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Association Annual Meeting

AACVPR 35th Annual Meeting Scientific Abstract Presentations

Journal of Cardiopulmonary Rehabilitation and Prevention: September 2020 - Volume 40 - Issue 5 - p E31-E51
doi: 10.1097/HCR.0000000000000556
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AACVPR Research Committee

Scientific Oral Abstract Presentations

Abstract ID: S101

Title: Comparison of Four Methods Used To Determine Exercise Training Target Heart Rate Ranges in Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Meredith Shea, MS1, Clinton A. Brawner, PhD2, Samuel Headley, PhD1, Quinn R. Pack, MD, Msc3.

Institution(s):1Springfield College, Springfield, MA, USA, 2Henry Ford Hospital, Detriot, MI, USA, 3Baystate Medical Center, Springfield, MA, USA.

Introduction: Different methods exist to calculate a target heart rate range (THRR) in cardiac rehabilitation (CR), but it is unclear how these methods vary in their recommended exercise intensity.

Purpose: To compare the difference in THRRs based on four commonly used exercise prescription methods in CR.

Design:

Methods: A total of 28 patients eligible for CR completed a symptom-limited maximum exercise test on a treadmill. A target heart rate range (upper and lower bounds) was calculated using: 1) resting heart rate plus 20-30 (RHR+20-30) bpm; 2) 70-85% of measured peak heart rate (mPHR); 3) 60-80% of measured peak heart rate reserve (HRR); and 4) 70-85% of predicted peak heart rate (pPHR) calculated based on 220-age.

Results: The mean age was 67 ± 7 years, 71% male, and 93% were on beta blockers. The mean resting and peak heart rates were 68 ± 13 and 121 ± 18 bpm, respectively. The lower end of the THRRs calculated from RHR +20, 70% mPHR, 60% HRR, and 70% pPHR were 88, 86, 100, and 106 bpm, respectively. The upper end of the THRRs calculated from RHR+30, 85% mPHR, 80% HRR, and 85% pPHR were: 98, 104, 111, and 130, respectively. The mean exercise target heart rate differed significantly between methods at both the lower and upper ranges. (P <0.001 between methods).

Conclusions: These four commonly used methods to calculate a THRR are significantly different and are not interchangeable. Exercise based on RHR+20 led to a very low intensity prescription, whereas 85% of pMHR was higher than mPHR in 68% of the patients. Neither are likely appropriate for use in CR. While there are some similarities between mPHR and HRR and both can be used, we agree with ACSM recommendations to use HRR when measured peak heart rate is available, to assure that most patients receive an adequate aerobic training stimulus in CR.

Abstract ID: S102

Title: Clinical Outcomes at 1 Year in Patients with Idiopathic Pulmonary Fibrosis (IPF) Stratified by Annualized Weight Loss and Baseline Body Mass Index (BMI): A Post-hoc Analysis from Ascend, Capacity, Inspire And Riff

Track: Pulmonary Rehabilitation & Medicine

Author(s): Stéphane Jouneau, MD, PhD1, Bruno Crestani, MD2, Ronan Thibault, MD, PhD3, Mathieu Lederlin, PhD4, Laurent Vernhet, MD1, Ming Yang, PhD5, Elizabeth Morgenthien, PhD5, Klaus-Uwe Kirchgaessler, MD6, Binoy Daniel, PharmD5, Vincent Cottin, MD, PhD7.

Institution(s):1Univ Rennes, INSERM, EHESP, IRSET UMR_S1085, Rennes, France, 22AP-HP, Hôpital Bichat, Service de Pneumologie A, DHU FIRE, Université Paris Diderot, Paris, France, 33INSERM, INRA, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Nutrition unit, CHU Rennes, Rennes, France, 4Univ Rennes, CHU Rennes, INSERM, LTSI, UMR 1099, Rennes, France, 5Genentech, Inc., South San Francisco, CA, USA, 6F. Hoffmann-La Roche, Ltd., Basel, Switzerland, 7National Reference Coordinating Center for Rare Pulmonary Diseases, Louis Pradel Hospital and Hospices Civils de Lyon, Université Claude Bernard Lyon 1, UMR754, Lyon, France.

Introduction: Weight loss is often reported in patients with IPF and has been linked with poorer prognosis.

Purpose: Here, we present the results of a post-hoc analysis investigating the relationship between body weight and clinical outcomes over 1 year in patients with IPF.

Design: Data were pooled from five randomized controlled trials of patients with IPF (ASCEND [NCT01366209], CAPACITY [NCT00287716 and NCT00287729], INSPIRE [NCT00075998], and RIFF [NCT01872689]). Patients from the placebo arms of ASCEND and CAPACITY were included, and all patients in INSPIRE and RIFF were included because no treatment effect was detected in the active treatment arms.

Methods: Analyses of clinical outcomes at 1 year were stratified by annualized percent change in body weight (no loss, >0 to <5% loss, or ≥5% loss) and baseline BMI (<25 kg/m2, 25 to <30 kg/m2, or ≥30 kg/m2). Outcomes included estimated annualized changes from baseline in percent predicted forced vital capacity (%FVC), percent predicted carbon monoxide diffusing capacity (%DLco), 6-minute walk distance (6MWD), and St. George's Respiratory Questionnaire (SGRQ) total score. All-cause hospitalization and mortality were also assessed.

Results: Patients with no weight loss had reduced estimated annualized worsening in %FVC (95%CI) vs. patients who experienced >0 to <5% loss or ≥5% loss (−4.2% [−4.7%, −3.8%] vs. −5.5% [−6.0%, −5.0%] vs. −9.5% [−10.7%, −8.2%], respectively). Similar trends were observed for %DLco, 6MWD, and SGRQ total score. Compared with patients with no weight loss, a greater percentage of patients with >0 to <5% loss or ≥5% loss experienced all-cause hospitalization (20.4% [15.2%, 25.7%] vs. 26.2% [20.5%, 32.0%] vs. 40.6% [30.3%, 50.9%], respectively), with a trend for increased mortality (7.6% [3.7%, 11.5%] vs. 10.6% [5.6%, 15.6%] vs. 11.7% [3.7%, 19.7%], respectively) in these patients. When outcomes were stratified by baseline BMI, patients with baseline BMI <25 kg/m2 had a greater estimated annualized decline in %FVC vs. patients with baseline BMI 25 to <30 kg/m2 and ≥30 kg/m2, and greater estimated annualized worsening of %DLco and SGRQ total score vs. patients with baseline BMI ≥30 kg/m2. A trend for greater estimated annualized 6MWD decline in patients with baseline BMI <25 kg/m2 vs. 25 to <30 kg/m2 and ≥30 kg/m2 was also observed. Estimated all-cause hospitalization and mortality up to 1 year were similar across the BMI subgroups.

Conclusions: The results of this post-hoc analysis of patients with IPF suggest that patients who lose >0 to <5% or ≥5% of their body weight in 1 year or who have baseline BMI <25 kg/m2 may experience worse clinical outcomes up to 1 year compared with those with no body weight loss or baseline BMI 25 to <30 kg/m2 (overweight) or ≥30 kg/m2 (obese).

Abstract ID: S103

Title: The Relationship Between Co-payment And Compliance In An Urban Outpatient Cardiac Rehabilitation Program

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Justin Raper, M.D., MSc.1, Nicole L. Pontee, MD1, Vanesssa Pahlad-Singh, MS2, David Prince, M.D.1.

Institution(s):1Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA, 2Montefiore Medical Center, Bronx, NY, USA.

Introduction: Cardiac rehabilitation is a medically supervised program that improves cardiovascular health and fitness following a cardiac event. It comprises group exercise training, education about risk factor reduction, behavioral modification and stress management. Cardiac rehabilitation is an essential component of secondary prevention and a class 1 indication following diagnosis of many cardiovascular diseases. It is an underutilized service, with only 8-20% of eligible patients being referred. To our knowledge, co-payment amount as a potential barrier to participation in cardiac rehabilitation has not been studied in an economically challenged community.

Purpose: To investigate the effect of insurance co-payment on patient compliance with cardiac rehabilitation in Bronx, NY with a poverty rate of 27.3%. Our hypothesis was that as the co-payment amount increased the patient compliance and exercise session attendance would decrease.

Design: Retrospective observational study conducted within a university hospital.

Methods: 713 patients referred to cardiac rehabilitation between September 1st, 2018 and September 1st, 2019 were included in the study. Patient exclusion criteria consisted of unqualified Medicare diagnoses, non-attendance at initial office visit, neurological or musculoskeletal conditions that preclude exercise, and transportation barriers. 431 patients remained after application of the exclusion criteria. The electronic health records were reviewed to extract patient data. Our population's data was stratified into four distinct co-payment groups (i.e. No = $0, Low = $5-24, Medium = $25-49, and High = $50+). Primary outcome measures were the difference in mean number of cardiac rehab sessions attended and time to quit the program. The difference in co-payment group means for the number of cardiac rehab sessions attended and the time to quit were determined using ANOVA. Post hoc analysis was performed using Tukey's test. Statistical significance was set at p < 0.05.

Results: Analysis of the co-payment groups revealed a decrease in the mean number of cardiac rehab sessions attended with increase in co-payment amount [No vs. Medium (14.76 +/− 14.48 vs. 1.82 +/− 6.97; p < 0.01); No vs. High (14.76 +/−14.48 vs. 0.00 +/− 0.00; p < 0.01); Low vs. Medium (10.21 +/− 13.53 vs. 1.82 +/− 6.97; p < 0.05); Low vs. High (10.21 +/− 13.53 vs. 0.00 +/− 0.00; p < 0.01)]. Analysis of the co-payment groups also revealed a mean decrease in time to quit with increase in co-payment amount [No vs. Medium (10.96 +/− 12.08 vs. 1.57 +/− 6.63 weeks; p < 0.01); No vs. High (10.96 +/− 12.08 vs. 0.00 +/− 0.00 weeks; p < 0.01); Low vs. High (6.70 +/− 8.92 vs. 0.00 +/− 0.00 weeks; p < 0.05)].

