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Aims: Adapting interventions with an existing evidence base offers a more efficient approach than developing a new intervention. The aim of this study was to describe the process of adapting a home-based cardiac rehabilitation (CR) programme (REACH-HF) intervention originally developed in the UK for people with heart failure (HF) to the Danish health system-the 'DK:REACH-HF' programme., Methods and Results: We followed methodological framework for the conduct and reporting of studies adapting interventions, utilizing documentary analysis, qualitative interviews, stakeholder consultations, and mapping of the Danish policy context. Our study found broad support for the REACH-HF intervention as an alternative to existing centre-based CR. We also identified three key areas of adaptation for the Danish context. First, reduce the word count of the intervention's resources by linking to existing publicly available CR materials. Second, while retaining REACH-HF core components, adapt its content and delivery to reflect differences between Denmark and UK. Third, develop a digital version of the intervention., Conclusion: Using an evidence-based approach, we successfully adapted the REACH-HF intervention to the context of the Danish healthcare setting, maintaining core components of the original intervention and developing both a paper-based and digital version of the programme material. To inform scaled national implementation of the DK:REACH-HF programme, we seek to undertake a pilot study to test the adapted intervention materials feasibility and acceptability to healthcare practitioners, patients, and their caregivers and confirm the positive impact on the outcomes of HF patients and caregivers., Competing Interests: Conflict of interest: R.S.T. and H.M.D. are part of the original developers of the REACH-HF intervention., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) is a home-based cardiac rehabilitation intervention designed for patients with heart failure and their caregivers. We present a pooled analysis of patients >18 years with a confirmed diagnosis of HF recruited to two REACH-HF randomized controlled trials. Where identified by patients and consented to participate, caregivers were randomly assigned with patients to receive the REACH-HF intervention plus usual care or usual care alone. Our analysis demonstrated that compared to control group, the REACH-HF group had a greater gain in their disease-specific health-related quality of life at follow-up., Competing Interests: Conflict of interest: R.S.T. and H.M.D. were co-chief investigators for the REACH-HF trials. R.S.T. is a member of the ACNAP Scientific Committee., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Alternative models of cardiac rehabilitation (CR) are required to improve CR access and uptake. Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) is a comprehensive home-based rehabilitation and self-management programme, facilitated by trained health professionals, for people with heart failure (HF) and their caregivers. REACH-HF was shown to be clinically effective and cost-effective in a multi-centre randomized trial. The SCOT:REACH-HF study assessed implementation of REACH-HF in routine clinical practice in NHS Scotland., Methods and Results: A mixed-method implementation study was conducted across six regional Health Boards. Of 136 people with HF and 56 caregivers recruited, 101 people with HF and 26 caregivers provided 4-month follow-up data, after participating in the 12-week programme. Compared with baseline, REACH-HF participation resulted in substantial gains in the primary outcome of health-related quality of life, as assessed by the Minnesota Living with Heart Failure Questionnaire (mean difference: -9.8, 95% CI: -13.2 to -6.4, P < 0.001). Improvements were also seen in secondary outcomes (PROM-CR+; EQ-5D-5L; Self-Care of Heart Failure Index (SCHFI) domains of maintenance and symptom perception; Caregiver Contribution to Self-Care domains of symptom perception and management). Twenty qualitative interviews were conducted with 11 REACH-HF facilitators, five supporting clinicians, and four national stakeholders. Interviewees were largely positive about REACH-HF, considering it to have 'filled a gap' where centre-based CR was not an option. Key issues to support future roll-out were also identified., Conclusion: Our findings support wider roll-out of REACH-HF as an alternative to centre-based models, to improve CR access and uptake for people with HF., Competing Interests: Conflict of interest: These affiliations had no influence on the interpretation or presentation of the results of the presentstudy. J.G.F.C. is supported by a British Heart Foundation Centre of Research Excellence award RE/18/6/34217. J.G.F.C. reports research funding and personal honoraria from Abbott, Amgen, Astra-Zeneca, Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, Cytokinetics, Idorsia, Johnson & Johnson, Medtronic, Myokardia, Novartis, NI Medical, Pharmacosmos, Pharma Nord, Philips, Respicardia, Servier, Torrent, Vifor, Viscardia. The other authors declare no competing interests., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, 'hybrid') and according to stage of disease and patient preference., Competing Interests: Conflict of interest None of the authors have any conflict of interest or relationships with industry that could have influenced this manuscript. R.S.T., H.D., and A.D.Z. are active cardiac rehabilitation researchers that include systematic reviews/meta-analyses