eHealth for maintenance cardiovascular rehabilitation—current status and future challenges

This editorial refers to ‘eHealth for maintenance cardiovascular rehabilitation: a systematic review and meta-analysis’, by M. Heimer et al., https://doi.org/10.1093/eurjpc/zwad145. Cardiovascular rehabilitation is a comprehensive intervention, which encompasses patient assessment, detection, modification, and control of cardiovascular risk factors, conducting tailored exercise training, dietary counselling, mental health care with stress management, social and vocational support, patient education, and support of daily physical activity as well as healthy lifestyle behaviour and adherence to treatment.1–3 According to current recommendations, all stable patients who suffered from cardiovascular diseases should participate in cardiac rehabilitation programmes.1–3 A long time ago, the World Health Organization divided cardiac rehabilitation into three phases: (i) gentle gradual mobilization during the acute phase of disease, (ii) reconditioning phase, and (iii) the maintenance phase.4 This division is still in use until today. The third phase of cardiac rehabilitation is extremely important in the context of data showing that patient adherence decreases over time after hospital discharge, with <50% of patients remaining compliant after 6 months.5,6 Currently, the development of eHealth raises the possibility of supervising and providing comprehensive rehabilitation at a distance by using advanced medical and telecommunication technologies.7,8 In this issue of the European Journal of Preventive Cardiology, Heimer et al.9 present the meta-analysis of the effects of eHealth-supported interventions on health outcomes during cardiac rehabilitation maintenance phase (III) for 1497 patients with coronary artery disease. There is a limited number of studies devoted to the third phase of cardiac rehabilitation using eHealth solutions. This meta-analysis was based on 14 articles; however, studies differed significantly in terms of applied technology, duration and type of intervention, and behavioural change techniques. The authors found that compared with usual care, eHealth intervention stimulated physical activity, improved exercise capacity and the quality of life, and led to decreasing systolic blood pressure.9 It is clear that achieving improvement depends on the duration of the third phase of cardiac rehabilitation. The improvement in the quality of life was applicable to patients who participated in the rehabilitation programmes for 6 months. These beneficial effects were not detected in the long-term observation. On the other hand, a decrease in systolic blood pressure was observed only in cardiac rehabilitation programmes lasting more than 6 months.9 These findings partially are in line with a previous systematic review including data from a large cohort (3752) of patients with cardiovascular diseases. Maintenance cardiac rehabilitation resulted in increased or maintained functional capacity (9 of 16 studies), quality of life (2 studies), and physical activity levels (4 studies) in comparison with control.10 In their meta-analysis, the authors did not observe significant differences in total cholesterol levels (eight studies), LDL (nine studies), triglycerides (six studies), and body mass index.9 In contrast to these results, some studies reported significant improvement of lipid profile11,12 and the reduction of body mass index as well as greater improvements in body composition (reduction of body fat).12 Heimer et al. in their meta-analysis did not evaluate the autonomic nervous system function, inflammatory markers, and hormone levels. In contrast, other papers describe long-term exercise-induced positive effect on heart rate variability, inflammation, and brain natriuretic peptide level reduction.13 The findings from this paper9 did not report the reduction in rehospitalization and major adverse events which are not in line with previous analysis. Anderson et al.14 conducted a systematic review of 63 studies with 14 486 patients with median follow-up of 12 months. The authors reported the reduction in cardiovascular mortality [relative risk: 0.74; 95% confidence interval (CI): 0.64–0.86] and the risk of hospital admissions (relative risk: 0.82; 95% CI: 0.70–0.96). There was no favourable effect in the reduction of total mortality, myocardial infarction, and revascularization. Another important issue is that women are unfortunately still underrepresented in scientific trials regarding cardiac rehabilitation and consequently also in meta-analyses.15,16 The population of women in the studies included in the meta-analysis by Heimer et al.9 vary from 0 to 38%. The sex is known to determine the rehabilitation effectiveness16; therefore, these results cannot be fully extrapolated to the female population. It is worth noting that the population included in the meta-analysis by Heimer et al.9 was mostly relatively young, highly educated men, with low residual risk. This fact does not allow to make generalizations about the results. The home-based programmes supported by eHealth solutions aim to maintain the patient’s motivation for lifestyle change at a time when there is limited face-to-face contact with health care professionals.17 During the third phase, there should be a periodic check-up aimed to determine whether the patient achieves pre-defined long-term health goals. Along with the development of telemedicine, there was a great potential for implementing eHealth solutions to conduct phase III rehabilitation in everyday clinical practice. These include very simple solutions that primarily involve the patient: mobile app and websites with educational materials that can be used for self-management. More advanced solutions encompass, for example, the monitoring of symptoms and parameters, and the remote supervision of exercise training.6 It is worth emphasizing that the use of technology alone is definitely less effective than solutions that involve providing feedback to the patient by medical staff. To sum up, it is necessary to plan multi-centre, international, randomized trials that will allow to select the optimal model of the third phase of cardiac rehabilitation, taking into account the patient engagement, the use of optimal eHealth technical solutions, and feedback provided by the medical staff. In order to achieve long-term effects in consolidating healthy behaviours and adherence to treatment recommendations, it is necessary to periodically control the achieved goals.