Conclusions: An inverse relationship between co-payment amount and compliance with cardiac rehabilitation was demonstrated. In our economically challenged population co-payment amount represents a significant barrier to accessing this essential service.

Abstract ID: S104

Title: The Importance Of Personal Values In Home-based Cardiac Rehabilitation

Track: Behavior Change

Author(s): Emily C. Gathright, PhD1,2, Lori A.J. Scott-Sheldon, PhD1,2, Wen-Chih Wu, MD3,4.

Institution(s):1The Miriam Hospital, Providence, RI, USA, 2Alpert Medical School of Brown University, Providence, RI, USA, 3The Miriam Hospital/Alpert Medical School of Brown University, Providence, RI, USA, 4Providence VA Medical Center, Providence, RI, USA.

Introduction: Home-based cardiac rehabilitation (CR) is an alternative to center-based CR for patients who have limited or no access to center-based CR. Home-based CR relies on patients' personal motivation to engage in behavior change. Patients' core values (e.g., health, family) may serve as motivational factors to strengthen the cardiac risk factor modification recommendations (e.g., increased physical activity). However, little is known about patient-reported personal core values in those completing home-based CR which likely differs from center-based CR participants.

Purpose: To (a) identify personal core values and (b) evaluate values that predict improvements in exercise capacity upon completion in patients participating in home-based CR.

Design: Chart review

Methods: Patients enrolled in the Providence Veteran's Affairs Medical Center's home-based CR program completed assessments at program intake and upon completion, including the six-minute walk test (6MWT) and a self-report survey of patients' core values adapted from the Chronic Pain Values Inventory (CPVI). Participants rated eight value domains (family, friendships, health, independence, hobbies, spirituality, growth/learning, and intimate relations) on their (a) degree of importance and (b) success in following those values on a 5-point scale ranging from “not at all important/successful” (0) to “extremely important/successful” (5). The proportion of patients reporting values as “very” or “extremely” important/successful is reported. Linear regression was used to test the association between the values ratings and 6MWT after controlling for age and baseline 6MWT.

Results: Seventy-eight patients (mean age 71±8 years, 91% white, 97% male) completed the adapted CPVI at intake; 48 patients completed the 6MWT upon completion of home-based CR. The most important values were independence (81%), family (73%), and health (64%) and participants rated themselves the most successful in living according with their values of family (46%), independence (46%), and friendships (31%). Only 23% of participants rated themselves as “very” or “extremely” successful in the health domain. The values of independence and health were positively associated with exercise capacity such that patients who rated independence and health as more important had greater improvements in the 6MWT upon CR completion (independence: β=.17, p<.05, n=48; health: β=.16, p<.05, n=48). None of the other values predicted exercise capacity upon home-based CR completion.

Conclusions: Home-based CR patients rated independence, family, and health as their most important values but reported that they were most successful in living according to the values of independence and family. Patients who reported that independence and health were more important to them demonstrated greater 6MWT performance at program completion. Patients who do not highly value independence and health may benefit from greater support to ensure optimal exercise capacity improvement. Future research should evaluate whether incorporating values-based activities in home-based CR can improve patient outcomes.

Abstract ID: S105

Title: Correlation Of Peak Oxygen Uptake To Six-minute Walk Distance And Oxygen Uptake Efficiency Slope Across Fitness Levels In Outpatient Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Addie Critcher, M.S., Sydney Stripling, M.S., Colleen Daubert, M.S., Jeffrey Soukup, Ph.D.

Institution(s): New Hanover Regional Medical Center, Wilmington, NC, USA.

Introduction: Peak oxygen uptake is the “gold standard” for the assessment of cardiorespiratory fitness (CRF) in both healthy and diseased populations. Improvements in CRF have been shown to result in reduced cardiovascular and all-cause mortality in patients with cardiovascular disease. However, direct measurement of VO2peak is rarely performed in the outpatient CR setting due to challenges with cost, expertise and knowledge. This has led to the widespread use of the six-minute walk test (6MWT) to assess improvements in functional capacity. While this assessment is simple to administer, it may not truly reflect changes in CRF. The OUES provides an alternative assessment of cardiorespiratory efficiency by evaluating the linear relationship between the log VE and oxygen uptake. We set out to examine the relationship between 6MWD, VO2peak and OUES across various levels of fitness in the CR setting.

Purpose: To report the correlation differences between peak oxygen uptake and oxygen uptake efficiency slope (OUES) when compared to peak oxygen uptake and six-minute walk distance (6MWD) across cardiorespiratory fitness domains in the outpatient cardiac rehabilitation (CR) setting.

Design: Eighty-five patients who were referred to out-patient CR and voluntarily agreed to cardiopulmonary exercise testing (CPET) at program entry were included. Each patient underwent 6MWT according to ATS guidelines and CPET at program entry. Following CPET, patients were categorized into High (VO2peak > 24.5 ml/kg/min), Moderate (VO2peak > 17.5 ml/kg/min and < 24.5 ml/kg/min) and Low (VO2peak < 17.5 ml/kg/min) categories.

Methods: Statistics were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY). Bivariate Pearson correlations were examined to assess the strength of the relationship between VO2peak, 6MWD and OUES. Significance was set at p <0.05.

Results: VO2peak was significantly correlated to OUES (R = .909; p = 0.000) and 6MWD (R = .613; p = 0.000) for all patients. Correlations for VO2peak and OUES were significant for each fitness group (High, R = .846; p = 0.000 vs. Moderate, R = .857; p = 0.000 vs. Low, R = .916; p = 0.000). Correlations for Peak VO2 and 6MWD were only significant for the High group (High, R = .543; p = 0.004 vs Moderate, R = .223; p = 0.173, Low, R = .383; p = 0.129) and the strength of the relationship between the two was considerably less than that seen with VO2peak and OUES.

Conclusions: This project examined simple correlational relationships between VO2peak, 6MWD and OUES across fitness categories in patients with known heart disease. Findings suggest that there is a strong relationship between VO2peak and OUES across all fitness levels while only patients with a high fitness level showed a moderate correlation between VO2peak and 6MWD. This should provide some hesitation toward the reliance on 6MWD as a surrogate for improved functional capacity and cardiorespiratory fitness.

Abstract ID: S106

Title: Sub-maximal Graded Exercise Testing (sgxt) Is Associated With Higher Improvements In Exercise Capacity And Clinical Outcomes Than Six-minute Walk Testing (6mwt)

Track: Physical Activity/Exercise

Author(s): Adam Valencia, Ms, CEP, Lillian L.C. Khor, MB.BCh, Msc, Dawn Young, BSN, Elizabeth Dranow, PhD, Kevin Manwaring, BS, Kalie Christensen, BS.

Institution(s): University of Utah Health, salt lake city, UT, USA.

Introduction: Exercise capacity (EC) and its improvement are powerful predictors of survival in patients with cardiovascular disease. The maximal oxygen uptake (VO2max) test is the gold standard to determine cardiovascular fitness (CRF), but is cumbersome and costly. 6MWT and SGXT are therefore more commonly used, but their relative effectiveness is unknown.

Purpose: To assess if modality of exercise assessment is correlated to improved clinical outcomes. We hypothesized that SGXT at orientation was associated with i) greater improvement in EC and ii) clinical outcome measures post CR completion.

Design: Retrospective case-controlled cohort study on measured exercise and clinical outcomes in our local American College of Cardiovascular and Pulmonary Rehabilitation (AACVPR) registry between 2012-2019.

Methods: Exercise data from patients who completed 16 or more sessions and a Duke Activity Score Index (DASI) of > 9.95 on initial evaluation were compared based on modality of CFR testing. Routine SGXT was introduced in 2017 for participants with a DASI >9.95; we excluded patients with a DASI of <9.95 to reduce bias associated with lower EC and 6MWT. The association between CFR testing with EC and clinical outcomes was assessed by univariate followed by multivariate regression.

Results: 1652 participants' exercise data were reviewed, with 51.5% completion rate for an average of 30 sessions. Following exclusion of patients with DASI <9.95, there were 290 participants with both initial and discharge 6MWT and 309 with initial and discharge SGXT. Patients with a 6MWT had significantly lower intake systolic and diastolic blood pressure (114/65 versus 119/72), lower incidence of non-ST-elevation myocardial infarction (11.9% versus 18.1%), and heart failure (6.5% versus 11.3%). There was a higher incidence of peripheral artery disease (8.1% versus 0.7%) and higher body max index (BMI), 29.6 versus 28.6 (p=0.012) in the 6MWT group, but no difference in age, gender or number of attended sessions. Overall the mean EC increased by 2.2 Metabolic equivalents (METs) in peak exercise during their pre-discharge session (p<0.001) with an average drop of 0.2 (p<0.001) in BMI. The EC improvement was 22.2 % in the 6MWT group compared to 52.3% in the SGXT group (P<0.001). After controlling for age, gender and BMI, SGXT remained an independent predictor of absolute and relative improvement in maximal EC. Improvement in EC was associated with a positive change in quality of life by the MacNew global score. There was a higher correlation between maximal METs and peak METS(0.65) with SGXT versus 6MWT(0.38). 6MWT estimated maximal METS was 0.6 METs lower than peak EC measured during intake sessions, whereas maximal METS by SGXT was 0.6 METs higher.

Conclusions: SGXT has higher correlation with patient's intake EC. SGXT at orientation to CR was associated with improved outcomes and 30% higher EC improvement compared to 6MWT. As EC is associated with a significant reduction in cardiovascular mortality, SGXT should be performed preferentially to 6MWT.

Abstract ID: S107

Title: Cardiac Rehab Performance Measures - Urban Vs. Rural

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Mike McNamara, MS, FAACVPR, Carrie Oser, MPH, Crystelle Fogle, MS, MBA, RD.

Institution(s): Montana Department of Public Health & Human Services, Helena, MT, USA.

Introduction: Performance measures were developed to evaluate key facets that programs should focus on and evaluate in delivering cardiac rehab (CR) services.