and clinical trials of cardiac rehabilitation in patients with heart failure. The authors declare that all illustrations and figures in the manuscript are entirely original and do not require reprint permission., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: The purpose of this British Association for Cardiovascular Prevention and Rehabilitation (BACPR) research priority setting project (PSP) was to identify a top 10 list of priority research questions for cardiovascular prevention and rehabilitation (CVPR)., Methods: The PSP was facilitated by the BACPR clinical study group (CSG), which integrates as part of the British Heart Foundation Clinical Research Collaborative. Following a literature review to identify unanswered research questions, modified Delphi methods were used to engage CVPR-informed expert stakeholders, patients, partners and conference delegates in ranking the relevance of research questions during three rounds of an anonymous e-survey. In the first survey, unanswered questions from the literature review were ranked and respondents proposed additional questions. In the second survey, these new questions were ranked. Prioritised questions from surveys 1 and 2 were incorporated in a third/final e-survey used to identify the top 10 list., Results: From 459 responses across the global CVPR community, a final top 10 list of questions were distilled from an overall bank of 76 (61 from the current evidence base and a further 15 from respondents). These were grouped across five broad categories: access and remote delivery, exercise and physical activity, optimising programme outcomes, psychosocial health and impact of the pandemic., Conclusions: This PSP used a modified Delphi methodology to engage the international CVPR community to generate a top 10 list of research priorities within the field. These prioritised questions will directly inform future national and international CVPR research supported by the BACPR CSG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To quantify the impact of a home-based cardiac rehabilitation intervention (Rehabilitation Enablement in Chronic Heart Failure (REACH-HF)) on objectively assessed physical activity (PA) of patients with heart failure (HF) and explore the extent by which patient characteristics are associated with a change in PA., Design: Secondary analysis of randomised controlled trial data., Setting: Five centres in the UK., Participants: 247 patients with HF (mean age 70.9±10.3 years; 28% women)., Interventions: REACH-HF versus usual care (control)., Primary and Secondary Outcome Measures: PA was assessed over 7 days via GENEActiv triaxial accelerometer at baseline (pre-randomisation), post-intervention (4 months) and final follow-up (6-12 months). Using HF-specific intensity thresholds, intervention effects (REACH-HF vs control) on average min/day PA (inactivity, light PA and moderate-to-vigorous PA (MVPA)) over all days, week days and weekend days were examined using linear regression analysis. Multivariable regression was used to explore associations between baseline patient characteristics and change in PA., Results: Although there was no difference between REACH-HF and control groups in 7-day PA levels post-intervention or at final follow-up, there was evidence of an increase in weekday MVPA (10.9 min/day, 95% CI: -2.94 to 24.69), light PA (26.9 min/day, 95% CI: -0.05 to 53.8) and decreased inactivity (-38.31 min/day, 95% CI: -72.1 to -4.5) in favour of REACH-HF. Baseline factors associated with an increase in PA from baseline to final follow-up were reduced MVPA, increased incremental shuttle walk test distance, increased Hospital Anxiety and Depression Scale anxiety score and living with a child >18 years (p<0.05)., Conclusions: While participation in the REACH-HF home-based cardiac rehabilitation intervention did not increase overall weekly activity, patient's behaviour patterns appeared to change with increased weekday PA levels and reduced inactivity. Baseline PA levels were highly predictive of PA change. Future focus should be on robust behavioural changes, improving overall levels of objectively assessed PA of people with HF., Trial Registration Numbers: ISRCTN78539530 and ISRCTN86234930., Competing Interests: Competing interests: RT, HMD, PJD and MH were investigators in the REACH-HF study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Many people with heart failure do not receive cardiac rehabilitation despite a strong evidence base attesting to its effectiveness, and national and international guideline recommendations. A more holistic approach to heart failure rehabilitation is proposed as an alternative to the predominant focus on exercise, emphasising the important role of education and psychosocial support, and acknowledging that this depends on patient need, choice and preference. An individualised, needs-led approach, exploiting the latest digital technologies when appropriate, may help fill existing gaps, improve access, uptake and completion, and ensure optimal health and wellbeing for people with heart failure and their families. Exercise, education, lifestyle change and psychosocial support should, as core elements, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual circumstances, such as with regard to age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices., Competing Interests: Disclosure: DRT is on the Cardiac Failure Review editorial board; this did not influence peer review. All other authors have no conflicts of interest to declare., (Copyright © 2022, Radcliffe Cardiology.)

