Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed.

ObjectiveCardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.MethodsA literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.ResultsAvailable data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.ConclusionsAdvocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.

Background:We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients. Methods: In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification. Results: Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption. Conclusion:Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges. Highlights:-COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.-In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries. Ghisi et al: Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World Art. 43, page 2 of 16-The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training. -There is also significant psychosocial and economic impact on CR providers.-Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

This tool may be useful to assess CR participants' knowledge gaps, and to evaluate the efficacy of educational delivery in CR.

Background: Being aware of the coronary artery disease can be considered the first step to reduce the risk of cardiac complications.

Background: Cardiovascular diseases show high incidence and prevalence in Brazil; however, participation in Cardiac Rehabilitation (CR) is limited and has been poorly investigated in the country. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess the barriers to participation and adherence to CR.

Background Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. Methods In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.

ObjectiveDespite the growing epidemic of cardiovascular diseases in middle-income countries, there is insufficient evidence about cardiac rehabilitation (CR) in these countries. Thus, the effects of comprehensive CR on functional capacity and risk factors were investigated in Brazil, to test the hypothesis that it results in better outcomes than exercise-only or no CR.MethodsSingle-blinded, randomised controlled trial with three parallel arms: comprehensive CR (exercise+education) versus exercise-only CR versus wait-list control. Eligible coronary patients were randomised in blocks of four with 1:1:1 concealed allocation. Participants randomised to exercise-only CR received 36 exercise classes; comprehensive CR group also received 24 educational sessions. The primary outcome was incremental shuttle walk test (ISWT) distance; secondary outcomes were cardiovascular risk factors. All outcomes were assessed at baseline and 6 months later. Analysis of covariance was performed on the basis of intention-to-treat (ITT) and per-protocol.Results115 (88.5%) patients were randomised; 93 (80.9%) were retained. There were improvements in ISWT distance from pretest to post-test with comprehensive (from 358.4±132.6 to 464.8±121.6 m; mean change=106.4; p<0.001) and exercise-only (from 391.5±118.8 to 488.1±106.3 m; mean change=96.5, p<0.001) CR, with significantly greater functional capacity with comprehensive CR versus control (ITT: mean difference=75.6±30.7 m, 95% CI 1.4 to 150.2). There were also reductions in systolic blood pressure with comprehensive CR (ITT: reduction of 6.2±17.8 mm Hg, p=0.04). There were no significant differences for other outcomes.ConclusionResults showed clinically significant improvements in functional capacity and blood pressure with CR, and significantly greater functional capacity with comprehensive CR compared with usual care.Trial registration numberNCT02575976; Results.