Exercise as it relates to Disease/Is a home-based exercise cardiac rehabilitation program effective for elderly coronary heart disease patients?

Title Article Oerkild, Bodil, Marianne Frederiksen, Jorgen Fischer Hansen, Lene Simonsen, Lene Theil Skovgaard, and Eva Prescott. 2011. Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: Results from a randomised clinical trial. Age and Ageing 40 (1): 78-85.

Cardiovascular Diseases (CDV)
Cardiovascular Diseases are the number 1 cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke. Over three quarters of CVD deaths take place in low- and middle-income countries. Out of the 16 million deaths under the age of 70 due to noncommunicable diseases, 82% are in low and middle income countries and 37% are caused by CVDs. Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol using population-wide strategies. People with cardiovascular disease or who are at high cardiovascular risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established disease) need early detection and may require intervention or the use of medicines to prevent potential death.

The conditions that fall under Cardiovascular Diseases are:
 * Coronary heart disease – disease of the blood vessels supplying the heart muscle;
 * Cerebrovascular disease – disease of the blood vessels supplying the brain;
 * Peripheral arterial disease – disease of blood vessels supplying the arms and legs;
 * Rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
 * Congenital heart disease – malformations of heart structure existing at birth;
 * Deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

Heart Disease In The Elderly
The aging of the population worldwide will result in increasing numbers of elderly patients, among whom heart disease is the leading cause of death. Changes in cardiovascular physiology with normal aging and prevalent comorbidities result in differences in the effects of common cardiac problems as well as the response to their treatments. This makes the elderly (over 65's) at a much higher risk of suffering from a cardiovascular disease or developing one

Cardiac Rehabilitation
Participation in cardiac rehabilitation (CR) is known to reduce mortality and morbidity and increase health-related quality of life. Rehabilitation programmes are often located at centres (hospitals), which make it difficult for some patients to participate. Reviews and meta-analyses have documented the effect of centre-based rehabilitation also among the elderly (≥65 years) with coronary heart disease, and since this group of patients is the fastest growing subgroup of cardiac patients, it is important to adapt the programmes according to their demands.

A suggested alternative to centre-based CR is home-based CR where the entire programme or part of this is moved from the centre to the patients' home. These programmes seem ideal in targeting the elderly patients, but have primarily been implemented in English-speaking countries. Research has found that home-based CR programmes were not inferior to centre-based programmes. However, the populations were highly selected with under-representation of the elderly and patients with high co-morbidity and congestive heart failure were excluded.

The Type of Research, Where it Originated and How it was Achieved
The study is a randomised clinical trial comparing home-based CR with centre-based comprehensive CR. Patients who declined participation in the study were offered the centre-based programme. A total of 75 patients were used for this study with the population consisting of patients ≥65 years with a ‘new’ event of coronary heart disease defined as acute myocardial infarction, percutaneous transluminal coronary intervention or coronary artery bypass graft. Exclusion criteria were mental disorders (dementia), social disorders (severe alcoholism and drug abuse), living at nursing home, language barriers and the use of wheelchair. Patients were recruited either from a database covering all invasive procedures in the catchment area of Bispebjerg University Hospital or from the Coronary Department. The recruitment period was from January 2007 to July 2008. Data was obtained at baseline and after 3, 6 and 12 months of rehabilitation work. The patients had to give informed consent before any trial-related procedures. The home programme was designed to focus on the exercise component of CR, which was moved to the patients' home. A training programme was developed with a physiotherapist. The centre consisted of a 6-week intensive programme where patients were offered group-based supervised exercise training 60 min twice a week.

The key indicator used for this research was Peak Vo2, this was assessed through a ramp based cycle ergometer test where gas exchange was measured by respiratory capture through a facemask. The secondary tests were a sit to stand test (STS), systolic and diastolic blood pressure, total, HDL and LDL cholesterol, body mass index (BMI), waist–hip ratio, proportion of smokers and health-related quality of life estimated by SF-12 and Hospital Anxiety and Depression Scale (HADS).

Basic Results
Baseline characteristics according to intervention show no significant differences between the two groups. In addition, no significant differences were found in the use of medication. All patients were treated with lipid-lowering drugs and 73.3% with beta-blockers.

Ten patients were not able to perform the exercise test, due to co-morbidity. A total of seven patients died (centre n= 3 and home n= 4) and four patients dropped out (centre n= 2 and home n= 2). Their baseline data were comparable with baseline data from patients who continued in the study. Both the clinic and at home interventions saw improvements in a large majority of the participants VO2 and physical health indicators, there was no discernible difference between the two. At both the 6 and 12 month test readings approximately one-third of patients in both groups did not improve in exercise capacity after the intervention, and continued to decline at post 12 months follow-ups. Predictors for lack of improvement were older age, having Chronic Obstructive Pulmonary Disease (COPD) and living alone. However, there were no indications of differences in the effect of the two interventions with increasing age, COPD and living alone, although statistical power to detect this was limited. No consistent patterns were seen for either clinical status outcomes, laboratory values or health-related quality of life at 3 and 12 months. However, there was a significant increase in HADS anxiety score in the centre group at 3 months followed by a decrease when ending the programme at 12 months.

Interpretation and Conclusions
The researchers developed a clear and precise picture with their study, the effects of rehabilitation/cardiovascular activation will improve overall cardiovascular health with the exception of severely chronic cases. With the location of the rehabilitation irrelevant. Whist anxiety levels were higher when rehabilitation was completed at a clinic, this was not a testable factor, but could be cause for further research knowing the definite effects of stress on the heart. Perhaps some further study into the level and intensity of the rehabilitation and where the best results come from.

My interpretation of the study was that not enough control was possible over the level of activity with the home based rehabilitation (this would defeat the purpose of getting away from the centre) but therefore it is possible the rehabilitation may have not been completed to the high standard/intensity of the centre programme. None the less, an at home regime has produced an as effective result in rehabilitation as in the centre.

Implications
The results have shown no difference between at home or centre rehabilitation. This could mean with the help of a drop in physiotherapist, that some elderly people with a cardiovascular disease could complete their programme from the comfort of their own home, in an environment they feel comfortable in. This may not only increase moral for the patients but could also potentially get their family or friends positively involved in their rehabilitation.