Purpose: To investigate performance measure differences between urban and rural CR programs.

Design: A cross-sectional study design was used for CR facilities participating in the Montana Outcomes Project (MOP).

Methods: The sample was drawn from participating MOP programs in Montana and northern Wyoming. Data were collected from April 2018 through September 2019. The performance measures in this study were: % of patients who met blood pressure (BP) target (<130/80mmHg), % of patients who attained a 10% improvement in 6-min walk distance, tobacco cessation referral, and % of patients that improved 1 or more levels of severity in the PHQ-9 depression screen. Statistical analysis included Chi-square, ANOVA tests, and T-test with p-value of ≤ 0.05 indicating statistical significance.

Results: The sample consisted of 972 urban patients (mean age: 68 years, 76% male) compared to 580 rural patients (mean age: 70 years, 71% male). Mean number of visits were similar (29.1 urban vs. 28.5 rural) as was the percentage of white patients (97% urban vs 95% rural). There were significant differences in BP control rates (81.2% urban vs. 68.8% rural) and in the % of patients attaining a 10% improvement in 6-minute walk distance (67.5% urban vs. 75.6% rural). No significant differences were noted between the groups related to tobacco cessation referral (84% urban vs. 90.4% rural) or the improvement of 1 or more levels of severity in PHQ-9 depression scores (76% urban vs. 77% rural).

Conclusions: There were significant differences in performance measures between rural and urban programs. Urban program patients had much better BP control rates while those in rural programs had better 6-min walk performance. Both rural and urban patients experienced similar improvements in depression scores and tobacco cessation referral.

Abstract ID: S108

Title: Comparison of The Dose Of Stress Management Practice On General Anxiety And Perceived Stress In Cardiac Rehabilitation Programs

Track: Behavior Change

Author(s): Danielle Beaudoin, BS EP, CCRP, Jamie Labelle, BS EP, CCRP.

Institution(s): The Miriam Hospital, Providence, RI, USA.

Introduction: According to American Heart Association (AHA) anxiety and stress are precipitating factors of a cardiovascular event and contribute to increased mortality amongst diagnosed patients. Cardiac Rehabilitation (CR) patients commonly score abnormally to anxiety and stress questionnaires upon program enrollment. Research suggests that implementing Stress Management Practice (SMP) can improve patient outcomes. It was concluded by AHA that CR paired with SMP is associated with a significant reduction in stress and near 50% reduction in adverse clinical events post CR, when compared to Traditional Cardiac Rehab without SMP.

Purpose: To compare improvement in General Anxiety (GAD7) and Perceived Stress Scale (PSS) across three programs within University Hospital system which provide varying levels of weekly SMP. Our hypothesis is that a larger intervention dose (minutes of SMP) results in greater improvement in GAD7 and PSS at discharge.

Design: A retrospective chart review study was performed to evaluate the effects of weekly SMP on GAD7 and PSS of patients in Traditional and Intensive Cardiac Rehabilitation from 2018-2019. GAD7 and PSS data were collected at entrance and discharge.

Methods: Intensive Cardiac Rehabilitation (ICR) provides a 9 week program of 4 hour session/twice weekly, including one hour of each element (exercise, nutrition, group support and stress management). Traditional Cardiac Rehabilitation at location 1 (TCR 1) provides a 12 week program of 1.5 hours/three times weekly of exercise and education; which includes a 25 minute weekly stress management practice. Traditional Cardiac Rehabilitation at location 2 (TCR 2) provides a 12 week program of 1.5 hours/three times weekly of exercise and education, including the topic of stress management. Data gathered from patient portal at baseline and discharge GAD7 and PSS, compared CR programs and between groups using analysis of variance. Correlation analysis was run to assess relationship of changes in GAD7, PSS and minutes of stress management performed.

Results: Total of 681 patients met study criteria; 405 patients in TCR 1, 183 ICR and 93 in TCR 2. Average age (67 +/− 11) and gender composition of males TCR 1 72%, ICR 72% and TCR 2 73%. Significant differences in GAD7 improvement were seen between ICR (M=2.08, SD=3.52), TCR 1 (M=1.00, SD=3.18) and TCR 2 (M=0.77, SD=3.69), p=012. Similarly, significant difference in PSS improvement were seen between ICR (M=2.80, SD=5.24), TCR 1 (M=1.42, SD=4.73) and TCR 2 (M=2.32, SD=5.64), p= .001. Improvements in GAD7 and PSS display a 40% correlation. Minutes of stress management performed shows a 98% positive correlation with improvements in both GAD7 and PSS.

Conclusions: Cardiac rehabilitation produces pronounced effect on improvement in GAD7 and PSS; with a positive correlation regardless of program. The impact of increased intervention dose of SMP is exhibited in the significant difference between ICR and TCR in both domains. In conclusion; stress management practice is a valuable component of any cardiac rehab program for all patients.

Abstract ID: S109

Title: Physical Function and Depressive Symptoms from Hospitalization to Completion of Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Patrick D. Savage, MS FAACVPR, Sherrie Khadanga, MD, Katherine Mahoney, BS, Natalie Robison, MS, Diann Gaalema, PhD, Philip Ades, MD, Jason Rengo, MSc, CCRP.

Institution(s): University of Vermont Medical Center, South Burlington, VT, USA.

Introduction: Participation in phase 2 Cardiac Rehabilitation (CR) is associated with improvements in self-reported physical function and depressive symptomology. Little is known, however, about levels of physical function and depression at the time of hospitalization for individuals eligible for CR.

Purpose: This study examines self-reported physical function and levels of depressive symptoms at 3 time points: (1) at hospitalization; (2) entry and (3) exit from CR.

Design: Prospective, observational.

Methods: Patients hospitalized for a CR-qualifying cardiac event completed the physical function component of the Medical Outcome Study Short Form-36 (MOS-SF) (score range 0-100; higher score associated with higher levels of physical function) and the Patient Health Questionnaire 9 (PHQ-9) (score range 0-27; higher score associated with higher levels of depressive symptoms). For those who enrolled in and completed CR, these measures were repeated at CR entry and exit. Scores at the three time points are reported as mean±SD. Unpaired t-tests were used to compare CR participants to non-participants and CR completers were compared to non-completers. Paired t-tests were used for within group comparison.

Results: The cohort included 322 (Female N=101) individuals with a mean age of 68.3±11.8years. For the entire cohort, at the time of hospitalization, mean values for MOS-SF and PHQ-9 were 60.7±30.0 and 2.8±4.8, respectively. Of the entire cohort, 183 (56.8%) enrolled in CR. Compared to nonparticipants, CR enrollees had a significantly higher MOS-SF (65.6±29.6 vs 50.7±28.7, p<0.0001) and lower PHQ-9 (2.2±4.7 vs 3.5±5.0, p<0.02) scores. For participants in CR, there was a significant increase in PHQ-9 scores from hospitalization to CR entry (2.2±4.7 vs 3.7±3.9, p<0.001). There was, however, no change in MOS-SF scores from hospitalization to CR entry (65.6±29.6 vs 61.0±27.0, respectively, p=0.NS). For individuals who enrolled in CR, 92 (50.2%) completed CR. Among CR participants, there was no difference in entry values for the MOS-SF between completers (60.1±26.3) and non-completers (61.9±27.8) (p=NS). Non-completers, at entry to CR, had a higher PHQ-9 scores than completers (4.4±4.4 vs 3.0±3.2, respectively, p<0.02). Completers of CR reported significant increases in MOS-SF scores from hospitalization to CR exit (65.6±29.6 vs 81.5±22.3, p<0.0001). For individuals that completed CR, there was no difference in PHQ-9 score between hospitalization and CR exit (1.2±3.6 vs 1.6±2.3, respectively p=NS).

Conclusions: Scores on the MOS-SF and PHQ-9 at the time of hospitalization are indicative of very low levels of physical function and minimal depressive symptoms. For individuals that enroll in CR, there is no change in MOS-SF scores from hospitalization to CR entry. Conversely, there is a significant increase in depressive symptoms from hospitalization and CR entry. At exit, completers of CR report a significant improvement in physical function scores while depressive symptoms decrease to similar levels reported at the time of hospitalization.

Abstract ID: S110

Title: Outcomes after Cardiac Rehabilitation for Patients With Stable Heart Failure Enrolled In Medicare Advantage Plan

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Yongming Zhao, Ph.D, Consuela Dennis, MSN, Todd Prewitt, MD.

Institution(s): Humana, Inc., Louisville, KY, USA.

Introduction: Clinical trials have reported cardiac rehabilitation (CR) may improve heart functional capacity and survival, reduce hospital admissions, and improve depressive symptoms. Recent clinical guidelines have suggested CR can be useful in clinically stable patients with heart failure (HF); however, evidence about CR benefits for patients with stable HF is still limited, especially among those enrolled in Medicare Advantage (MA) plans.

Purpose: To evaluate impacts within a year of CR on survival, major depressive disorder (MDD), and hospital care utilization among patients enrolled in a MA plan with stable HF.

Design: Retrospective cohort study.

Methods: The CR group contained patients with stable HF, defined as HF stage C with evidence of pharmacologic HF treatment for >6 weeks, and no major cardiovascular hospitalizations or procedures within 6 weeks of the index day, the first day the patient started CR from July 2016 - December 2017. Patients were included if they had continuous enrollment with MA provided by Humana, a large health insurance firm, for more than 2 months with at least 8 completed CR sessions. Other patients meeting the same inclusion/exclusion criteria as those in the CR group with the exception of no CR claims were pulled as a potential comparison group. The comparison cohort's index dates were defined as the first day of a calendar month by which they stayed in HF stage C for the same duration as those in the CR group. Major data sources were pharmacy claims, insurance enrollment records, and medical claims from which CR was identified based on Current Procedural Terminology codes (93797 and 93798), and confounding factors were identified. One-to-one propensity score matching was performed based on a multiple logistic regression predicting the likelihood of receiving CR. Kaplan-Meier analyses and analysis of variance (ANOVA) were employed to assess CR impacts a year after the index date.

