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Reliable change indices can determine pre-post intervention changes at an individual level that are greater than chance or practice effect. We applied previously developed minimal meaningful change (MMC RCI) scores for oxygen uptake (V̇O 2) values associated with estimated lactate threshold (θ LT), respiratory compensation point (RCP), and peak oxygen uptake (V̇O 2peak) to evaluate the effectiveness of exercise training in cardiovascular disease patients. 303 patients (65 ± 11 yrs.; 27% female) that completed a symptom-limited cardiopulmonary exercise test (CPET) before and after 6-months of guideline-recommended exercise training were assessed to determine absolute and relative V̇O 2 at θ LT , RCP, and V̇O 2peak. Using MMC RCI ∆V̇O 2 scores of ±3.9 mL·kg−1·min−1, ±4.0 mL·kg−1·min−1, and ± 3.6 mL·kg−1·min−1 for θ LT , RCP, and V̇O 2peak , respectively, patients were classified as "positive" (Δθ LT , ΔRCP, and/or ΔV̇O 2peak ≥ +MMC RCI), "non-" (between ±MMC RCI), or "negative" responders (≤ -MMC RCI). Mean RCP (n = 86) and V̇O 2peak (n = 303) increased (p < 0.05) from 19.4 ± 3.6 mL·kg−1·min−1 and 18.0 ± 6.3 mL·kg−1·min−1 to 20.1 ± 3.8 mL·kg−1·min−1 and 19.2 ± 7.0 mL·kg−1·min−1 at exit, respectively, whereas θ LT (n = 140) did not change (15.5 ± 3.4 mL·kg−1·min−1 versus 15.7 ± 3.8 mL·kg−1·min−1, p = 0.324). For changes in θ LT , 6% were classified as "positive" responders, 90% as "non-responders", and 4% as "negative" responders. For RCP, 10% exhibited "positive" changes, 87% were "non-responders", and 2% were "negative" responders. For ΔV̇O 2peak , 57 patients (19%) were classified as "positive" responders, 229 (76%) as "non-responders", and 17 (6%) as "negative" responders. Most patients that completed the exercise training program did not achieve reliable improvements greater than that of chance or practice at an individual level in θ LT , RCP and V̇O 2peak. • We previously established minimal meaningful change scores for peak oxygen uptake in patients with cardiovascular disease. • We used these scores to assess the effectiveness of traditional exercise training-based cardiac rehabilitation (CR) program. • In 303 patients, mean peak oxygen uptake increased before versus after the CR program. • However, the magnitude of change in peak oxygen uptake after CR achieved reliable improvement in only 19% of patients. • Our minimal meaningful change scores can quantify exercise response and assess exercise training intervention effectiveness. [ABSTRACT FROM AUTHOR]

Background: Ischemic heart disease (IHD) is linked to brain white matter (WM) breakdown but how age or disease effects WM integrity, and whether it is reversible using cardiac rehabilitation (CR), remains unclear., Purpose: To assess the effects of brain aging, cardiovascular disease, and CR on WM microstructure in brains of IHD patients following a cardiac event., Study Type: Retrospective., Population: Thirty-five IHD patients (9 females; mean age = 59 ± 8 years), 21 age-matched healthy controls (10 females; mean age = 59 ± 8 years), and 25 younger controls (14 females; mean age = 26 ± 4 years)., Field Strength/sequence: 3 T diffusion-weighted imaging with single-shot echo planar imaging acquired at 3 months and 9 months post-cardiac event., Assessment: Tract-based spatial statistics (TBSS) and tractometry were used to compare fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) in cerebral WM between: 1) older and younger controls to distinguish age-related from disease-related WM changes; 2) IHD patients at baseline (pre-CR) and age-matched controls to investigate if cardiovascular disease exacerbates age-related WM changes; and 3) IHD