and hospital cardiac rehabilitation patients for not taking up or adhering to cardiac rehabilitation, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation. Research is recommended into cardiac rehabilitation in patients from ethnic minority groups; measurement tools to assess physical activity and dietary change; evaluating the Heart Manual in patients who decline centre-based cardiac rehabilitation; the implementation of home-based programmes in the UK; and strategies that sustain physical activity in the long term. Participation in cardiac rehabilitation after acute myocardial infarction is sub-optimal. Offering home-based rehabilitation may improve uptake. We report the first randomized study of cardiac rehabilitation to include patient preference.
                To compare the clinical effectiveness of a home-based rehabilitation with hospital-based rehabilitation after myocardial infarction and to determine whether patient choice affects clinical outcomes.
                Pragmatic randomized controlled trial with patient preference arms.
                Rural South West England.
                Patients admitted with uncomplicated myocardial infarction were offered hospital-based rehabilitation classes over 8-10 weeks or a self-help package of six weeks' duration (the Heart Manual) supported by a nurse. Primary outcomes at 9 months were mean depression and anxiety scores on the Hospital Anxiety Depression scale, quality of life after myocardial infarction (MacNew) score and serum total cholesterol.
                Of the 230 patients who agreed to participate, 104 (45%) consented to randomization and 126 (55%) chose their rehabilitation programme. Nine month follow-up data were available for 84/104 (81%) randomized and 100/126 (79%) preference patients. At follow-up no difference was seen in the change in mean depression scores between the randomized home and hospital-based groups (mean difference: 0; 95% confidence interval, -1.12 to 1.12) nor mean anxiety score (-0.07; -1.42 to 1.28), mean global MacNew score (0.14; -0.35 to 0.62) and mean total cholesterol levels (-0.18; -0.62 to 0.27). Neither were there any significant differences in outcomes between the preference groups.
                Home-based cardiac rehabilitation with the Heart Manual was as effective as hospital-based rehabilitation for patients after myocardial infarction. Choosing a rehabilitation programme did not significantly affect clinical outcomes. The British Heart Foundation and the Chest, Heart and Stroke Association have allocated funds to develop cardiac rehabilitation programmes. We have recently completed and now evaluate an exercise-based rehabilitation course reinforced with advice about return to normal activity for 110 patients who had suffered acute myocardial infarction. Patients admitted to the Plymouth cardiac care unit were randomised into groups: a control group to receive standard hospital care, and a rehabilitation group who, in addition, received an exercise programme reinforced with advice. Patients were assessed at entry to the study and at intervals thereafter. Assessment was by questionnaire and objective tests consisting of a 12-minute walking test and weekly outpatient pedometry. In the rehabilitation group patients were able to walk further and faster, return to work earlier, undertake more housework, and resume normal sexual activity; they were less short of breath and did not experience more angina. However, the rehabilitation course brought little benefit to the patients' perception of well-being and their anxiety about health or their outlook on life. Exercise and advice are important components of a rehabilitation programme, but more attention needs to be given to the psychological aspects of recovery from a heart attack. The aim of the study was to evaluate a multifactorial rehabilitation programme based on interdisciplinary caring efforts for myocardial infarction (MI) patients. Randomly chosen MI-patients participated, either in a six-month rehabilitation programme (intervention group = 53) or in routine cardiac follow-ups (control group = 63). Subjective and objective instruments were used for measuring their health recovery. Biophysical improvements were showed as an increased physical capacity (p less than 0.001) using a submaximal exercise test six months after MI, and less reinfarctions (p less than 0.024) twelve months after MI, to the intervention patients' advantage. Psychological improvements were demonstrated in a higher life satisfaction (p less than 0.001) six months and (0.1 greater than p greater than 0.05) twelve months after MI to the intervention patients' advantage. Social improvements were indicated as a better leisure situation (p less than 0.004) six months after MI, and as a better partner situation (p less than 0.010), including a less influenced sex life (p less than 0.017), twelve months after MI to the intervention patients' advantage. As to the overall view, the caring rehabilitation programme appeared to be required for the MI-patients' health recovery. In order to be able to reach an optimal state of human health, an even more individualised programme seems to be necessary. A home-based exercise programme has been found to be as useful as a hospital-based one in improving cardiovascular fitness after an acute myocardial infarction. To find out whether a comprehensive home-based programme would reduce psychological distress, 176 patients with an acute myocardial infarction were randomly allocated to a self-help rehabilitation programme based on a heart manual or to receive standard care plus a placebo package of information and informal counselling. Psychological adjustment, as assessed by the Hospital Anxiety and Depression Scale, was better in the rehabilitation group at 1 year. They also had significantly less contact with their general practitioners during the following year and significantly fewer were readmitted to hospital in the first 6 months. The improvement was greatest among patients who were clinically anxious or depressed at discharge from hospital. The cost-effectiveness of the home-based programme has yet to be compared with that of a hospital-based programme, but the findings of this study indicate that it might be worth offering such a package to all patients with acute myocardial infarction. The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu, China.