Results: Propensity score analysis resulted in 719 matched pairs of patients. Distributions of observed characteristics, which included demographics, Medicare eligibility and MA product types, prevalent comorbidities, and recent cardiologist visit, between the two matched groups were well balanced. Kaplan-Meier analyses showed the CR group had a significantly higher survival probability at 1 year than the matched comparison group (90.32% versus 85.64%, P<0.01). Among study participants without previous evidence of MDD, the CR group had a significantly lower risk of developing new incidences of MDD at 1 year than the matched comparison group (12.92% versus 19.90%, P<0.01). ANOVA showed hospital admissions and hospital days of the CR group were significantly lower by 13.76 and 67.12 days per 1,000 patients per month, respectively (P<0.01 and P=0.02), than the matched comparison group.

Conclusions: CR may help improve survival, prevent new MDDs, and reduce hospital care utilization among patients with stable HF.

Abstract ID: S111

Title: Can Cardiac Rehabilitation Improve Frailty In Adults With Cardiovascular Disease?

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Andrew Lutz, MD1, Amanda Delligatti, M.S.2, Kelly Allsup, M.A.2, Daniel E. Forman, M.D.1.

Institution(s):1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.

Introduction: Frailty is highly prevalent among adults with cardiovascular disease (CVD) and is associated with greater than twofold risk for morbidity and mortality, independent of age and comorbidities. Meanwhile, cardiac rehabilitation (CR) is underutilized; many eligible patients are not referred due to perceived frailty.

Purpose: We analyzed changes in several domains of physical function in frail, intermediate-frail, and non-frail adults with CVD after completing a course of CR to assess whether frailty status affects gains in physical function derived from CR. We hypothesized that CR benefits frail adults as much as intermediate-frail and non-frail.

Design: Retrospective quality improvement study of CVD patients who completed a phase II CR program at the Veterans Affairs Pittsburgh Healthcare System.

Methods: Patients were classified as frail by meeting ≥ 2 frailty criteria, intermediate-frail by meeting 1 criterion, and non-frail if met 0 criteria. These included 6-minute walk distance (6MWD) <300m, Timed Up and Go (TUG) <15s, weak hand grip strength (HGS) per Fried criteria, tandem stand <10s, and gait speed <0.65m/s or 0.76m/s, normalized to height and gender. Changes within and between groups were compared from physical function assessments before and after completion of CR.

Results: 243 patients were assessed: 98 frail, 70 intermediate-frail and 75 non-frail. Each group experienced significant improvements in all measures of physical function aside from tandem stand. For 6MWD, nonfrail: 387m (pre) to 433m (post), p<0.001; intermediate-frail: 315m (pre) to 369m (post), p<0.001; frail: 215m (pre) to 266m (post), p<0.001. For TUG, nonfrail: 8.1s (pre) to 7.3s (post), p<0.001; intermediate-frail: 9.5s (pre) to 8.9s (post), p=0.002; frail: 14.1s (pre) to 12.5s (post), p<0.001. For hand grip strength, nonfrail: 38.8kg (pre) to 40.1kg (post), p<0.001; intermediate-frail: 33.6kg (pre) to 35.1kg (post), p=0.001; frail: 31.1kg (pre) to 32.1kg (post), p=0.02. For tandem stand, nonfrail: 28.1s (pre) to 27.4s (post), p=0.42; intermediate-frail: 23.3s (pre) to 25.4s (post), p=0.39; frail: 13.0s (pre) to 14.7s (post), p=0.25. For GS, nonfrail: 1.16m/s (pre) to 1.23m/s (post), p=0.002; intermediate-frail: 1.02m/s (pre) to 1.10m/s (post), p=0.002; frail: 0.79m/s (pre) to 0.86m/s (post), p=0.002. There were no significant differences between the frail, intermediate-frail, and non-frail groups in pre-to-post CR changes in 6MWD, GS, hand grip strength, or tandem stand. Frail patients showed greater improvement in TUG compared to intermediate-frail and non-frail groups (p=0.007).

Conclusions: Among frail patients, multiple domains of physical function improved with CR. Gains achieved by frail adults were similar to or greater than those achieved by intermediate-frail and non-frail patients, and may confer greater relative benefit with respect to physical function and quality of life to this patient population. These data provide strong rationale for referring all CVD patients, particularly those who are frail.

Abstract ID: S112

Title: Response to Exercise Training During Cardiac Rehabilitation Differs By Sex

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jason L. Rengo, MS, Sherrie Khadanga, MD, Patrick D. Savage, MS, Philip A. Ades, MD.

Institution(s): University of Vermont Medical Center, Burlington, VT, USA.

Introduction: Directly measured peak aerobic capacity (VO2peak) is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) programs with significantly lower baseline measures. Additionally, there is some evidence that women do not improve their aerobic fitness as much as men.

Purpose: To examine training response and VO2peak at entry and exit from CR and identify clinical characteristics which may influence change in VO2peak.

Design: Prospective observational study.

Methods: The cohort consisted of 3925 CR patients (24% female) who underwent an entry exercise tolerance test. Data obtained included sex, age, qualifying diagnosis (coronary artery bypass surgery (CABG), heart valve surgery (HVS), myocardial infarction (MI), percutaneous coronary intervention (PCI), stable angina, congestive heart failure (CHF), transaortic valve replacement (TAVR) and arrhythmia (atrial fibrillation or ventricular tachycardia), self-reported physical function (Medical Outcome Study-SF 36), body weight, VO2peak and exercising training response. Paired t-tests, chi-square and ANOVA were used for within and between group differences. Data are presented as mean±SD and statistical significance was set at p<0.05.

Results: CABG and HVS (37%) and MI (31%) were the main qualifying diagnosis. Mean age and baseline VO2peak were 64±12 years and 19.1±6.7 mLO2*kg−1*min−1, respectively. There was a significant interaction between baseline VO2peak and diagnosis (p <0.001). Post hoc analysis showed PCI and MI baseline values were significantly greater than CABG, HVS, stable angina, CHF and TAVR (p<0.001). Women had lower VO2peak at entry to CR compared to men for all diagnoses (p <0.02) except TAVR (p=NS).

Exit VO2peak was obtained in 1789 patients (23% female). Mean number of sessions completed was 27±10 and entry to CR was 38±22 days following the index event, with no differences between women and men. Overall, VO2peak increased from 19.2±6.4 to 22.4±7.5 mL*kg−1*min−1 (+17%, p<0.001). Body weight and self-reported physical function improved with no differences between genders. There was a significant interaction between improvement in VO2peak and diagnosis (p<0.001) with CABG and HVS increasing more than MI, PCI, stable angina, arrhythmia and TAVR (p<0.05). Despite an overall mean increase in VO2peak, 18% (320/1789) of patients failed to demonstrate any improvement (exit VO2peak less than or equal to entry VO2peak). Women demonstrated less improvement in VO2peak compared to men (13% vs 17%, respectively p<0.001). Furthermore, a higher percentage of women failed to demonstrate any improvement in VO2peak compared to men (24% vs 16%, p=0.001). Although women improved estimated peak METs less than men (+1.7±1.7 vs +2.2±2.0, p<0.01), percent improvement was similar for women (33%) and men (31%)(p=NS).

Conclusions: While there are no differences in training effect using estimated METs, directly measured VO2peak showed a significantly decreased training response for women compared to men. Additionally, 18% of all patients do not see improvements in VO2peak despite completing CR. Finally, patients entering CR with a surgical diagnosis have lower baseline VO2peak but demonstrate greater improvements with exercise training.

Beginning Investigator Presentations

Abstract ID: S113

Title: Exercise Prescription In Cardiac Rehabilitation: A Pilot Randomized Controlled Trial

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Meredith Shea, MS1, Samuel Headley, PhD1, Clinton A. Brawner, PhD2, Jami Burris-Merrill, MS3, Patrick Schilling, BS3, Elizabeth Mullin, PhD1, Quinn R. Pack, MD, Msc3.

Institution(s):1Springfield College, Springfield, MA, USA, 2Henry Ford Hospital, Detriot, MI, USA, 3Baystate Medical Center, Springfield, MA, USA.

Introduction: Exercise can be prescribed in cardiac rehabilitation (CR) using either ratings of perceived exertion (RPE) or a target heart rate range (THRR). However, it is unclear which method leads to the greatest gains in exercise capacity.

Purpose: To assess changes in exercise capacity among patients prescribed an exercise prescription based on RPE only or THRR.

Design: Randomized controlled trial.

Methods: In this pilot study, patients referred to CR were randomized to one of three groups: RPE of 3-4 on the 10-point modified Borg, 60-80% of heart rate reserve (HRR) with heart rate (HR) monitored by ECG telemetry, or 60-80% of HRR via personal heart rate monitor (HRM), allowing patients to carefully adhere to their THRR. For each daily CR session, we noted exercise heart rate, reported RPE, and frequency of changes in the exercise workload. At program completion, we measured changes in functional exercise capacity based on metabolic equivalents of task calculated from exercise workloads (fMETs).

Results: Of 48 participants (age 68 ± 7 years, 35 males, 13 females), 4 patients dropped out, 20 were stopped prematurely due to the COVID-19 pandemic, and 24 completed the protocol participating in a median of 35 (25, 36) sessions. During the first 10 sessions after randomization exercise workload increased in 39, 50, and 52% of CR sessions, (η2 = 0.08, p = 0.24); HR increased from baseline (average HR of first 4 sessions of CR) by 4 ± 2, 9 ± 3, and 9 ± 3 bpm (η2 = 0.13, p = 0.17), and RPE was similar 2.9 ± 0.07, 3.1± 0.07, 3.1 ± 0.07 (p = 0.94), for the RPE, THR, and HRM groups, respectively. The change in fMETS was 1.7 ± 1.0, 2.2 ± 1.0, and 2.7 ± 1.0, respectively (η2 = 0.16, p = 0.17).