patients pre-CR and post-CR to investigate the neuroplastic effect of CR on WM microstructure., Statistical Tests: Two-sample unpaired t-test (age: older vs. younger controls; IHD: IHD pre-CR vs. age-matched controls). One-sample paired t-test (CR: IHD pre- vs. post-CR). Statistical threshold: P < 0.05 (FWE-corrected)., Results: TBSS and tractometry revealed widespread WM changes in older controls compared to younger controls while WM clusters of decreased FA in the fornix and increased MD in body of corpus callosum were observed in IHD patients pre-CR compared to age-matched controls. Robust WM improvements (increased FA, increased AD) were observed in IHD patients post-CR., Data Conclusion: In IHD, both brain aging and cardiovascular disease may contribute to WM disruptions. IHD-related WM disruptions may be favorably modified by CR., Level of Evidence: 3 TECHNICAL EFFICACY: Stage 2., (© 2023 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Purpose: Improving aerobic fitness through exercise training is recommended for the treatment of cardiovascular disease (CVD). However, strong justifications for the criteria of assessing improvement in key parameters of aerobic function including estimated lactate threshold (θ LT ), respiratory compensation point (RCP), and peak oxygen uptake (V˙ o2peak ) at the individual level are not established. We applied reliable change index (RCI) statistics to determine minimal meaningful change (MMC RCI ) cutoffs of θ LT , RCP, and V˙ o2peak for individual patients with CVD., Methods: Sixty-six stable patients post-cardiac event performed three exhaustive treadmill-based incremental exercise tests (modified Bruce) ∼1 wk apart (T1-T3). Breath-by-breath gas exchange and ventilatory variables were measured by metabolic cart and used to identify θ LT , RCP, and V˙ o2peak . Using test-retest reliability and mean difference scores to estimate error and test practice/exposure, respectively, MMC RCI values were calculated for V˙ o2 (mL·min -1. kg -1 ) at θ LT , RCP, and V˙ o2peak ., Results: There were no significant between-trial differences in V˙ o2 at θ LT ( P = .78), RCP ( P = .08), or V˙ o2peak ( P = .74) and each variable exhibited excellent test-retest variability (intraclass correlation: 0.97, 0.98, and 0.99; coefficient of variation: 6.5, 5.4, and 4.9% for θ LT , RCP, and V˙ o2peak , respectively). Derived from comparing T1-T2, T1-T3, and T2-T3, the MMC RCI for θ LT were 3.91, 3.56, and 2.64 mL·min -1. kg -1 ; 4.01, 2.80, and 2.79 mL·min -1. kg -1 for RCP; and 3.61, 3.83, and 2.81 mL·min -1. kg -1 for V˙ o2peak . For each variable, MMC RCI scores were lowest for T2-T3 comparisons., Conclusion: These MMC RCI scores may be used to establish cutoff criteria for determining meaningful changes for interventions designed to improve aerobic function in individuals with CVD., Competing Interests: No conflicts of interest, financial or otherwise, are declared by the authors., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Five themes emerged from the data: (1) Lack of emotional intimacy when receiving virtual care, (2) Inadequacy of virtual platforms, (3) Saving time with virtual care, (4) Virtual care facilitated accessibility, and (5) Loss of connections with patients and colleagues. Given that virtual care continues to be implemented, and in some instances touted as an optimal option for the delivery of cardiac rehabilitation, it is critical to address the needs of older adults living with cardiovascular disease and their healthcare providers. This is particularly crucial related to issues accessing and using technology, as well as older adults' need to build trust and emotional connection with their providers.