Objectives: This study aimed to identify barriers to, and facilitators of, implementation of the Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme within existing cardiac rehabilitation services, and develop and refine the REACH-HF Service Delivery Guide (an implementation guide cocreated with healthcare professionals). REACH-HF is an effective and cost-effective 12-week home-based cardiac rehabilitation programme for patients with heart failure., Setting/participants: In 2019, four early adopter 'Beacon Sites' were set up to deliver REACH-HF to 200 patients. In 2020, 5 online REACH-HF training events were attended by 85 healthcare professionals from 45 National Health Service (NHS) teams across the UK and Ireland., Design: Our mixed-methods study used in-depth semi-structured interviews and an online survey. Interviews were conducted with staff trained specifically for the Beacon Site project, identified by opportunity and snowball sampling. The online survey was later offered to subsequent NHS staff who took part in the online REACH-HF training. Normalisation Process Theory was used as a theoretical framework to guide data collection/analysis., Results: Seventeen healthcare professionals working at the Beacon Sites were interviewed and 17 survey responses were received (20% response rate). The identified barriers and enablers included, among many, a lack of resources/commissioning, having interest in heart failure and working closely with the clinical heart failure team. Different implementation contexts (urban/rural), timing (during the COVID-19 pandemic) and factors outside the healthcare team/system (quality of the REACH-HF training) were observed to negatively or positively impact the implementation process., Conclusions: The findings are highly relevant to healthcare professionals involved in planning, delivering and commissioning of cardiac rehabilitation for patients with heart failure. The study's main output, a refined version of the REACH-HF Service Delivery Guide, can guide the implementation process (eg, designing new care pathways) and provide practical solutions to overcoming common implementation barriers (eg, through early identification of implementation champions)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cardiac rehabilitation for heart failure continues to be greatly underused worldwide despite being a Class I recommendation in international clinical guidelines and uptake is low in women and patients with mental health comorbidities., Methods: Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme was implemented in four UK National Health Service early adopter sites ('Beacon Sites') between June 2019 and June 2020. Implementation and patient-reported outcome data were collected across sites as part of the National Audit of Cardiac Rehabilitation. The change in key outcomes before and after the supervised period of REACH-HF intervention across the Beacon Sites was assessed and compared to those of the intervention arm of the REACH-HF multicentre trial., Results: Compared to the REACH-HF multicentre trial, patients treated at the Beacon Site were more likely to be female (33.8% vs 22.9%), older (75.6 vs 70.1), had a more severe classification of heart failure (26.5% vs 17.7%), had poorer baseline health-related quality of life (MLHFQ score 36.1 vs 31.4), were more depressed (HADS score 6.4 vs 4.1) and anxious (HADS score 7.2 vs 4.7), and had lower exercise capacity (ISWT distance 190 m vs 274.7 m). There appeared to be a substantial heterogeneity in the implementation process across the four Beacon Sites as evidenced by the variation in levels of patient recruitment, operationalisation of the REACH-HF intervention and patient outcomes. Overall lower improvements in patient-reported outcomes at the Beacon Sites compared to the trial may reflect differences in the population studied (having higher morbidity at baseline) as well as the marked challenges in intervention delivery during the COVID-19 pandemic., Conclusion: The results of this study illustrate the challenges in consistently implementing an intervention (shown to be clinically effective and cost-effective in a multicentre trial) into real-world practice, especially in the midst of a global pandemic. Further research is needed to establish the real-world effectiveness of the REACH-HF intervention in different populations., (© 2022. The Author(s).)

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings., (© 2021. Springer Nature Limited.)

Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests. HMD and PD have also co-authored Cochrane reviews in cardiac rehabilitation with RST. RST is an author on a number of other Cochrane reviews of cardiac rehabilitation. HMD, RST, PD, and KP were co-investigators on the REACH-HF programme of research, which developed and evaluated a home based cardiac rehabilitation intervention for people with heart failure and their carers (NIHR PGfAR RP-PG-0611-12004). South West Academic Health Sciences Network COVID-19 Innovation Adoption Fund provided several two day REACH-HF online facilitator training sessions over summer 2020 (1 May-31 December 2020). British Heart Foundation Hope for Hearts Funding for Digital Rehabilitation Enablement in Chronic Heart Failure (D REACH-HF) (1 July 2020–31/12 /2021). Implementation of an evidence based cardiac rehabilitation home programme for heart failure patients and their care givers in Scotland (SCOT: REACH-HF Project), Heart Research UK, Scotland (1 March 2020-31 August 2021).