Conclusions: Compared to patients prescribed exercise with RPE, patents randomized to the THRR and HRM group had more frequent upward adjustments in exercise intensity but similar RPE ratings. We also noted large effect sizes on changes in fMETs and changes in HR, although these results were not statistically significant, likely due to the small sample size. These findings should be confirmed in a larger and more definitive trial as they suggest patients randomized to THRR may have better outcomes than patients prescribed exercise using RPE.

Abstract ID: S114

Title: Effect of Smoking on Changes in Cardiorespiratory Fitness in Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Katharine Mahoney, BA, Hypatia Bolívar, PhD, Patrick Savage, MS, Philip Ades, MD, Diann Gaalema, PhD.

Institution(s): University of Vermont, Burlington, VT, USA.

Introduction: Continued smoking in patients with cardiovascular disease greatly increases risk for subsequent cardiac events. Smoking is associated with reduced aerobic capacity and lower adherence to secondary prevention strategies like cardiac rehabilitation (CR). Physical fitness among smokers attending CR is understudied despite being at a higher risk of future mortality and morbidity. Examining changes in fitness among lower-socioeconomic status (SES) patients, who are more likely to be current smokers, can help inform this understudied area.

Purpose: We examined the role of smoking at the time of hospitalization and changes in cardiorespiratory fitness levels during CR.

Design: Secondary analysis of data from two randomized clinical trials testing interventions to increase CR attendance in individuals of lower SES.

Methods: Peak Metabolic Equivalents of Task (METpeak) was determined via a symptom-limited exercise tolerance test (ETT) at entry and exit from CR. Baseline demographics, self-reported smoking status, qualifying cardiac event (surgical vs. non-surgical), and number of CR sessions completed were collected. Smokers were defined as patients reporting smoking at hospitalization. T-tests and Chi-square tests were used to examine baseline differences and changes in METpeak over time. Multiple linear regression was used to examine the impact of baseline smoking status on change in METpeak controlling for age, sex, surgical diagnosis, number of CR sessions completed, and baseline body mass index (BMI) and METpeak.

Results: The study sample included 120 patients (mean age 58.5±8.9 yrs, 33% female, 94% Caucasian). Individuals that were smokers (N=38) at the time of hospitalization were younger (55.9±8.8 yrs vs. 59.6±8.8 yrs, p=0.034), completed fewer CR sessions (21 vs. 27, p=0.02) and had a lower mean BMI (30.4 vs. 34.0, p=0.015) compared to non/former smokers. There was no difference in METpeak at entry to CR (5.3 smokers vs. 5.1 non/former smokers, p=0.68). For the entire sample, mean METpeak improved during CR (5.1 to 6.6, p<.001). In the regression analysis, smoking predicted smaller METpeak change (β= −0.963, p=0.012), as did older age (β=−0.056, p=0.009), higher BMI (β=−0.052, p=0.039), and higher intake METpeak (β=−.184, p=.012). Larger METpeak change was predicted by more CR sessions completed (β=0.044; p<0.0001). Sex and surgical status were not significant predictors (ps>.05).

Conclusions: After adjusting for confounders including baseline fitness, smoking at the time of hospitalization was a significant predictor of smaller changes in METpeak during CR program, suggesting that smoking negatively impacts improvements in cardiorespiratory fitness. Smoking cessation should remain a top priority for patients entering CR.

Abstract ID: S115

Title: Examining Energy Expenditure During Aerobic And Resistance Training In Overweight Patients With Heart Failure With Preserved Ejection Fraction

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Hannah Schultz, MS, Tessa Roberts, BS, Michael Berry, Ph.D., Peter Brubaker, Ph.D.

Institution(s): Wake Forest University, Winston-Salem, NC, USA.

Introduction: Previous studies have demonstrated that aerobic training (AT) and/or weight loss through a caloric restricted (CR) diet can be beneficial in older, overweight heart failure patients with preserved ejection fraction (HFpEF). However, few studies have evaluated the benefits of resistance training (RT) in these patients. Moreover, weight loss is recommended for overweight/obese HFpEF patients, but the actual energy expenditure (EE) associated with AT and/or RT has not been measured in these patients.

Purpose: Therefore, the purpose of this study was to compare the EE, adjusted for exercise duration and bodyweight, during AT versus RT session in older, overweight HFpEF patients.

Design: This is a sub study of the randomized, controlled, single-blind clinical trial called Study Examining Caloric Restriction and Exercise Trials II (SECRET II).

Methods: Ten overweight/obese HFpEF participants from the Studies Examining Caloric Restriction and Exercise Trial II (SECRET II) trial were randomly assigned to either an AT (n=5) or AT+RT (n=5) intervention. In addition to a baseline cardiopulmonary exercise test (CPET) to measure oxygen update, heart rate, and rating of perceived exertion (VO2peak, HRpeak, and RPEpeak), each participant in this study wore the COSMED K5 during a single exercise session (∼1 hr) in order to determine VO2peak, HRpeak, and RPEpeak as well as EE during the two modes of exercise. Total energy expenditure (kcal) for each exercise session was adjusted for the duration of the session (kcal/min) and for the participants bodyweight (kcal/kg/min).

Results: The average exercise session was 60.4 ± 14.9 minutes which resulted in a total EE of 283.9 ± 130.1 kcal for these older overweight/obese HFpEF patients. On average the participants exercised at 65.4% ± 0.1, 68.1% ± 0.1, and 72% ± 0.1 of their VO2peak, HRpeak, and RPEpeak, respectively. The EE, when adjusted for the duration of the exercise session and bodyweight, was not significantly different between an AT and RT session (0.045 and 0.040 kcal/kg/min, respectively). These EE values are within the “normal” ranges reported for healthy adults during various walking speeds.

Conclusions: The results of this small study indicate that AT and RT results in similar levels of EE in older, overweight/obese HFpEF and that either mode can create a negative energy balance sufficient to result in weight loss over time in these patients. A larger and longer study will be needed to confirm these findings.

Abstract ID: S116

Title: Is Improvement In Depression In Patients Attending Cardiac Rehabilitation With New Onset Depressive Symptoms Determined By Patient Characteristics?

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Serdar Sever, MSc, Patrick Doherty, Ph.D., Su Golder, Ph.D., Alexander Harrison, MSc.

Institution(s): University of York, York, United Kingdom.

Introduction: Cardiovascular disease (CVD) patients commonly experience depressive symptoms which is associated with adverse outcome and increased mortality. Examining the baseline characteristics of cardiac rehabilitation (CR) patients that determine Hospital Anxiety and Depression Scale (HADS) depression outcome may facilitate adjustments in CR programme delivery.

Purpose: This study aims to investigate whether comorbidities, demographic and clinical characteristics of patients, with new onset post cardiac event depressive symptoms, determine change in their depression following CR.

Design: An observational study.

Methods: Analysing the routine practice data of British Heart Foundation (BHF) National Audit of Cardiac Rehabilitation (NACR) between April 2012 and March 2018. Patients with new onset post cardiac event depressive symptoms and no previous documented history of depression constituted the study population. Independent sample t-tests and chi-square tests were used to examine the baseline characteristics followed by binary logistic regression analysis to predict the change in Hospital Anxiety and Depression Scale (HADS) depression outcome.

Results: The analyses included 64,658 CR patients (66.24±10.69 years, 75% male) with new onset HADS measures, excluding patients with a history of depression. The comorbidities determining reduced likelihood of improvement in depression outcomes after CR were: angina (OR: 0.778, 95%CI: 0.661 to 0.916), diabetes (OR: 0.830, 95%CI: 0.714 to 0.965), stroke (OR: 0.718, 95%CI: 0.550 to 0.937), emphysema (OR: 0.665, 95%CI: 0.443 to 0.999), and chronic back problems (OR: 0.812, 95%CI: 0.674 to 0.977). In addition, higher total number of comorbidities (OR: 0.932, 95%CI: 0.888 to 0.977), increased weight (OR: 0.992, 95%CI: 0.989 to 0.996), a higher HADS anxiety score (OR: 0.900, 95%CI: 0.885 to 0.915), smoking at baseline (OR: 0.755, 95%CI: 0.599 to 0.952), physical inactivity (OR: 0.822, 95%CI: 0.721 to 0.937), presence of heart failure (OR: 0.749, 95%CI: 0.610 to 0.919), and being single (OR: 0.761, 95%CI: 0.660 to 0.877) were other significant determinants. However, receiving CABG treatment was associated with better improvement (OR: 1.436, 95%CI: 1.108 to 1.861). Furthermore, the analysis was also adjusted for age, gender and deprivation.

Conclusions: The study identified specific baseline comorbid conditions of patients with new onset depressive symptoms including angina, diabetes, stroke, emphysema, and chronic back problems that were determinants of poorer mental health outcomes (HADS) following CR. Higher total number of comorbidities, increased weight, physical inactivity, smoking, presence of heart failure (HF) and being single were other determinants of a negative change in depression. These findings could help CR programs focus on tailoring the CR intervention around comorbidity, physical activity status, weight management and smoking cessation in patients with new onset depressive symptoms.

Abstract ID: S117

Title: Patients With Acute Myocardial Infarction Type 2 Were Less Likely To Get Referred To Cardiac Rehabilitation Than Patients With Acute Myocardial Infarction Type 1

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Lue Lao, MD, MPH, Anna Awolope, BS, Xuan-Khoi Dang, BS, Eddie Eabisa, BA, Francis Sitorus, BS, Armon Hosseini, MSN, Duncan Warren, BA, MA, Susan Stewart, PhD, Radhika Bukkapatnam, MD, MAS, and Javier López, MD, MAS.

Institution(s): University of California-Davis, Sacramento, CA, USA.

Introduction: Cardiac Rehabilitation (CR) improves mortality and re-hospitalization. However, CR is nationally underutilized. The current guidelines recommend patients with acute myocardial infarction (AMI) Type I to participate in CR. However, the guidelines are less clear on patients with AMI Type 2.