                Epidemiological studies indicate a dose-, level- and duration-dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality. Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes.
                A randomized controlled trial was conducted. Coronary heart disease patients (n = 167) who met the sampling criteria in two tertiary medical centres in Chengdu, south-west China, were randomly assigned to either an intervention group (the cardiac rehabilitation programme) or control group (the routine care). The change of health behaviours (walking performance, step II diet adherence, medication adherence, smoking cessation) and physiological risk parameters (serum lipids, blood pressure, body weight) were assessed to evaluate the programme effect.
                Patients in the intervention group demonstrated a significantly better performance in walking, step II diet adherence, medication adherence; a significantly greater reduction in serum lipids including triglyceride, total cholesterol, low-density lipoprotein; and significantly better control of systolic and diastolic blood pressure at three months. The majority of these positive impacts were maintained at six months. The effect of the programme on smoking cessation, body weight, serum high-density lipoprotein, was not confirmed.
                A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients. Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease.
                This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients. Furthermore, the hospital-home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care. The autonomic dysfunction is known to adversely affect clinical outcome in patients with cardiovascular disease, and exercise training has been shown to modify the sympathovagal control of heart rate. The purposes of this study were to investigate the effect of cardiac rehabilitation on heart rate recovery in patients who received coronary artery bypass grafting (CABG) and compare the effect with that of a home-based exercise program.
                Fifty-four male patients having undergone CABG were randomly assigned to a cardiac rehabilitation exercise program (n = 18), a home-based exercise program (n = 18), and a control group (n = 18) for 12 wks to evaluate the differences in heart rate recovery among groups.
                Patients in the cardiac rehabilitation group had significant increases in heart rate recovery (19.1 +/- 6.2 vs. 14.0 +/- 5.4 beats/min, P = 0.022) compared with those in the control group. There were no significant differences in heart rate recovery between cardiac rehabilitation and home-based exercise groups (16.2 +/- 4.8 beats/min) or between home-based exercise and control groups. All three groups had significantly improved heart rate recovery compared with their baseline data (P < 0.001, < 0.001, and 0.007).
                Our results point out that a cardiac rehabilitation exercise program has a positive effect on heart rate recovery in patients having undergone CABG and is consistent with the autonomic improvement. Although the home-based exercise group did not reveal statistical significances over those in the control group, it had comparable efficacy to that demonstrated in the cardiac rehabilitation group. Heart failure, a condition predominantly affecting the elderly, represents an ever-increasing clinical and financial burden for the NHS. Cardiac rehabilitation, a service that incorporates patient education, exercise training and lifestyle modification, requires further evaluation in heart failure management.
                The aim of this study was to determine whether a cardiac rehabilitation programme improved on the outcomes of an outpatient heart failure clinic (standard care) for patients, over 60 years of age, with chronic heart failure.
                Two hundred patients (60-89 years, 66% male) with New York Heart Association (NYHA) II or III heart failure confirmed by echocardiography were randomised. Both standard care and experimental groups attended clinic with a cardiologist and specialist nurse every 8 weeks. Interventions included exercise prescription, education, dietetics, occupational therapy and psychosocial counselling. The main outcome measures were functional status (NYHA, 6-min walk), health-related quality of life (MLHF and EuroQol) and hospital admissions.
                There were significant improvements in MLHF and EuroQol scores, NYHA classification and 6-min walking distance (meters) at 24 weeks between the groups (p<0.001). The experimental group had fewer admissions (11 vs. 33, p<0.01) and spent fewer days in hospital (41 vs. 187, p<0.001).
                Cardiac rehabilitation, already widely established in the UK, offers an effective model of care for older patients with heart failure. The aim of cardiac rehabilitation (CR) is not only physical improvement but also increased quality of life (QoL). A CR programme based upon problem based learning (PBL) philosophy was developed, to achieve and apply new knowledge related to coronary artery disease (CAD). The aim of this paper was to evaluate the impact of the PBL programme on QoL.
                207 consecutive patients <70 years of age with a recent event of CAD were randomised to a PBL group (n=104) or a control group (n=103). In addition to standard treatment, the PBL patients participated in 13 group sessions during 1 year, where individual learning needs and behavioural changes were focused upon. QoL was measured by the Ladder of Life, Self-Rated Health (SRH), SF 36, and Cardiac Health Profile (CHP).
                Significant differences between the groups, favouring the PBL patients, were found by global instruments: more optimistic expectations of the future QoL and a better general condition. No differences were found by SRH, SF 36 or subscales of CHP, but QoL increased in both groups during the year.
                The main outcome was that QoL improved in both groups with some effects favouring the PBL programme.
Home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of life outcomes in acute MI and revascularisation patients. This finding, together with an absence of evidence of difference in healthcare costs between the two approaches, would support the extension of home-based cardiac rehabilitation programmes such as the Heart Manual to give patients a choice in line with their preferences, which may have an impact on uptake of cardiac rehabilitation in the individual case.