Introduction: Despite evidence that cardiac rehabilitation (CR) is an essential component of care for people with heart failure, uptake is low. A centre-based format is a known barrier, suggesting that home-based programmes might improve accessibility. The aim of SCOT: Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) is to assess the implementation of the REACH-HF home-based CR intervention in the context of the National Health Service (NHS) in Scotland.This paper presents the design and protocol for this observational implementation study. Specific objectives of SCOT:REACH-HF are to: (1) assess service-level facilitators and barriers to the implementation of REACH-HF; (2) compare real-world patient and caregiver outcomes to those seen in a prior clinical trial; and (3) estimate the economic (health and social) impact of implementing REACH-HF in Scotland., Methods and Analysis: The REACH-HF intervention will be delivered in partnership with four 'Beacon sites' across six NHS Scotland Health Boards, covering rural and urban areas. Health professionals from each site will be trained to facilitate delivery of the 12-week programme to 140 people with heart failure and their caregivers. Patient and caregiver outcomes will be assessed at baseline and 4-month follow-up. Assessments include the Minnesota Living with Heart Failure Questionnaire (MLHFQ), five-dimension EuroQol 5L, Hospital Anxiety and Depression Scale, and the Caregiver Burden Questionnaire. Qualitative interviews will be conducted with up to 20 health professionals involved in programme delivery (eg, cardiac nurses, physiotherapists). 65 facilitator-patient consultations will be audio recorded and assessed for fidelity. Integrative analysis will address key research questions on fidelity, context and CR participant-related outcomes. The SCOT:REACH-HF findings will inform the future potential roll-out of REACH-HF in Scotland., Ethics and Dissemination: The study has been given ethical approval by the West of Scotland Research Ethics Service (reference 20/WS/0038, approved 25 March 2020). Written informed consent will be obtained from all participants. The study is listed on the ISRCTN registry with study ID ISRCTN53784122. The research team will ensure that the study is conducted in accordance with both General Data Protection Regulations and the University of Glasgow's Research Governance Framework. Findings will be reported to the funder and shared with Beacon Sites, to facilitate service evaluation, planning and good practice. To broaden interest in, and understanding of REACH-HF, we will seek to publish in peer-reviewed scientific journals and present at stakeholder events, national and international conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: International guidelines for physical activity recommend at least 150 min per week of moderate-to-vigorous physical activity (MVPA) for adults, including those with cardiac disease. There is yet to be consensus on the most appropriate way to categorise raw accelerometer data into behaviourally relevant metrics such as intensity, especially in chronic disease populations. Therefore the aim of this study was to estimate acceleration values corresponding to inactivity and MVPA during daily living activities of patients with heart failure (HF), via calibration with oxygen consumption (VO 2 ) and to compare these values to previously published, commonly applied PA intensity thresholds which are based on healthy adults., Methods: Twenty-two adults with HF (mean age 71 ± 14 years) undertook a range of daily living activities (including laying down, sitting, standing and walking) whilst measuring PA via wrist- and hip-worn accelerometers and VO 2 via indirect calorimetry. Raw accelerometer output was used to compute PA in units of milligravity (mg). Energy expenditure across each of the activities was converted into measured METs (VO 2 /resting metabolic rate) and standard METs (VO 2 /3.5 ml/kg/min). PA energy costs were also compared with predicted METs in the compendium of physical activities. Location specific activity intensity thresholds were established via multilevel mixed effects linear regression and receiver operator characteristic curve analysis. A leave-one-out method was used to cross-validate the thresholds., Results: Accelerometer values corresponding with intensity thresholds for inactivity (< 1.5METs) and MVPA (≥3.0METs) were > 50% lower than previously published intensity thresholds for both wrists and waist accelerometers (inactivity: 16.7 to 18.6 mg versus 45.8 mg; MVPA: 43.1 to 49.0 mg versus 93.2 to 100 mg). Measured METs were higher than both standard METs (34-35%) and predicted METs (45-105%) across all standing and walking activities., Conclusion: HF specific accelerometer intensity thresholds for inactivity and MVPA are lower than previously published thresholds based on healthy adults, due to lower resting metabolic rate and greater energy expenditure during daily living activities for HF patients., Trial Registration: Clinical trials.gov NCT03659877, retrospectively registered on September 6th 2018., Competing Interests: Competing interestsNone declared., (© The Author(s) 2020.)

Aim: To quantify the impact of involving caregivers in self-management interventions on health-related quality of life of patients with heart failure or chronic obstructive pulmonary disease., Design: Systematic review, meta-analysis., Data Sources: Searched: Medline Ebsco, PsycINFO, CINAHL, Embase, Web of Science, The British Library and ProQuest. Search time frame; January 1990-March 2018., Review Methods: Randomized controlled trials involving caregivers in self-management interventions (≥2 components) compared with usual care for patients with heart failure or chronic obstructive pulmonary disease. A matched sample based on publication year, geographic location and inclusion of an exercise intervention of studies not involving caregivers were identified. Primary outcome of analysis was patient health-related quality of life., Results: Thirteen randomized controlled trials (1,701 participants: 1,439 heart failure; 262 chronic obstructive pulmonary disease) involving caregivers (mean age 59; 58% female) were identified. Reported patient health-related quality of life measures included; Minnesota Living with Heart Failure questionnaire, St. George's respiratory questionnaire and Short-Form-36. Compared with usual care, there was similar magnitude in mean improvement in patient health-related quality of life with self-management interventions in trials involving caregivers (SMD: 0.23, 95% confidence interval: -0.15-0.61) compared with trials without caregivers (SMD: 0.27, 0.08-0.46)., Conclusion: Within the methodological constraints of this study, our results indicate that involving caregivers in self-management interventions does not result in additional improvement in patient health-related quality of life in heart failure or chronic obstructive pulmonary disease. However, involvement of caregivers in intervention delivery remains an important consideration and key area of research., Impact: Greater understanding and awareness is needed of the methodology of caregiver engagement in intervention development and delivery and its impact on patient outcomes., (© 2019 John Wiley & Sons Ltd.)