Background: To evaluate the feasibility of "threshold-based" aerobic exercise prescription in cardiovascular disease, we aimed to quantify the proportion of patients whose clinical cardiopulmonary exercise test (CPET) permit identification of estimated lactate threshold (θ LT ) and respiratory compensation point (RCP) and to characterize the variability at which these thresholds occur., Methods: Breath-by-breath CPET data of 1102 patients (65 ± 12 years) referred to cardiac rehabilitation were analyzed to identify peak O 2 uptake (V˙O 2peak ; mL·min -1 and mL·kg -1 ·min -1 ) and θ LT and RCP (reported as V˙O 2 , %V˙O 2peak , and %peak heart rate [%HR peak ]). Patients were grouped by the presence or absence of thresholds: group 0: neither θ LT nor RCP; group 1: θ LT only; and group 2: both θ LT and RCP., Results: Mean V˙O 2peak was 1523 ± 627 mL·min -1 (range: 315-3789 mL·min -1 ) or 18.0 ± 6.5 mL·kg -1 ·min -1 (5.2-46.5 mL·kg -1 ·min -1 ) and HR peak was 123 ± 24 beats per minute (bpm) (52 bpm-207 bpm). There were 556 patients (50%) in group 0, 196 (18%) in group 1, and 350 (32%) in group 2. In group 1, mean θ LT was 1240 ± 410 mL·min -1 (580-2560 mL·min -1 ), 75% ± 8%V˙O 2peak (52%-92%V˙O 2peak ), or 84% ± 6%HR peak (64%-96%HR peak ). In group 2, θ LT was 1390 ± 360 mL·min -1 (640-2430 mL·min -1 ), 70% ± 8%V˙O 2peak (41%-88%V˙O 2peak ), or 78% ± 7%HR peak (52%-96%HR peak ), and RCP was 1680 ± 440 mL·min -1 (730-3090 mL·min -1 ), 84% ± 7%V˙O 2peak (54%-99%V˙O 2peak ), or 87% ± 6%HR peak (59%-99%HR peak ). Compared with group 1, θ LT in group 2 occurred at a higher V˙O 2 but lower %V˙O 2peak and %HR peak (P < 0.05)., Conclusions: Only 32% of CPETs exhibited both θ LT and RCP despite flexibility in protocol options. Commonly used step-based protocols are suboptimal for "threshold-based" exercise prescription., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Despite well-established efficacy for patients with a cardiovascular diagnosis or event, exercise-based cardiac rehabilitation program participation and completion has remained alarmingly low due to both system-level barriers and patient-level factors. Patient mental health, particularly depression, is now recognized as significantly associated with reduced enrollment, participation, attendance, and completion of a cardiac rehabilitation program. More recently, anxiety sensitivity has emerged as an independent construct, related to but distinct from both depression and anxiety. Anxiety sensitivity has been reported to be adversely associated with participation in exercise and, thus, may be important for patients in cardiac rehabilitation. Accordingly, the objective of this study was to conduct a scoping review to summarize the evidence for associations between anxiety sensitivity and cardiovascular disease risk factors, exercise, and clinical outcomes in cardiac rehabilitation., Methods: A formal scoping review, following PRISMA-ScR guidelines, was undertaken. Searches of MEDLINE, Web of Science, CINAHL, PSYCINFO, and Scopus databases were conducted, supplemented by hand searches; studies published through December of 2020 were included. The initial screening was based on titles and abstracts and the second stage of screening was based on full text examination., Results: The final search results included 28 studies. Studies reported statistically significant associations between anxiety sensitivity and exercise, cardiovascular disease, and participation in cardiac rehabilitation. Many studies, however, were conducted in non-clinical, community-based populations; there were few studies conducted in cardiovascular disease and cardiac rehabilitation clinical patient populations. Additionally, significant gaps remain in our understanding of the sex-based differences in the complex relationships between anxiety sensitivity, exercise and cardiac rehabilitation., Conclusion: More research is needed to understand specific associations between anxiety sensitivity and clinical outcomes among clinical cardiovascular disease patients and participants in cardiac rehabilitation programs. Treatment of anxiety sensitivity to optimize clinical outcomes in cardiac rehabilitation programs should be investigated in future studies., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors. Published by Elsevier B.V.)