Purpose: To assess if there is a discrepancy in cardiac rehabilitation referral between AMI Type 1 and AMI Type 2 patients.

Design: Retrospective study and chart review.

Methods: Retrospective study on hospitalized patients at the University of California-Davis Medical Center from 6/1/2017 - 2/29/2020. SAS was used to compute p-value.

Results: From 6/1/2017 - 2/29/2020, there was a total of 12,554 hospitalized patients. Of this cohort, 2,993 patients had acute myocardial infarction (AMI) (1163 Type 1 and 1830 Type 2). Among AMI patients, 15.74% were referred to CR (24.80% Type 1 versus 4.30% Type 2 with P-value of 0.00). Patients with AMI Type 1 were mostly middle age, White, and received PCI intervention. Patients with AMI Type 2 were middle age and White but were less likely to get PCI. However, Patients with AMI Type 2 were more likely than AMI Type 1 to have co-morbidities (CHF, CAD, VR) and be re-admitted.

Conclusions: Patients hospitalized with AMI Type 1 were more likely to get referred to CR than patients hospitalized with AMI Type 2. Given that patients with AMI Type 2 had more co-morbidities and re-admissions, it may be reasonable to refer AMI Type 2 patients with cardia risk factors and cardiac co-morbidities to CR as they share the same benefits from CR as AMI Type 1 patients.

Abstract ID: S118

Title: Safety And Feasibility Of Early Resistance Training Following Median Sternotomy: The Safe-arms Study

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jacqueline Marie Stacey Pengelly, PhD, MClinExPhys, MTeach, BExSpSci1,2, Stuart Boggett, MRes3, Adam Bryant, PhD3, Alistair Royse, MD3,4, Colin Royse, MD3,5, Gavin Williams, PhD3, Doa El-Ansary, PhD1,3.

Institution(s):1Swinburne University of Technology, Melbourne, Australia, 2Charles Sturt University, Bathurst, Australia, 3University of Melbourne, Melbourne, Australia, 4Royal Melbourne Hospital, Melbourne, Australia, 5Outcomes Research Consortium Cleveland Clinic, Cleveland, OH, USA.

Introduction: Emerging evidence demonstrating the safety and feasibility of unweighted upper limb movements following median sternotomy has led calls for less restrictive sternal precautions to be adopted. However, current sternal precautions often discourage the use of the upper limbs, impacting physical and functional recovery following surgery. Cardiac rehabilitation resistance training tends to be implemented much more conservatively than the American College of Sports Medicine's guidelines recommend, which is likely attributed to the lack of evidence investigating its effect on sternal healing.

Purpose: To determine whether early post-operative upper-limb resistance exercises are safe and feasible in regard to sternal healing and pain, when commenced two weeks following cardiac surgeries via median sternotomy.

Design: Sub-study of a pilot randomised controlled trial, resistance training arm.

Methods: The study population was the resistance training intervention group of the Supervised Early Resistance study. Six upper limb exercises (seated row, shoulder pulldown, shoulder press, bicep curl, triceps dip and lateral raise), commenced at 20lbs for 12 repetitions, were assessed at 2-, 8- and 14- weeks postoperatively. Sternal edge motion in the lateral (coronal plane) and anterior-posterior (sagittal plane) directions were measured using real-time ultrasound at the mid and lower sternum, at 6 and 10 cm from the sternal notch, respectively. Maximal pain was recorded during exercise, using a Visual Analogue Scale (0-10). As movement >2mm may compromise bone healing, exercises were deemed safe if micromotion did not exceed 2mm. HREC ethical approval was granted by the Melbourne Health prior to commencement of recruitment (ID: 2017.266). Prospective ANZCTR registration (ACTRN12617001430325p).

Results: Sixteen post-sternotomy patients (n=15 males, n=1 female; 71.3± 6.2 years) who participated in the resistance arm of the SEcReT study were included. The resistance training intervention was commenced 14.5 days (IQR= 2.5 days) following surgery. Maximum sternal micromotion occurred in the coronal plane (lateral movement) in contrast to the sagittal plane (anterior-posterior movement) for all six exercises. The greatest median micromotion occurred during the bicep curl (median= 1.5mm; IQR= 1.9mm) at the mid-sternum in the lateral direction and the shoulder pulldown (median= 0.5mm; IQR= 1.1mm) at the lower-sternum in the anterior-posterior direction. Sternal pain at rest was 0/10 at all three time points and did not increase with exercise. Ultrasound inter-rater reliability for lateral micromotion (ICC=0.73; 95% CI=0.58-0.83) and anterior-posterior micromotion (ICC=0.83; 95% CI=0.73-0.89) was moderate-good.

Conclusions: Supervised early bilateral upper limb resistance training is safe and feasible with respect to sternal micromotion and pain, when performed on machines that move in one plane in a controlled environment. Sternal micromotion did not exceed 2mm during the bicep curl, triceps dip, lateral raise, shoulder pulldown, shoulder press and seated row at 2-, 8- or 14-weeks post-operatively. The safety on unsupervised home-based exercises are unknown.

Scientific Posters

Abstract ID: S119

Title: Do Incentive-Based Games Increase Cardiac Rehab Adherence

Track: Behavior Change

Author(s): Amber Capozzi, RDN, CSOWM, LD, CDE, Megan Hasse, Student Intern, Cathy Spranger, DrPH.

Institution(s): Seton Medical Center Austin, Austin, TX, USA.

Introduction: Cardiac Rehabilitation is considered the standard of care for optimizing health outcomes and preventing secondary heart events among cardiac patients. Yet, many cardiac rehab centers struggle with participant attendance, engagement and program completion.

Purpose: Research in other areas of health behavior change such as smoking cessation and weight loss has shown promising results utilizing incentive-based programs for motivation. However, little research exists as to how these strategies might work within a cardiac rehabilitation setting. The purpose of this project was to determine how these types of interventions might improve participant attendance and engagement within the cardiac rehabilitation setting.

Design: An incentive-based competition was developed in which outpatient cardiac rehabilitation participants were divided into teams based on class times. The competition was set to run for 6 weeks; starting on February 11, 2019. During this time, participants earned points by completing health behaviors such as 30 min. of cardiovascular exercise on non-cardiac rehabilitation days (1 point), attending nutrition education classes (1 point), and coming to all scheduled cardiac rehab sessions in a week (5 points). Participants were provided verbal and written instruction on the competition and encouraged to track their points and turn in to the program dietitian and/or program intern. Points were then tallied on a board on the cardiac rehab unit, so participants could track team progress. Encouragement and support was provided to participants throughout the duration the intervention period.

Methods: Cardiac rehabilitation attendance rates and nutrition education class attendance rates during the game period were collected and compared to attendance rates from a similar length of time starting on October 1st, 2018. Late November, December, and January were excluded from the study due to traditionally lower attendance rates during these months related to holidays and insurance changes.

Results: For the pre-intervention period starting on October 1st, 2018, average daily attendance to Cardiac Rehabilitation was 60.3%. For the intervention period starting February 11th, 2019, the average daily attendance rate was 60.9% which does not represent a statistically significant increase. However, attendance to nutrition education classes showed a 200% increase during the intervention period when compared to the pre-intervention period.

Conclusions: The primary finding of this intervention demonstrates that short-term, incentive-based programs might not affect over-all cardiac rehabilitation attendance but may impact participant engagement during enrollment. Further research is warranted to determine the most effective intervention and whether increased engagement during CR enrollment translates to increased long-term behavior change.

Abstract ID: S120

Title: Implementing A Fall Screening Program In An Outpatient Pulmonary Rehabilitation Clinic

Track: Pulmonary Rehabilitation & Medicine

Author(s): Deborah Bennett, M. Ed., RRT, Roland Abou-Nader, BS, RRT, Maureen Baidy, RRT, Chelsea Clayton, BS, RRT, Sandra Hooper, RRT, Mark Jackson, MPPA, RRT, Melissa Leidner, BS, RRT, Heidi Tymkew, DPT, MHS, PT, CCS.

Institution(s): Barnes-Jewish Hospital, Saint Louis, MO, USA.

Introduction: There is growing evidence that patients with chronic lung disease exhibit impairments in balance that can place them at an increased risk for falls. ATS/ERS recommend that balance be included as an outcome in pulmonary rehabilitation.

Purpose: Determine the feasibility of respiratory therapists implementing a fall-risk assessment in an outpatient pulmonary rehabilitation clinic.

Design: Retrospective chart review.

Methods: The staff participated in didactic and hands on training on the use of the Timed Up and Go (TUG) assessment in August of 2018 which was incorporated into clinical practice in September 2018. If a patient scored ≥ 13.5 seconds on the TUG then he/she was considered at risk for falls, and fall reduction interventions were implemented such as posting fall risk signs by the treadmill and recommending a referral to outpatient physical therapy for balance interventions. A retrospective chart review was conducted from September 2018 to July 2019. The following information was extracted from the medical chart: TUG scores, age and pulmonary diagnosis.

Results: The TUG fall risk assessment was completed on all patients (n=129) who attended pulmonary rehabilitation during this time period. The mean age was 59.6 ± 11.8 years and 33.3% of these patients were considered at fall risk with a mean TUG of 13.7 ± 6 seconds. In a subgroup of patients who recently received a lung transplant (n=86), the mean TUG was 14.4 ± 6.4 seconds with 40.7% of these patients being deemed at risk for falls.

Conclusions: The use of the TUG to screen for fall risk was successfully implemented into clinical practice in the pulmonary rehabilitation program at Barnes-Jewish Hospital demonstrating feasibility. More than a third of patients who participate in this program are at risk for falls while patients who are status post lung transplant are at a greater risk. A comprehensive balance intervention within the pulmonary rehabilitation program that incorporates specific balance activities to reduce fall risk may be beneficial for this patient population.

Abstract ID: S121

Title: An Exercise Prescription Method For Cardiac Rehab Using Submaximal Treadmill Test Data To Estimate Maximal Hearts Rates And Vo2 Max

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Daniel Moser, PhD1, David Warren Martens, MS, CEP2, Stephen Sloan, MD2.