Background: The REACH-HF (Rehabilitation EnAblement in CHronic Heart Failure) trial found that the REACH-HF home-based cardiac rehabilitation intervention resulted in a clinically meaningful improvement in disease-specific health-related quality of life in patients with reduced ejection fraction heart failure (HFrEF). The aims of this study were to assess the long-term cost-effectiveness of the addition of REACH-HF intervention or home-based cardiac rehabilitation to usual care compared with usual care alone in patients with HFrEF., Design and Methods: A Markov model was developed using a patient lifetime horizon and integrating evidence from the REACH-HF trial, a systematic review/meta-analysis of randomised trials, estimates of mortality and hospital admission and UK costs at 2015/2016 prices. Taking a UK National Health and Personal Social Services perspective we report the incremental cost per quality-adjusted life-year (QALY) gained, assessing uncertainty using probabilistic and deterministic sensitivity analyses., Results: In base case analysis, the REACH-HF intervention was associated with per patient mean QALY gain of 0.23 and an increased mean cost of £400 compared with usual care, resulting in a cost per QALY gained of £1720. Probabilistic sensitivity analysis indicated a 78% probability that REACH-HF is cost effective versus usual care at a threshold of £20,000 per QALY gained. Results were similar for home-based cardiac rehabilitation versus usual care. Sensitivity analyses indicate the findings to be robust to changes in model assumptions and parameters., Conclusions: Our cost-utility analyses indicate that the addition of the REACH-HF intervention and home-based cardiac rehabilitation programmes are likely to be cost-effective treatment options versus usual care alone in patients with HFrEF.

Background: Previous systematic reviews have indicated that exercise-based cardiac rehabilitation (ExCR) for patients with heart failure (HF) has a beneficial effect on health-related quality-of-life (HRQoL) and exercise capacity. However, there is uncertainty regarding potential differential effects of ExCR across HF patient subgroups., Objectives: The authors sought to undertake an individual participant data (IPD) meta-analysis to: 1) assess the impact of ExCR on HRQoL and exercise capacity in patients with HF; and 2) investigate differential effects of ExCR according to a range of patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischemic etiology, ejection fraction, and exercise capacity., Methods: A single dataset was produced, comprising randomized trials where ExCR (delivered for 3 weeks or more) was compared with a no exercise control group. Each trial provided IPD on HRQoL or exercise capacity (or both), with follow-up of 6 months or more. One- and 2-stage meta-analysis models were used to investigate the effect of ExCR overall and the interactions between ExCR and participant characteristics., Results: IPD was obtained from 13 trials for 3,990 patients, predominantly (97%) with reduced ejection fraction HF. Compared with the control group, there was a statistically significant difference in favor of ExCR for HRQoL and exercise capacity. At 12-month follow-up, improvements were seen in 6-min walk test (mean 21.0 m; 95% confidence interval: 1.57 to 40.4 m; p = 0.034) and Minnesota Living With HF score (mean improvement 5.9; 95% confidence interval: 1.0 to 10.9; p = 0.018). No consistent evidence was found of differential intervention effects across patient subgroups., Conclusions: These results, based on an IPD meta-analysis of randomized trials, confirm the benefit of ExCR on HRQoL and exercise capacity and support the Class I recommendation of current international clinical guidelines that ExCR should be offered to all HF patients. (Exercise Training for Chronic Heart Failure [ExTraMATCH II]: protocol for an individual participant data meta-analysis; PROSPERO: international database of systematic reviews CRD42014007170)., (Copyright © 2019. Published by Elsevier Inc.)