The current study evaluated the hypothesis that 6 mo of exercise-based cardiac rehabilitation (CR) would improve sympathetic neural recruitment in patients with ischemic heart disease (IHD). Microneurography was used to evaluate action potential (AP) discharge patterns within bursts of muscle sympathetic nerve activity (MSNA), in 11 patients with IHD (1 female; 61 ± 9 yr) pre (pre-CR) and post (post-CR) 6 mo of aerobic and resistance training-based CR. Measures were made at baseline and during maximal voluntary end-inspiratory (EI-APN) and end-expiratory apneas (EE-APN). Data were analyzed during 1 min of baseline and the second half of apneas. At baseline, overall sympathetic activity was less post-CR (all P < 0.01). During EI-APN, AP recruitment was not observed pre-CR (all P > 0.05), but increases in both within-burst AP firing frequency (Δpre-CR: 2 ± 3 AP spikes/burst vs. Δpost-CR: 4 ± 3 AP spikes/burst; P = 0.02) and AP cluster recruitment (Δpre-CR: -1 ± 2 vs. Δpost-CR: 2 ± 2; P < 0.01) were observed in post-CR tests. In contrast, during EE-APN, AP firing frequency was not different post-CR compared with pre-CR tests (Δpre-CR: 269 ± 202 spikes/min vs. Δpost-CR: 232 ± 225 spikes/min; P = 0.54), and CR did not modify the recruitment of new AP clusters (Δpre-CR: -1 ± 3 vs. Δpost-CR: 0 ± 1; P = 0.39), or within-burst firing frequency (Δpre-CR: 3 ± 3 AP spikes/burst vs. Δpost-CR: 2 ± 2 AP spikes/burst; P = 0.21). These data indicate that CR improves some of the sympathetic nervous system dysregulation associated with cardiovascular disease, primarily via a reduction in resting sympathetic activation. However, the benefits of CR on sympathetic neural recruitment may depend upon the magnitude of initial impairment.

The survival rate of patients with ischemic heart disease (IHD) is increasing. However, survivors experience increased risk for neurological complications. The mechanisms for this increased risk are unknown. We tested the hypothesis that patients with IHD have greater carotid and cerebrovascular stiffness, and these indexes predict white matter small vessel disease. Fifty participants (age, 40-78 yr), 30 with IHD with preserved ejection fraction and 20 healthy age-matched controls, were studied using ultrasound imaging of the common carotid artery (CCA) and middle cerebral artery (MCA), as well as magnetic resonance imaging (T1, T2-FLAIR), to measure white matter lesion volume (WMLv). Carotid β-stiffness provided the primary measure of peripheral vascular stiffness. Carotid-cerebral pulse wave transit time (ccPWTT) provided a marker of cerebrovascular stiffness. Pulsatility index (PI) and resistive index (RI) of the MCA were calculated as measures of downstream cerebrovascular resistance. When compared with controls, patients with IHD exhibited greater β-stiffness [8.5 ± 3.3 vs. 6.8 ± 2.2 arbitrary units (AU); P = 0.04], MCA PI (1.1 ± 0.20 vs. 0.98 ± 0.18 AU; P = 0.02), and MCA RI (0.66 ± 0.06 vs. 0.62 ± 0.07 AU; P = 0.04). There was no difference in WMLv between IHD and control groups (0.95 ± 1.2 vs. 0.86 ± 1.4 mL; P = 0.81). In pooled patient data, WMLv correlated with both β-stiffness ( R = 0.34, P = 0.02) and cerebrovascular ccPWTT ( R = -0.43, P = 0.02); however, β-stiffness and ccPWTT were not associated ( P = 0.13). In multivariate analysis, WMLv remained independently associated with ccPWTT ( P = 0.02) and carotid β-stiffness ( P = 0.04). Patients with IHD expressed greater β-stiffness and cerebral microvascular resistance. However, IHD did not increase risk of WMLv or cerebrovascular stiffness. Nonetheless, pooled data indicate that both carotid and cerebrovascular stiffness are independently associated with WMLv. NEW & NOTEWORTHY This study found that patients with ischemic heart disease (IHD) with preserved ejection fraction and normal blood pressures exhibit greater carotid β-stiffness, as well as middle cerebral artery pulsatility and resistive indexes, than controls. White matter lesion volume (WMLv) was not different between vascular pathology groups. Cerebrovascular pulse wave transit time (ccPWTT) and carotid β-stiffness independently associate with WMLv in pooled participant data, suggesting that regardless of heart disease history, ccPWTT and β-stiffness are associated with structural white matter damage.

