Cardiac Rehabilitation Services in Low- and Middle-Income Countries

Shanmugasegaram, Shamila; Perez‐Terzic, Carmen; Jiang, Xiaolian; Grace, Sherry L.

doi:10.1097/jcn.0b013e31829c1414

Cited by 30 publications

(18 citation statements)

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“…While the availability of CR programs in the majority of Latin American countries is just beginning to be known, their broader implementation is hampered by lack of evidence demonstrating benefits in these lower-resource settings 12 . A recent review of randomized controlled trials (RCTs) of CR in LMICs identified only two RCTs, neither of which was undertaken in Latin America 13 . To support broader CR delivery and service reimbursement, we must robustly demonstrate that CR is beneficial in this context.…”

Section: Introductionmentioning

confidence: 99%

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Chaves¹,

Ghisi²,

Grace³

et al. 2016

Braz. J. Phys. Ther.

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BackgroundCardiovascular Disease (CVD) is the leading burden of disease worldwide. Moreover, CVD-related death rates are considered an epidemic in low- and middle-income countries (LMICs). Research shows that cardiac rehabilitation (CR) participation reduces death and improves disability and quality of life. Given the growing epidemic of CVD in LMICs and the insufficient evidence about CR programs in these countries, a Randomized Control Trial (RCT) in Latin America is warranted.ObjectiveTo investigate the effects of comprehensive CR on functional capacity and cardiovascular risk factors.MethodThe design is a single-blinded RCT with three parallel arms: comprehensive CR (exercise + education) versus exercise-based CR versus wait-list control (no CR). The primary outcome will be measured by the Incremental Shuttle Walk Test. Secondary outcomes are risk factors (blood pressure, dyslipidemia, dysglycemia, body mass index and waist circumference); tertiary outcomes are heart health behaviors (exercise, medication adherence, diet, and smoking), knowledge, and depressive symptoms. The CR program is six months in duration. Participants randomized to exercise-based CR will receive 24 weeks of exercise classes. The comprehensive CR group will also receive 24 educational sessions, including a workbook. Every outcome will be assessed at baseline and 6-months later, and mortality will be ascertained at six months and one year.ConclusionThis will be the first RCT to establish the effects of CR in Latin America. If positive, results will be used to promote broader implementation of comprehensive CR and patient access in the region and to inform a larger-scale trial powered for mortality.

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Section: Introductionmentioning

confidence: 99%

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Chaves¹,

Ghisi²,

Grace³

et al. 2016

Braz. J. Phys. Ther.

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“…Brazil was chosen as the LMIC for testing because of: (1) the great burden of CVD, 10 (2) the availability of country-specific CR guidelines10 11 (there are few national CR guidelines developed in LMICs) and (3) no RCT of CR (with any outcome) in South America to our knowledge 5…”

Section: Methodsmentioning

confidence: 99%

Effects of comprehensive cardiac rehabilitation on functional capacity in a middle-income country: a randomised controlled trial

Chaves

Ghisi

Grace

et al. 2018

Heart

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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.

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“…Of the 103 middle-income countries globally, this search revealed CR services exist in 29 (28.2%) countries (Figure 1). These were: Algeria, 70 Argentina,42 Belarus, 69 Bosnia And Herzegovina, 69 Brazil, 68 Bulgaria, 69 China, 71 Colombia, 68 Costa Rica, 69 Cuba, 69 Ecuador, 42 Egypt, 72 India, 73 Indonesia, 74 Iran, 75 Malaysia, 69 Mexico, 68 Pakistan, 76 Panama, 69 Paraguay, 42 Peru, 68 Philippines, 43 Romania, 77 South Africa, 78 Sri Lanka, 69 Thailand, 69 Tunisia, 79 Turkey, 80 and Venzuela. 42 …”

Section: Cr Availability In Middle-income Countriesmentioning

confidence: 99%

Global availability of cardiac rehabilitation

2014

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The most prevalent non-communicable disease globally, namely cardiovascular disease (CVD), is also the leading cause of mortality, with over 80% of the deaths occurring in low-and middleincome countries. To lessen the impact of CVDs on individuals and societies, a comprehensive approach is needed. Cardiac rehabilitation (CR) involves delivery of structured exercise, education and risk reduction, in a cost-effective manner. Robust evidence demonstrates it reduces mortality up to 25%, improves functional capacity, as well as decreases re-hospitalization. Despite its benefits, and clinical practice guideline recommendations to refer cardiac patients, CR programs are grossly under-used. Worldwide, there is low availability of CR; only 38.8% of countries globally have CR programs. Specifically, 68.0% of high-income and 23% of LMICs (28.2% for middle-and 8.3% for low-income countries) have CR. CR density estimates ranged from 1 program per 0.1-6.4 million inhabitants. CR availability is much lower than that of other evidencebased secondary prevention therapies, such as revascularization and pharmacological therapies. Multi-level strategies to augment CR capacity and availability at national and international levels such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.

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Cardiac Rehabilitation Services in Low- and Middle-Income Countries

Abstract: Although patients similarly benefit from CR, few programs are available in LMICs. Policies need to be implemented to increase provision of tailored CR models at the global and national level, with evaluation.

Cited by 30 publications

References 18 publications

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Effects of comprehensive cardiac rehabilitation on functional capacity in a middle-income country: a randomised controlled trial

Global availability of cardiac rehabilitation

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