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Objectives: This study aimed to generate new qualitative insights to understand the rehabilitation needs of people living with a confirmed or presumed diagnosis of ischaemia with no obstructive coronary arteries (INOCA), explore which aspects of current cardiovascular prevention and rehabilitation programmes could meet the needs of people with INOCA and where adjustments (if any) may be appropriate., Design: Semistructured qualitative interview study., Participants: Interviews were undertaken (n=17; 88% female, age range 31-69 years) with people with a confirmed or presumed diagnosis of INOCA., Results: Findings highlighted concerns around a lack of evidence-based guidance for cardiovascular prevention and rehabilitation programmes for patients with INOCA. Participants expressed a desire for modular cardiovascular prevention and rehabilitation programmes that could be accessed flexibly to accommodate episodic fluctuations in symptoms. Participants suggested that existing cardiovascular prevention and rehabilitation programme content needed adjustment including enhanced psychosocial support, supervised low-impact physical activity and specialist dietary advice and medication reviews. Additional elements specific to INOCA should be made available as appropriate including acute care planning and a module to provide information and support for female-specific issues. The importance of involving INOCA patients in the codesign of future programmes and associated training was emphasised., Conclusions: People with INOCA are willing to engage with cardiovascular prevention and rehabilitation programmes and express a desire for more support. This patient group shares some barriers to rehabilitation programme attendance with other cardiac patient groups, but they also have specific concerns about the need for improved professional knowledge and evidence-based guidance regarding the management of INOCA. Cardiovascular rehabilitation programmes need to be delivered flexibly and individually tailored to ensure the relapsing and remitting nature of INOCA and associated support needs are addressed., Competing Interests: Competing interests: CB is employed by the University of Glasgow which holds consultancy and research agreements with companies that have commercial interests in the diagnosis and treatment of ischaemic heart disease. The companies include Abbott Vascular, AstraZeneca, Boehringer Ingelheim, GSK, HeartFlow, Menarini, Novartis and Siemens Healthcare. These companies had no involvement in this manuscript. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017., Objectives: To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied., Selection Criteria: We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation., Data Collection and Analysis: Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE., Main Results: We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar., Authors' Conclusions: This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Remote delivery of cardiovascular rehabilitation (CR) has been vital during the COVID pandemic when restrictions have been placed on face-to- face services. In the future, CR services are likely to offer alternatives to centre- based CR, including digital options. However, little is known about the digital access and confidence of CR service users, or their CR delivery preferences. A telephone survey was conducted of those referred for CR in the London boroughs of Lambeth and Southwark (n=60) in which questions were asked about digital access and confidence, as well as current and future delivery preferences for their CR. Between March and July 2021, 60 service-users met the inclusion criteria and were recruited for a telephone survey (mean age 60 ± 11.2 years). Of those, 82% had regular access to a smartphone, 60% to a computer or laptop and 43% to a tablet device. A high proportion of service users perceived themselves to be 'extremely' or 'somewhat' confident to use their devices. Thirty-nine (65%) service users would currently prefer a face-to- face assessment, rising to 82% once the perceived COVID-19 threat and restrictions are less. Preferences for accessing exercise were equally split between face-to-face and remotely supported independent exercise, with low interest in digital options. Delivery preferences for education, relaxation and peer support were more heterogeneous with interest in all delivery options. In conclusion, digital access and confidence in CR service users was good. Redesigning CR services to offer more rehabilitation delivery options, aligned with patient choice may increase uptake and further trials are needed to assess the impact., Competing Interests: Conflicts of interest None declared., (Copyright © 2023 Medinews (Cardiology) Limited.)