Calling for telemedicine as an alternative model of cardiac rehabilitation in promoting health to patients with coronary heart disease

This invited commentary refers to ‘Effects of personalized structured telemedicine-based exercise cardiac rehabilitation on health outcomes in patients with coronary heart disease: a systematic review and meta-analysis’, by Y. Liu et al., https://doi.org/10.1093/eurjcn/zvaf195. The health benefits of centre-based exercise cardiac rehabilitation are well-documented among those who complete the programme, but participation rates and long-term adherence remain disappointingly low.1 Alternative models that improve accessibility, participation, and adherence may be vital in addressing this disconnect between health impacts and participation.2 A recent systematic review and meta-analysis by Liu et al.3 evaluated the effectiveness of personalized, structured, telemedicine-based cardiac rehabilitation for patients with coronary heart disease. Nineteen randomized controlled trials (n = 1119 telemedicine-based; n = 254 centre-based; n = 855 usual care) were included, comparing telemedicine-based with centre-based cardiac rehabilitation and usual care. Interventions employed mobile health technologies such as smartphones, apps, and biosensors to deliver individualized exercise prescriptions.3 Compared with centre-based cardiac rehabilitation, telemedicine-based programmes showed similar improvements in exercise capacity, physical activity, cardiovascular risk factors, and quality of life. When compared with usual care, telemedicine-based cardiac rehabilitation improved exercise capacity, physical activity, diastolic blood pressure, body mass index, and depressive symptoms. Most studies included in the review showed low risk of bias for attrition and reporting, high risk due to lack of participant blinding, and an unclear risk for selection and detection biases. These findings based on randomized controlled trials provide high level evidence that telemedicine-based cardiac rehabilitation may serve as an accessible alternative to traditional rehabilitation and is superior to general advice and pamphlet-based usual care. The review by Liu et al.3 used the term telemedicine to describe its heterogeneous inclusion of various interventions involving mobile health monitoring. As a result of these encouraging results, knowing the specific type of telemedicine model that balances effectiveness and feasibility would be useful considerations for the practical integration of telemedicine into healthcare. Virtual cardiac rehabilitation refers to synchronous sessions conducted through real-time audiovisual communication, enabling direct interaction between patients and clinicians during exercise.4 In contrast, remote cardiac rehabilitation denotes asynchronous delivery, where exercise sessions occur without live supervision; monitoring and feedback are provided later through digital platforms, mobile applications, or wearable devices.4 Hybrid models, combine in-person, virtual, and/or remote. Although the authors used the term telemedicine-based cardiac rehabilitation, the interventions primarily relied on mobile apps, biosensors, and web platforms for monitoring and feedback, rather than real-time audiovisual supervision. The review indicates that remote cardiac rehabilitation provides modest improvements in exercise capacity, physical activity, diastolic blood pressure, body mass index, and depressive symptoms compared with usual care, but shows no major advantage over centre-based rehabilitation.3 These results are highly encouraging given the low effort and less resources of remote models of health delivery. Whether synchronous models of rehabilitations that permit real-time interaction for clinicians to monitor exercise performance, address safety concerns promptly, and adjust prescriptions dynamically, while maintaining a greater ease access are superior to centre-based or remote models are unclear. Furthermore, synchronous communication may foster patient engagement and accountability, which may enhance adherence and psychosocial support to a greater extent than remote models. Altogether, the commonly integrated centre-based models have inherent challenges specific to their setting (e.g. health centre, urban locations, etc.), timing of the programme, and person-specific barriers (e.g. childcare, transportation, etc.), and the presented review provides an important step in advancing the delivery of healthcare through non-traditional methods of delivery. A major strength of the review3 is the inclusion of randomized controlled trials, consisting of a large sample of intervention and control patients and covering several measures of health. A central consideration in interpreting this review is the representativeness of the included study populations, as this shapes the extent to which the findings can be generalized. A prior report in samples of ∼785 000 people indicate that 48% of cardiovascular disease patients are female, and the average age of coronary artery disease onset is generally 55–85 years for males and females.5 The included studies were primarily conducted in males (four-in-five participants) and the average age tended to be younger (mean ± standard deviation: ∼59 ± 8 years).3 Telemedicine offers privacy, flexibility, and reduced logistical demands, features that may be particularly advantageous individuals experiencing exercise-related anxiety or social discomfort. Although the review appropriately acknowledges implementation challenges associated with telemedicine-based CR among older adults (e.g. digital literacy, technology access, etc.), the implications of clinical and functional heterogeneity within this population remains insufficiently explored. Core features of telemedicine-based models, such as reduced supervision and greater reliance in patient autonomy, may be advantageous for robust individuals; however, these same characteristics may pose challenges for patients with increased vulnerability (e.g. frail persons, patients with polypharmacy, etc.). In addition, women face persistent barriers to participation in cardiac rehabilitation; including caregiving responsibilities, lower referral rates, and higher psychosocial burden, all of which contribute to reduced engagement.6 Whether telemedicine-based cardiac rehabilitation mitigates these well-established barriers among females and older adults are unclear, but the advantages of telemedicine may address some of these crucial barriers and act as a key facilitator in helping more people get the care they need. It is not clear why telemedicine is going to voicemail in these patients. The findings by Liu et al.3 encourages that controlled trials in these populations are highly warranted. The systematic review and meta-analysis by Liu et al.3 provide strong support for the superiority of telemedicine-based cardiac rehabilitation to brief, usual care and similar results to centre-based models albeit with less in-person specific barriers for patients. Such findings are an important step in determining certain aspects including the most optimal model of telemedicine and the impact of such models among female patients and older adults. Altogether, these observations based on randomized controlled trials are highly encouraging and may assist more patients with coronary health disease receive the evidence-based care they need. Pamela Tanguay PhD: Conceptualization, Writing—original draft, Writing—review & editing. Jasmine Allain BSc: Conceptualization, Writing—original draft, Writing—review & editing. Myles W. O’Brien PhD: Conceptualization, Writing—original draft, Writing—review & editing. Pamela Tanguay (PhD (Conceptualization [equal]; Investigation [equal]; Writing—original draft [equal]; Writing—review & editing [equal])), Jasmine Allain (BSc (Conceptualization [equal]; Investigation [equal]; Writing—original draft [equal]; Writing—review & editing [equal])), and Myles O'Brien (PhD (Conceptualization [equal]; Investigation [equal]; Writing—original draft [equal]; Writing—review & editing [equal])) None declared. No primary data related to this commentary.

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