Institution(s):1Temple University, Philadelphia, PA, USA, 2Doylestown Hospital, Doylestown, PA, USA.

Introduction: Abstract published in JCRP of 2018, showed submaximal treadmill testing (STT) produced a higher MET level and heart rate (HR) vs 6 minute walk test (6MWT). STT resulted in being a better tool for measuring improvement as well as being a better guide for exercise prescription. Maximal stress tests pre and post cardiac rehab are no longer performed, which adds challenges to using the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) and American College of Sports Medicine (ACSM) cardiac rehabilitation intensity of 40-80% maximum HR (HRmax). STT data can be used to calculate HRmax and VO2max and use the above guidelines.

Purpose: Assess efficacy of increasing aerobic capacity using a calculated HRmax and VO2max vs. using the 2017 STT data which used rate of perceived exertion (RPE) range of 11 to 13/14 out of 20. This study also assessed the difference in the prescribed upper and lower target HR range comparing the RPE method vs using a calculated HRmax.

Design: Heart rate and MET data using the RPE method (data collected in 2017 and 2018-2019) vs the calculated HRmax and VO2max method (data collected 2018-2019) using recommended intensities by AACVPR/ACSM. Heart rate and MET data stored at RPE of 11 and 13/14 and calculated HRmax and VO2max at 40%, 60% and 80% of HR reserve (HRR) and VO2 reserve (VO2R). The calculated HRmax and VO2max were determined to be 20% higher than the STT heart rate and MET level at RPE of 13/14.

Methods: The cardiac rehab staff were trained to identify the patients' RPE of 13/14, which was used to calculate the patients' HRmax and VO2max. Staff rated the RPE each stage of the STT by assessing the patient (questioning the patient, assessing changes in breathing, HR, signs of struggle, etc.). The calculated HRmax should never exceed the age predicted maximal HR (APMHR) by >10 beats. If the HRmax exceeded the APMHR, the previous stage STT data was used to calculate.

Results: The RPE method STT data of 2017 improved max METs (METmax) by 1.75 METs. The calculated HRmax and VO2max Method STT data increased METmax by 2.0 and increased exercise MET level by 1.9. The prescribed HR at RPE of 11 was 2.2 beats below calculated 40% HRR on pre STT and 5.7 beats below post STT. The prescribed HR at RPE of 13/14 was 8.7 below calculated 80% HRR. No negative outcomes resulted from this method.

Conclusions: Using the calculated HRmax and VO2max help standardize exercise prescription and allows staff to use the recommended range of 40-80% as well as the use of high intensity interval training. This method resulted in a slightly higher improvement to the pre/post MET variance. It is easier to calculate next 30 day MET goal as well as how to progress the upper range of the target HR.

Abstract ID: S122

Title: Implementation Of A Group Orientation In To Cardiopulmonary Rehabilitation To Reduce Patient Wait Time And Increase Staff Productivity

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Brenda Baird, RN, CCRP, Kelly Yellick, MSEP, CCRP.

Institution(s): Southern NH Medical Center, Nashua, NH, USA.

Introduction: Researchers have reported that following a cardiovascular hospitalization, the optimal time from discharge to a cardiac rehab evaluation is 14-17 days. Nakano et al reported that participation in cardiac rehabilitation decreases by 1% for every day that enrollment is prolonged beyond the date of discharge. Individual evaluations can create an inefficient work flow for staff productivity. Literature shows a decrease in required staffing hours by up to 44% by implementing group orientations.

Purpose: To determine the impact on patient wait times and staff productivity by implementing a group orientation of up to 4 patients in comparison to the traditional one to one evaluation into cardiopulmonary rehab. Research shows positive effects of group orientations.

Design: The idea of group orientations were first proposed to staff and the management development team. The department schedule was adjusted to accommodate patient group setting. We identified components that were repeated with every new patient. Patients continued to receive individual health assessments and exercise testing.

Methods: Patients are referred to cardiac or pulmonary rehab by hospitalization automatic referral or Dr. initiated referral. Our goal was to schedule an appointment within one to seven days of receiving a referral. A multidisciplinary team of an RN or RT an EP and RD worked together in an approx. 90 minute time block with a group of up to 4 patients. We created a mapping for a group evaluation structure and adapted materials for delivery in a group. A pilot program was implemented for pre and post outcome measures.

Results: In a comparison of patients seen over a three month time period, after implementation of group orientations there was a 48% decrease in wait time from the time a referral was received to an orientation appointment scheduled. In the same three month comparison the number of patients seen in evaluations increased by 67.5 %. Department hours were freed up to develop other programs.

Conclusions: Group orientation decreases wait time for patients enabling them to start their rehab sooner and optimizing recovery. The interaction through the group engages and motivates new patients and instills confidence with exercise. Group orientation promotes peer support and knowledge sharing while reducing repetitive work of staff.

Results: Participants who listened to success stories had significantly higher exercise adherence rates, t (126)=2.414, p =.017, and reported significant improvements in ESES, t (126)=−2.44, p =.016, compared to the control group. Groups did not differ significantly on OEE, t (126)=−1.6, p =.11. Results show effect of success stories on exercise adherence was not mediated by ESES, b =−.76, 95% CI [−4.13 to 2.29], or outcome expectations, b =−.60, 95% CI [−3.26 to 1.46].

Conclusions: Success stories were found to be effective in promoting exercise adherence in outpatient cardiac rehabilitation patients. Further research is needed to examine the length, dose, type, and content of success stories that can produce a significant impact on the patient health-related attitudes and behaviors.

Abstract ID: S123

Title: Pre And Post Fitness Testing In An Outpatient Cardiac Rehabilitation Program

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Brandon Hathorn, B.S., Jenny Adams, PhD.

Institution(s): Baylor Scott and White, Dallas, TX, USA.

Introduction: Use of pre and post-cardiac rehabilitation (CR) fitness tests to promote the development of personalized exercise prescriptions which is essential for an enhanced connection between clinicians and patients.

Purpose: To perform muscular strength, flexibility and mobility tests before and after completion of a CR program.

Design: In a prospective pilot study, data was collected from 39 patients (26 men and 13 women, aged 43 to 88 years) before and after completion of a CR program.

Methods: A force dynamometer and an inclinometer were used to obtain muscular strength, flexibility and mobility measurements before and after participation in a CR program. One-sample t-tests were used to compare pre and post measurement values.

Results: During pre-CR tests, subjects exerted (mean ± SD) force-pounds during: deadlift-112.2 ± 71.3, elbow flexion-35.3 ± 13.8 and extension-24.7 ± 9.1. Subjects achieved (mean ± SD) degrees of mobility during: shoulder flexion-139.6°± 36.4° and extension-44.3°± 21.9°, and active straight leg raise-72.6°± 20.6°. During post-CR tests, subjects exerted (mean ± SD) force-pounds during: deadlift-170.9 ± 96.2, elbow flexion-43.9 ± 15.9 and extension-29.6 ± 12.1. Subjects achieved (mean ± SD) degrees of mobility during: shoulder flexion-146.6°± 29.2° and extension-50.9°± 16.5° and active straight leg raise-75.6°± 18.1°. For the 6 fitness tests, p-values were as follows: (0.003, 0.013, 0.05, 0.35, 0.135 and 0.491, respectively).

Conclusions: The significant change in deadlift, elbow flexion and extension is an indication that the exercise prescription is effective regarding muscular strength but lacking regarding mobility and flexibility. Pre and post fitness testing is an effective way to quantify improvement in CR and may serve as a foundation to empower patients and clinicians through personalized patient care.

Abstract ID: S124

Title: Results Of The Pilot Cardiac Rehabilitation Program Of The Sant Joan De déU Hospital In Barcelona In Children And Adolescents With Congenital Heart Disease And Cardiomyopathy

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Ariadna Riera Castelló, MD, Andrea Lopez Erdoain, Physiotherapist.

Institution(s): Sant Joan de Déu Children's Hospital Barcelona, Barcelona, Spain.

Introduction: Thanks to technological and pharmacological advances, the survival of patients with congenital heart disease and cardiomyopathy has increased1. We are talking about a complex population, overprotected by family and professionals2 in terms of performing physical activity and this is reflected in the physical condition of children and adolescents, functional capacity and quality of life3.

1. https://doi.org/10.1186/s12887-018-1377-3 2. doi:10.1017/S1047951111002010. 3. https://doi.org/10.1007/978-3-030-16818-6_27

Purpose: Design of a pilot phase2 program for cardiac RHB in children and adolescents with cardiac pathology, assessing the improvement in functional capacity and quality of life, as well as adherence to sports activity and safety.

Design: Prospective study, pre post intervention analysis.

Methods: Patients with complex heart disease were included. Age between 7-21 years in clinical, hemodynamic and electrically stable condition. At the same time they had to have the capacity and commitment to come to the hospital 2d/week for the duration of the program. Consent to participate in the program. The protocol passed the ethics committee at our hospital. It is a multidisciplinary assessment by cardiology that is selected by the patients, by physical medicine and rehabilitation(PM&R), nutrition and psychology. Initial assessment and at the end of the group 3months duration. Cardiology assessment (electrocardiogram, echocardiogram and egoespirometry). PM&R assessment (musculoskeletal and neurological physical examination, inspiratory and expiratory strength assessment, peripheral strength lower and upper extremities and six minute walk test). Nutrition assessment (Impedanciometry and food record). Psychology assessment (assessment and quality of life questionnaires) During the program they conduct 2 sessions monitored by live telemetry and a day of home based pulse rate monitor. Each session has a 60-minute session with regular structure (warm up, respiratory muscle work, and flexing ribcage, aerobic exercise and relaxation). At the session physiotherapist and rehabilitation doctor were present for live monitoring and any possible incidents.