Globally, there are ∼ 26 million people living with heart failure (HF), 50% of them with reduced ejection fraction, costing countries billions of dollars each year. Improvements in treatment of cardiovascular diseases, including advanced HF, have allowed an unprecedented number of patients to survive into old age. Despite these advances, patients with HF deteriorate and often require advanced therapies. As the proportion of elderly patients in the population increases, there will be an increasing number of patients to be evaluated for advanced therapies and an increasing number that do not qualify for, won't be considered for, or decline orthotopic heart transplantation. The purpose of this article is to review the benefits of palliative care (PC), exercise-based cardiac rehabilitation (ExCR), device therapy (cardiac resynchronization therapy and mitral clip), and mechanical circulatory support (MCS) in advanced HF patients who are transplant ineligible. PC interventions should be introduced early in the course of a patient's diagnosis to manage symptoms, address goals of care, and improve patient-centered outcomes. Further improvement in health-related quality of life as well as functional capacity can be achieved safely in patients with advanced HF through patient participation in ExCR. Device therapy and MCS can reduce HF hospitalizations and improve survival. In fact, early survival with MCS approaches that of heart transplantation. Despite their being transplant ineligible, there are a variety of treatment options available to patients to improve their quality of life, decrease hospitalizations, and potentially improve mortality., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) is a chronic, progressive, incurable condition characterized by periods of apparent stability interspersed with acute exacerbations. Despite many important advances in its treatment, approximately one-third of deaths in Canada each year result from CVD. While this might lead one to assume that a comprehensive medical approach exists to the management of this inevitable outcome, the reality is much different. The current Canadian medical model emphasizes the management of acute exacerbations of CVD during which end-of-life issues figure frequently and prominently, although in a setting that is inappropriate to address the comprehensive needs of patients and their families.As a result, end-of-life care was made a theme of the recently reported Canadian Heart Health Strategy and Action Plan (www.chhs-scsc.ca). From this, several recommendations are made, central to which is the need to reframe CVD as a condition ideally suited to a chronic disease management approach. In addition, replacement of the term 'palliative care' with the term 'end-of-life planning and care' is proposed to foster earlier and more integrated comprehensive care, which, it is proposed, denotes the provision of advanced care planning, palliative care, hospice care and advanced directives, with a focus on decision making and planning. Finally, end-of-life planning and care should be a routine part of assessment of any patient with CVD, should be reassessed whenever important clinical changes occur and should be provided in a manner consistent with relevant CVD practice guidelines. Specifically, a Canadian strategy to improve end-of-life planning and care should focus on the following: * Integrated end-of-life planning and care across the health care system; * Facilitated communication and seamless care provision across all providers involved in end-of-life planning and care; * Adequate resources in the community for end-of-life planning and care; * Specialized training in sensitive communication and supportive care as part of core training for all members of the interdisciplinary care team; * Measurement of key performance indicators for end-of-life planning and care; and * Research into effective end-of-life planning and care.Heart failure is an advanced form of CVD with very high morbidity, mortality and burden of care, making it an ideal condition for implementation and testing of interventions to improve end-of-life planning and care.

