Cardiac rehabilitation in the time of COVID-19
Author: Abraham Samuel Babu, WHF Emerging Leader. This article was first published in The Heart in the Time of COVID-19, a blog led by Dr Amitava Banerjee and Prof Pablo Perel in which WHF Emerging Leaders combine a global perspective with updates of the most recent science relating to CVD and COVID-19.
Cardiac rehabilitation (CR) is an integral part of cardiovascular care. Yet, it is one of the most underutilized evidence-based interventions across the world. With uptake to CR varying greatly around the world, the novel coronavirus (COVID-19), has been no help to this. Nevertheless, this has brought the entire CR community together to work towards alternate forms of delivery of CR and move away from a traditional institution / supervised CR.
Over the years, home-based CR and telerehabilitation have been gaining some prominence, but not to the extent one would expect it to. With the COVID-19 pandemic and the cessation of all on-site programs, the need to expand home-based CR and technology-driven CR models has hastened the spread of these models. A proposed technology-driven approach to facilitate a complete delivery of CR from assessment to intervention to follow up has been suggested by two studies (2, 3). One suggested the use of accessibility of information through social media or online sources for education and the digitization of patient support groups (2), while the other focused on its use for assessment and follow-up (3). However, both did recommend the use of various technologically driven methods for exercise prescription.
From these preliminary reports, professional organizations around the world began to respond to the need for continual delivery of CR during the COVID-19 pandemic. Three-position statements from leading cardiovascular organizations in Australia (4), Italy (5) and Europe (6) have recommended various strategies to ensure a smooth transition for the delivery of CR for secondary prevention. Specific technology-driven recommendations for the delivery of CR from these guidelines are for:
- Patient assessment (history, symptoms, adherence to medications), physical examination and investigations
- Assessment of physical activity, frailty and exercise capacity
- Delivery of patient education
- Provision of psychosocial support
From these recommendations, it would seem that technology can be used to ensure the delivery of CR services through home-based delivery models. The use of home-based models is most crucial as patients with cardiovascular disease (with or without comorbidities) places them at a greater risk for COVID-19 infection. Considering that the COVID-19 is here to stay, CR programs around the world would need to consider long term transition to technologically driven CR method to improve and sustain CR services. A recent statement has provided three simple steps to adapt and transition to virtual CR over a period of a year (7), which could be worth considering by CR programs.
For those being admitted to hospitals for acute cardiovascular events, delivery of CR may be limited due to the relocation of CR staff to COVID-19 duties. However, where CR can be provided on-site for acute cardiac events, protective equipment should be used as recommended for the safe delivery of CR. Regular assessments of this dynamic situation should be carried out by the CR team to ensure safety for both patients and the CR team members.
Even though many of the recommendations for virtual CR are applicable across most settings, low-resource settings could have their own challenges. Nevertheless, the use of simple technological methods like a phone call would be more than adequate to ensure the continuity of care for patients with cardiovascular diseases. In addition, home-based delivery models, which are common in low-resource settings, should be continued with monitoring through technological methods such as messaging, phone calls, and video calls, where feasible.
In conclusion, CR is an essential service for ensuring the continuity of care for patients with cardiovascular disease. Technology-driven strategies should be used to facilitate uptake, delivery and monitoring of CR. Simple methods like messaging and phone calls could be considered useful tools in low resource settings, while more advanced technological methods could be considered in high resource settings and where access to technology is not limited by the purchasing capacity of an individual.
References:
1. Turk-Adawi K, Supervia M, Lopez-Jimenez F, et al. Cardiac Rehabilitation Availability and Density around the Globe. EClinicalMedicine 2019; 13: 31–45.
2. Yeo TJ, Wang YL, Low TT. Have a heart during the COVID-19 crisis: Making the case for cardiac rehabilitation in the face of an ongoing pandemic. Eur J Prev Cardiol 2020: 2047487320915665.
3. Babu AS, Arena R, Ozemek C, Lavie CJ. COVID-19: A Time for Alternate Models in Cardiac Rehabilitation to Take Center Stage. Can J Cardiol 2020.
4. Nicholls SJ, Nelson M, Astley C, et al. Optimising Secondary Prevention and Cardiac Rehabilitation for Atherosclerotic Cardiovascular Disease During the COVID-19 Pandemic: A Position Statement from the Cardiac Society of Australia and New Zealand (CSANZ). Heart, lung & circulation 2020.
5. Mureddu GF, Ambrosetti M, Venturini E, et al. Cardiac rehabilitation activities during the COVID-19 pandemic in Italy. Position Paper of the AICPR (Italian Association of Clinical Cardiology, Prevention and Rehabilitation). Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace 2020; 90(2).
6. Scherrenberg M, Wilhelm M, Hansen D, et al. The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2020: 2047487320939671.
7. Moulson N, Bewick D, Selway T, et al. Cardiac Rehabilitation during the COVID-19 Era: Guidance on Implementing Virtual Care. Can J Cardiol 2020.
8. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. 2020. https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance#p05 (accessed 7th July 2020).