Background: Cardiac rehabilitation improves health-related quality of life (HRQoL) and reduces hospitalizations in patients with heart failure, but international uptake of cardiac rehabilitation for heart failure remains low., Design and Methods: The aim of this multicentre randomized trial was to compare the REACH-HF (Rehabilitation EnAblement in CHronicHeart Failure) intervention, a facilitated self-care and home-based cardiac rehabilitation programme to usual care for adults with heart failure with reduced ejection fraction (HFrEF). The study primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL (Minnesota Living with Heart Failure questionnaire (MLHFQ)) at 12 months compared with usual care alone., Results: The study recruited 216 participants, predominantly men (78%), with an average age of 70 years and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of -5.7 points (95% confidence interval -10.6 to -0.7) in favour of the REACH-HF intervention group ( p = 0.025). With the exception of patient self-care ( p < 0.001) there was no significant difference in other secondary outcomes, including clinical events ( p > 0.05) at follow-up compared with usual care. The mean cost of the REACH-HF intervention was £418 per participant., Conclusions: The novel REACH-HF home-based facilitated intervention for HFrEF was clinically superior in disease-specific HRQoL at 12 months and offers an affordable alternative to traditional centre-based programmes to address current low cardiac rehabilitation uptake rates for heart failure.

Aims: To undertake an individual patient data (IPD) meta-analysis to assess the impact of exercise-based cardiac rehabilitation (ExCR) in patients with heart failure (HF) on mortality and hospitalisation, and differential effects of ExCR according to patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology, ejection fraction, and exercise capacity., Methods and Results: Randomised trials of exercise training for at least 3 weeks compared with no exercise control with 6-month follow-up or longer, providing IPD time to event on mortality or hospitalisation (all-cause or HF-specific). IPD were combined into a single dataset. We used Cox proportional hazards models to investigate the effect of ExCR and the interactions between ExCR and participant characteristics. We used both two-stage random effects and one-stage fixed effect models. IPD were obtained from 18 trials including 3912 patients with HF with reduced ejection fraction. Compared to control, there was no statistically significant difference in pooled time to event estimates in favour of ExCR although confidence intervals (CIs) were wide [all-cause mortality: hazard ratio (HR) 0.83, 95% CI 0.67-1.04; HF-specific mortality: HR 0.84, 95% CI 0.49-1.46; all-cause hospitalisation: HR 0.90, 95% CI 0.76-1.06; and HF-specific hospitalisation: HR 0.98, 95% CI 0.72-1.35]. No strong evidence was found of differential intervention effects across patient characteristics., Conclusion: Exercise-based cardiac rehabilitation did not have a significant effect on the risk of mortality and hospitalisation in HF with reduced ejection fraction. However, uncertainty around effect estimates precludes drawing definitive conclusions., (© 2018 The Authors. European Journal of Heart Failure © 2018 European Society of Cardiology.)

Objective: To undertake a systematic review and meta-analysis to assess the impact of cardiac rehabilitation (CR) on physical activity (PA) levels of patients with heart disease and the methodological quality of these studies., Methods: Databases (MEDLINE, EMBASE, CENTRAL, CINAHL, PsychINFO and SportDiscus) were searched without language restriction from inception to January 2017 for randomised controlled trials (RCTs) comparing CR to usual care control in adults with heart failure (HF) or coronary heart disease (CHD) and measuring PA subjectively or objectively. The direction of PA difference between CR and control was summarised using vote counting (ie, counting the positive, negative and non-significant results) and meta-analysis., Results: Forty RCTs, (6480 patients: 5825 CHD, 655 HF) were included with 26% (38/145) PA results showing a statistically significant improvement in PA levels with CR compared with control. This pattern of results appeared consistent regardless of type of CR intervention (comprehensive vs exercise-only) or PA measurement (objective vs subjective). Meta-analysis showed PA increases in the metrics of steps/day (1423, 95% CI 757.07 to 2089.43, p<0.0001) and proportion of patients categorised as physically active (relative risk 1.55, 95% CI 1.19 to 2.02, p=0.001). The included trials were at high risk of bias, and the quality of the PA assessment and reporting was relatively poor., Conclusion: Overall, there is moderate evidence of an increase in PA with CR participation compared with control. High-quality trials are required, with robust PA measurement and data analysis methods, to assess if CR definitely leads to important improvements in PA., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Home-based cardiac rehabilitation may overcome suboptimal rates of participation. The overarching aim of this study was to assess the feasibility and acceptability of the novel Rehabilitation EnAblement in CHronic Hear Failure (REACH-HF) rehabilitation intervention for patients with heart failure with preserved ejection fraction (HFpEF) and their caregivers., Methods and Results: Patients were randomised 1:1 to REACH-HF intervention plus usual care (intervention group) or usual care alone (control group). REACH-HF is a home-based comprehensive self-management rehabilitation programme that comprises patient and carer manuals with supplementary tools, delivered by trained healthcare facilitators over a 12 week period. Patient outcomes were collected by blinded assessors at baseline, 3 months and 6 months postrandomisation and included