Objective: Cardiac rehabilitation remains grossly under-utilized despite its proven benefits. This study prospectively compared verified cardiac rehabilitation enrollment following automatic vs usual referral, postulating that automatic referral would result in significantly greater enrollment for cardiac rehabilitation., Design: Prospective controlled multi-center study., Patients and Methods: A consecutive sample of 661 patients with acute coronary syndrome treated at 2 acute care centers (75% response rate) were recruited, one site with automatic referral via a computerized prompt and the other with a usual referral strategy at the physician's discretion. Cardiac rehabilitation referral was discerned in a mailed survey 9 months later (n = 506; 84% retention), and verified with 24 cardiac rehabilitation sites to which participants were referred., Results: A total of 124 (52%) participants enrolled in cardiac rehabilitation following automatic referral, vs 84 (32%) following usual referral (p < 0.001). Automatically referred participants were more likely to be referred from an in- patient unit (p < 0.01), and to be referred in a shorter time period (p < 0.001). Logistic regression analyses revealed that, after controlling for sociodemographic characteristics and case-mix, automatically referred participants were significantly more likely to enroll in cardiac rehabilitation (odds ratio = 2.1; 95% confidence interval 1.4-3.3) than controls., Conclusion: Automatic referral resulted in over 50% verified cardiac rehabilitation enrollment; 2 times more than usual referral. It also significantly reduced utilization delays to less than one month.

Background: Expansion of cardiac rehabilitation (CR) could save both lives and costs by reducing illness and use of health care services. In February 2001, the Ontario Ministry of Health and Long-Term Care (the Ministry) announced a pilot project (the Pilot) to implement and evaluate a comprehensive, multifactoral model of CR service delivery at 17 centres across Ontario., Objectives: To design, coordinate and evaluate a coordinated model of CR service delivery, and to collect and evaluate an extensive set of clinical and administrative data., Methods and Results: The Pilot was a large, province-wide observational investigation of a health service delivery model for CR and secondary prevention care. The present paper is the third in a three-part, policy-related series. In the present paper, the results of the evaluation of the service delivery model and the final health policy recommendations that were made to the Ministry in September 2002 are presented., Conclusions: Within approximately one year, 4922 patients were enrolled in the Pilot at participating sites throughout Ontario; 88% of sites implemented all elements of the comprehensive services model, either on-site or through internal/external partnerships, and 94% of sites implemented the multidisciplinary Pilot staffing model. Based on this rapid and near-total implementation of the Pilot model, it was concluded that the Pilot model of care was generalizable. Furthermore, regional coordination was achieved through operationalization of the coordinating centres' roles in quality management, regional planning and program development, education and outreach.

In February 2001, the Ontario Ministry of Health and Long-Term Care announced a $9.6 million, 15-month pilot project (the Pilot) to implement and evaluate a comprehensive, multifactoral model of cardiac rehabilitation (CR) service delivery at 17 sites across Ontario. This is the second paper in a three-part, policy-related series which provides a summary of the Ontario CR Pilot model and the Pilot implementation and evaluation methodology. The aim of the present paper was to outline the goals of the Pilot, the Pilot model of care, the organizational structure that facilitated implementation of the model, and the operational procedures that were put in place to evaluate patient outcomes and the generalizability of a regional model of CR service delivery. The model was based on the findings and recommendations of the Cardiac Care Network of Ontario's 1999 Consensus Panel on Cardiac Rehabilitation and Secondary Prevention, which was described in part one of this series. An upcoming final paper will describe the outcomes of the project and its recommendations for CR health policy decisions in Ontario.

The Cardiac Care Network of Ontario Consensus Panel on Cardiac Rehabilitation and Secondary Prevention drew on the literature and its own expertise, and surveyed existing cardiac rehabilitation and secondary prevention (CR) services in Ontario to make recommendations for the delivery of CR services in Ontario. This report, which is not an official position paper for the Canadian Cardiovascular Society, presents these recommendations. The key recommendations were a regional coordination model for the delivery of CR services that would provide CR close to home and promote access to CR in groups traditionally underrepresented in CR; high quality central data collection; the creation of a provincial CR registry to allow future planning, coordination, monitoring and evaluation of CR services in Ontario; and the establishment of specific CR program funding from the Ontario Ministry of Health and Long Term Care.