Novel intervention for cardiovascular enhancement and rehabilitation (NICER)

Background: Cardiac rehabilitation (CR) programs support patients recovering from cardiac surgery or a serious cardiac event such as a myocardial infarction (MI). These secondary prevention programs have become an integral part of healthcare for such patients, with automatic referral processes in place throughout Australian hospitals. However CR programs are currently applied primarily as cardiologic follow-up interventions. Despite the importance of such clinical follow-up, little or no evidence is currently available regarding a comprehensive outpatient CR program built within the context of clinical and exercise physiology principles.Objective: The NICER project aims to: determine the links between MI history and the most common comorbidities seen in CR populations, and trends in physiologic and functional capacity outcomes post-intervention; provide in-depth insights into patient perceptions of barriers to exercise participation and their personal lived-experience with their health status; and establish the safety and effectiveness of a novel CR intervention based on essential clinical and exercise physiology principles and comprising multiple newly developed elements.Methods: Retrospective review of patient data from Westmead hospital was undertaken, comprising all patients (n = 4202) who attended the outpatient CR program between January 2000 and December 2011, with the aim of clarifying the influence of MI history and comorbidities on clinical outcomes. The barriers to rehabilitation questionnaire (BARE-Q) was administered to patients (n = 28) attending the outpatient CR programs at Westmead and Mt Druitt hospitals, to reveal insights into the patients’ personal lived-experience with their health and healthcare. An observational pilot study of the NICER intervention was undertaken in patients (n = 14) attending the outpatient CR program at Mt Druitt hospital, with the objective of evaluating the initial safety and effectiveness of the intervention. Novel elements comprising the intervention included a patient classification system, pre- and post-program outcomes testing protocols, an aerobic exercise prescription matrix, an exercise periodisation strategy, exercise technique and functional breathing training, a patient motivation strategy, and an integrated patient education and goal setting program. Statistical analysis involved binary and multinomial logistic regression, one-way and two-way ANOVA/MANOVA, Pearson’s correlation, and theme analysis, as appropriate.Results: Retrospective data analysis showed that patient MI history, pre-program resting SBP, age, BMI and metabolic syndrome comorbidity clustering were all found to influence clinical outcomes, with these trends suggesting that some current generalisations as to the effects of exercise on resting and peak physiology outcomes may not be applicable within the context of CR. Interval training (IT) based CR appears to normalise resting SBP post-program, while increasing peak HR and peak SBP in all subgroups. Results from the BARE-Q study revealed that patients who felt more involved with the planning of their healthcare generally also felt they understood their condition better and less limited by fatigue to participate in exercise, but also felt that their health significantly limits their activities of daily living and participation in desirable lifestyle activities. Limited patient knowledge of exercise and a poor exercise history, as well as pain and fatigue, were rated by BARE-Q responders as important barriers to exercise adherence, in addition to time and cost restraints. Goal setting and enhancing long-term support mechanisms were found to be important areas for improvement based on BARE-Q data. Clinical pilot results from the NICER intervention demonstrate the approach to be safe and effective in delivering significant adaptations in resting and peak physiology and functional capacity outcomes. Novel elements comprising the NICER framework therefore warrant further research and validation studies aiming to conclusively demonstrate the effectiveness of this novel approach and CR-specific components.Conclusions: Comparisons of clinical outcomes based on pre-program resting SBP demonstrate that interval training normalises resting SBP (i.e. reducing or increasing blood pressure, in hyper- and hypotensive patients respectively), and revealed other important trends in resting and peak physiologic outcomes. The additional application of comorbidity classifications demonstrated an important interaction of these factors with MI history in grading peak physiologic changes. Limited patient knowledge and poor experiences with exercise, along with pain and fatigue, were shown to be significant patient-perceived barriers to exercise adherence. Improved goal setting and long-term maintenance planning were identified as important measures towards enhancing patient adherence to exercise. The NICER pilot demonstrated this cardiac rehabilitation intervention to be safe and feasible. The NICER model provides a comprehensive approach to CR practice based on clinical and exercise physiology principles.