health-related quality of life (primary) and psychological well-being, exercise capacity, physical activity and HF-related hospitalisation (secondary). Outcomes were also collected in caregivers.We enrolled 50 symptomatic patients with HF from Tayside, Scotland with a left ventricular ejection fraction ≥45% (mean age 73.9 years, 54% female, 100% white British) and 21 caregivers. Study retention (90%) and intervention uptake (92%) were excellent. At 6 months, data from 45 patients showed a potential direction of effect in favour of the intervention group, including the primary outcome of Minnesota Living with Heart Failure Questionnaire total score (between-group mean difference -11.5, 95% CI -22.8 to 0.3). A total of 11 (4 intervention, 7 control) patients experienced a hospital admission over the 6 months of follow-up with 4 (control patients) of these admissions being HF-related. Improvements were seen in a number intervention caregivers' mental health and burden compared with control., Conclusions: Our findings support the feasibility and rationale for delivering the REACH-HF facilitated home-based rehabilitation intervention for patients with HFpEF and their caregivers and progression to a full multicentre randomised clinical trial to test its clinical effectiveness and cost-effectiveness., Trial Registration Number: ISRCTN78539530., Competing Interests: Competing interests: RST is the lead for the ongoing portfolio of Cochrane reviews of cardiac rehabilitation. RST and HMD are named Scientific Advisors for the ongoing National Institute of Health and Care Excellence (NICE) updated clinical guidelines for the management heart failure (CG108). HMD is an ordinary member of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) council. All other coauthors declare no conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: Competing interests: We have read and understood the BMJ Group’s policy on declaration of interests and declare the following interests. HMD has co-authored Cochrane reviews on cardiac rehabilitation, is co-chief investigator on a National Institute for Health Research (NIHR) and NHS-funded programme grant for applied research (NIHR PGfAR RP-PG-0611-12004), and is an ordinary member of the council of the British Association of Cardiovascular Prevention and Rehabilitation (BACPR). MMG is a co-investigator on the NIHR funded CADENCE study of enhanced psychological interventions in cardiac rehabilitation. Provenance and peer review: Encouraged; externally peer reviewed.

Objective: To assess the extent by which programmes meet national minimum standards for the delivery of cardiac rehabilitation (CR) as part of the National Certification Programme for Cardiovascular Rehabilitation (NCP&#95;CR)., Methods: The analysis used UK National Audit of Cardiac Rehabilitation (NACR) data extracted and validated for the period 2013-2014 set against six NCP&#95;CR measures deemed as important for the delivery of high-quality CR programmes. Each programme that achieved a single minimum standard was given a score of 1. The range of the scoring for meeting the minimum standards is between 1 and 6. The performance of CR programmes was categorised into three groups: high (score of 5-6), middle (scores of 3-4) and low (scores of 1-2). If a programme did not meet any of the six criteria, they were considered to have failed., Results: Data from 170 CR programmes revealed statistically significant differences among UK CR programmes. The principal findings were that, based on NCP&#95;CR criteria, 30.6% were assessed as high performance with 45.9% as mid-level performance programmes, 18.2% were in the lower-level and 5.3% failed to meet any of the minimum criteria., Conclusions: This study shows that high levels of performance is achievable in the era of modern cardiology and that many CR programmes are close to meeting high performance standards. However, substantial variation, below the recommended minimum standards, exists throughout the UK. National certification should be seen as a positive step to ensure that patients, irrespective of where they live, are accessing quality services., Competing Interests: Conflicts of Interest: None declared.

Objective: To update the Cochrane review comparing the effects of home-based and supervised centre-based cardiac rehabilitation (CR) on mortality and morbidity, quality of life, and modifiable cardiac risk factors in patients with heart disease., Methods: Systematic review and meta-analysis. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL were searched up to October 2014, without language restriction. Randomised trials comparing home-based and centre-based CR programmes in adults with myocardial infarction, angina, heart failure or who had undergone coronary revascularisation were included., Results: 17 studies with 2172 patients were included. No difference was seen between home-based and centre-based CR in terms of: mortality (relative risk (RR) 0.79, 95% CI 0.43 to 1.47); cardiac events; exercise capacity (mean difference (MD) -0.10, -0.29 to 0.08); total cholesterol (MD 0.07 mmol/L, -0.24 to 0.11); low-density lipoprotein cholesterol (MD -0.06 mmol/L, -0.27 to 0.15); triglycerides (MD -0.16 mmol/L, -0.38 to 0.07); systolic blood pressure (MD 0.2 mm Hg, -3.4 to 3.8); smoking (RR 0.98, 0.79 to 1.21); health-related quality of life and healthcare costs. Lower high-density lipoprotein cholesterol (MD -0.07 mmol/L, -0.11 to -0.03, p=0.001) and lower diastolic blood pressure (MD -1.9 mm Hg, -0.8 to -3.0, p=0.009) were observed in centre-based participants. Home-based CR was associated with slightly higher adherence (RR 1.04, 95% CI 1.01 to 1.07)., Conclusions: Home-based and centre-based CR provide similar benefits in terms of clinical and health-related quality of life outcomes at equivalent cost for those with heart failure and following myocardial infarction and revascularisation.

Objective: To update the Cochrane systematic review of exercise-based cardiac rehabilitation (CR) for heart failure., Methods: A systematic review and meta-analysis of randomised controlled trials was undertaken. MEDLINE, EMBASE and the Cochrane Library were searched up to January 2013. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise interventions alone or as a component of comprehensive CR programme compared with no exercise control., Results: 33 trials were included with 4740 participants predominantly with a reduced ejection fraction (<40%) and New York Heart Association class II and III. Compared with controls, while there was no difference in pooled all-cause mortality between exercise CR with follow-up to 1 year (risk ratio (RR) 0.93; 95% CI 0.69 to 1.27, p=0.67), there was a trend towards a reduction in trials with follow-up beyond 1 year (RR 0.88; 0.75 to 1.02, 0.09). Exercise CR reduced the risk of overall (RR 0.75; 0.62 to 0.92, 0.005) and heart failure-specific hospitalisation (RR 0.61; 0.46 to 0.80, 0.0004) and resulted in a clinically important improvement in the Minnesota Living with Heart Failure questionnaire (mean difference: -5.8 points, -9.2 to -2.4, 0.0007). Univariate meta-regression analysis showed that these benefits were independent of the type and dose of exercise CR, and trial duration of follow- up, quality or publication date., Conclusions: This updated Cochrane review shows that improvements in hospitalisation and health-related quality of life with exercise-based CR appear to be consistent across patients regardless of CR programme characteristics and may reduce mortality in the longer term. An individual participant data meta-analysis is needed to provide confirmatory evidence of the importance of patient subgroup and programme level characteristics (eg, exercise dose) on outcome.

Introduction: We conducted a systematic review to assess the effect of exercise training in patients with heart failure with preserved ejection fraction (HFPEF)., Methods: A number of electronic databases were searched up to November 2011 to identify comparative studies of exercise training in HFPEF. Where possible, outcome data from included studies were pooled using meta-analysis., Results: Three randomised controlled trials, one non-randomised controlled trial and one pre-post study were included, for a total of 228 individuals. The combined duration of exercise programmes and follow-up ranged from 12 to 24 weeks. No deaths, hospital admissions or serious adverse events were observed during or immediately following exercise training. Compared to control, the change in exercise capacity at follow-up was higher with exercise training (between group mean difference: 3.0 ml/kg/min, 95% CI: 2.4 to 2.6). In the four studies, that reported the Minnesota Living with Heart Failure questionnaire, there was evidence of a larger gain in health-related quality of life with exercise training (7.3 units, 3.3 to 11.4). The largest study showed some evidence of improvement in the E/E' ratio with exercise training, but this was not confirmed in the other studies (overall -0.9, -3.8 to 2.0); E/A ratios were not changed., Conclusions: Exercise training for patients with HFPEF confers benefit in terms of enhancements in exercise capacity and health-related quality of life and appears to be safe. The impact on diastolic function remains unclear. Further trials should provide data on long term effects, prognostic relevance and cost-effectiveness., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To determine why so few patients with chronic heart failure in England, Wales and Northern Ireland take part in cardiac rehabilitation., Design: Two-stage, postal questionnaire-based national survey., Participants and Setting: Stage 1: 277 cardiac rehabilitation centres that provided phase 3 cardiac rehabilitation in England, Wales and Northern Ireland registered on the National Audit of Cardiac Rehabilitation register. Stage 2: 35 centres that indicated in stage 1 that they provide a separate cardiac rehabilitation programme for patients with heart failure., Results: Full data were available for 224/277 (81%) cardiac rehabilitation centres. Only 90/224 (40%) routinely offered phase 3 cardiac rehabilitation to patients with heart failure. Of these 90 centres that offered rehabilitation, 43% did so only when heart failure was secondary to myocardial infarction or revascularisation. Less than half (39%) had a specific rehabilitation programme for heart failure. Of those 134 centres not providing for patients with heart failure, 84% considered a lack of resources and 55% exclusion from commissioning contracts as the reason for not recruiting patients with heart failure. Overall, only 35/224 (16%) centres provided a separate rehabilitation programme for people with heart failure., Conclusions: Patients with heart failure as a primary diagnosis are excluded from most cardiac rehabilitation programmes in England, Wales and Northern Ireland. A lack of resources and direct exclusion from local commissioning agreements are the main barriers for not offering rehabilitation to patients with heart failure.