Results: 6patients (1girl and 5boys). Mean Age: 17.3years. Base pathology: 3Fallot thetralogy- 3DAI. 5 of them with Functional capacity 1 NYHA. 4 of them slight restriction spirometric pattern. Inicial ergoespirometry results: Test duration 569.6seconds(9.49 min) all stop by muscle fatigue. Vo2peak 26ml/kg/min (65.1% of theoretical). AT 20ml/kg/min(67.1% theoretical). Pulse O2 11.1(78.6%of theoretical). They realized a mean of 17.16 sessions of 24 (73.3%). Increase of 133.3m in the test of the gait of 6 minutes, increase of 26.1 mmH2O in PIM. No incidents (no emergency consultations, no admissions, no surgeries) during the program.

Conclusions: From the data obtained our patients show an improvement in quality of life and functional capacity. We consider our intervention safe. However, there is still a lot of work to be done on adhering to these programs, both face-to-face and home.

Abstract ID: S125

Title: Don't Miss A Beat: Refer More Hearts

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Brittany Henderson, MS, BSN, RN1, Kelly A. Gallagher, MSN, RN-BC, NE-BC1, Lisa Lozzo, BSN, RN-BC1,2.

Institution(s):1Penn Medicine Chester County Hospital, West Chester, PA, USA, 2Chester Country Hospital, West Chester, PA, USA.

Introduction: Cardiac rehabilitation (CR) has been shown to decrease all-cause mortality by 20-30%, improve quality of life, decrease return to work time, and reduce readmission by up to 30%. Despite the benefits, the national average of participation is less than 30%. Eligible diagnoses include myocardial infarction, stable angina, cardiomyopathy, systolic heart failure, transplant, valve replacement or repair, bypass surgery, and percutaneous coronary intervention.

Purpose: To increase the referral rate for CR by educating clinicians about program offerings and eligibility criteria.

Design: Prior to implementation of this project, the number of patients referred to and starting the CR program was explored. Cardiovascular nurse navigators began to attend daily inter-professional rounds. During rounds, CR was discussed, eligible patients were identified, and questions were answered. In addition, staff was invited to attend educational sessions to increase awareness and knowledge of CR. Post implementation, the data displaying the number of patients referred and starting CR was reexamined.

Methods: The PICO method was used to develop the clinical question: will educating providers and nursing staff (clinicians) about benefits of CR and criteria for patient eligibility increase the number of patients referred? Literature revealed importance of CR in outcomes and readmission rates. The literature also supported education in small groups, in short bursts on the unit. Pre-data was collected from the team's hospital chest pain registry and the CR department quality data.

Results: In December 2018, education for clinicians was initiated and referrals improved from a previous 63% to an impressive 100%. On average in 2018, 66 patients started the program per quarter. The first and second quarter of 2019 demonstrated 85 and 82 patients, respectively, started the CR program, resulting in a 28% and 24% increase. This confirms that the education initiative directly impacted patient referrals and number of program participants. Increasing patient participation reduces 30-day readmission rates, which at our institution averages $13,000 per patient.

Conclusions: With the success of this initiative, the nurse navigators will continue to attend daily inter-professional rounds to further identify eligible patients. We can consider hosting additional educational sessions to increase the awareness of the bedside clinicians who could further promote our CR program. Additionally, this initiative could be taken to the other Penn Medicine entities, such as Pennsylvania Hospital, Lancaster General, or Princeton Hospital to enhance CR referrals at their locations.

Abstract ID: S126

Title: Depressive Symptom Benchmarking Within Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): William A. Middleton, BS, Patrick Savage, M.S., Sherrie Khadanga, MD, Jason Rengo, M.S., Jeffrey S. Priest, PhD, Philip A. Ades, MD, Diann E. Gaalema, PhD.

Institution(s): University of Vermont, Burlington, VT, USA.

Introduction: Persons with depression are more likely to experience a cardiac event. Higher levels of depression are also associated with lower rates of participation in Phase 2 Cardiac Rehabilitation (CR) and subsequent increased risk of mortality. Assessing depression symptomology is a performance measure required for AACVPR program certification, but presently there are no normative values for programs to benchmark outcomes. Describing changes in depressive symptoms within CR provides benchmarks for program comparison and will assist in identifying vulnerable individuals who are at elevated risk of the negative consequences of elevated depressive symptoms.

Purpose: This investigation establishes entrance, exit, and change in depression scores during CR across demographic and clinical variables. This study establishes benchmarks for changes in depressive symptoms and identifies subpopulations at higher risk of depression in CR.

Design: Prospective, observational.

Methods: Data were drawn from patients enrolled in Phase II of the University of Vermont Medical Center Cardiac Rehabilitation program between January 2011 to July 2019. Depression was benchmarked across clinical and demographic variables utilizing the Geriatric Depression Scale Short Form (GDS-SF; none:0-4, mild:5-8, moderate:9-11, severe:12-15) and Patient Health Questionnaire (PHQ-9; none/minimal:0-4, mild:5-9, moderate:10-14, moderately-severe:15-19, severe:20-27). Entrance, exit, and change in depressive symptomology scores were observed through score means, analyzed via ANOVA, and severity level frequencies analyzed with Chi Square and McNemar's test. For analyses by clinical and demographic variables age was dichotomized as <65 vs. ≥65yr., and VO2peak divided into quartiles.

Results: The original cohort included 2443 patients of which 1242 individuals completed 9+ sessions. Among them mean depression scores were generally low (PHQ-9=4.21+−5.47, GDS-SF=3.02+−2.82) and lower than those who did not complete at least 9 sessions (PHQ-9=5.32+−5.47, p <.01 GDS-SF=3.60+−2.82 p <.01). At CR entry, within those completing at least 9 sessions, prevalence of mild or worse levels of depression was 31.4% and 20.1% on the PHQ-9 and GDS-SF, respectively, with the PHQ-9 identifying significantly more patients as having at least mild symptoms (p <.01). Patients with higher symptoms on the PHQ-9 at entry were younger (Chi2 (4)=20.4, p <.01, more likely to be female (Chi2 (4)=20.6, p <.01), attended fewer sessions (Chi2 (8)=36.6, p <.01), and had lower VO2 (Chi2(12)=22.8, p =.03). Of those with at least mild symptoms, the majority decreased depression severity by at least one level by exit (PHQ-9=73.4%, GDS-SF=72.0%). Improvement in symptoms did not differ by screener type, either within the whole population, or within those who are 65+ (p >.05).

Conclusions: Our results provide benchmarks of depression scores for patients in CR and identify younger patients and women as higher risk subpopulations. Future work should compare depression screeners on ability to describe clinically significant depression and changes in depression, within CR.

Abstract ID: S127

Title: Psychosocial And Cognitive Changes Following A Cardiac Rehabilitation Qualifying Event In A Vulnerable Population

Track: Behavior Change

Author(s): Diann Gaalema, PhD, Sarahjane Dube, MS, Hypatia Bolívar, PhD, Katharine Mahoney, BS.

Institution(s): University of Vermont, Burlington, VT, USA.

Introduction: Participation in cardiac rehabilitation (CR) following a qualifying cardiac event is often associated with subjective improvements in psychosocial and cognitive functioning. However, most of these examinations have been in general CR populations and have not examined how changes persist after CR. Within cardiac patients, those of lower socio-economic (SES) are at higher risk for psychosocial and cognitive difficulties and are under-studied within the context of CR.

Purpose: This investigation examines short-term and long-term changes in psychosocial and cognitive characteristics in a sample of lower-SES patients following a CR-qualifying event.

Design: Secondary analysis of a randomized clinical trial.

Methods: Patients who were eligible for CR and had state-supported insurance (e.g. Medicaid) were approached for inclusion in a randomized clinical trial with the aim of increasing CR attendance among lower-SES patients. As part of this trial, measurements of psychosocial and cognitive characteristics were collected prior to CR attendance and then 4 and 12 months later, independent of CR completion (attending ≥30 of 36 sessions). Variables collected included self-reported anxious/depressed symptoms (ASEBA), total problems (general psychopathology/maladaptive behaviors; ASEBA), executive function problems (higher-order cognitive abilities, BRIEF), and overall health status (EuroQoL). Repeated, mixed model ANOVAs were used to test for changes over time and for interactions with CR completion.

Results: Of the 130 patients randomized to the main trial 122 were included in this secondary analysis. Of these, 61 completed CR. At intake, elevated scores associated with clinically significant impairment were seen in 27% of the sample for anxious/depressed symptoms, 46% for total problems, and 24% for problems with executive function. Main effects of time were found for total problems (p=0.0267) and executive function problems (p=0.0159), but not for anxious/depressed symptoms. Specifically, total problems and executive function problem scores improved from intake to 4 months (p=0.020 and p=0.015, respectively) and these gains were maintained at 12 months (p=0.986 and p=0.917, respectively). No interaction effect of CR completion with time was observed for any of the dependent variables (ps>0.05). Additionally, the changes in psychosocial and cognitive characteristics were not correlated with self-rated improvements in overall health status.

Conclusions: Lower-SES patients are a high-risk group facing unique barriers to accessing care that may include higher psychosocial and cognitive burdens. While anxious/depressive symptoms persist over time regardless of participation in CR, subjective reports of total problems and problems specific to executive function appear to improve over time, although still independent of CR participation. CR programs will need to continue to understand the unique challenges posed by psychosocial and cognitive problems to adapt and better serve these vulnerable populations.

Abstract ID: S128

Title: The Effects Of A Goal Setting And Counseling Intervention On Attendance In A Cardiac And Pulmonary Rehab

Program Track: Behavior Change

Author(s): John Christopher Cole, BA, MS1, Joseph D. Ostrem, PhD2.

Institution(s):1Maria Parham Health, Henderson, NC, USA, 2Concordia Univeristy St. Paul, St. Paul, MN, USA.

Introduction: Cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs are effective at improving outcomes in cardiovascular (CVD) and respiratory populations. CR and PR also share many other intersecting characteristics. Despite their effectiveness at improving outcomes in CVD and respiratory populations, CR and PR programs experience low attendance rates nationwide. Strategies aimed at improving attendance in both CR and PR programs require investigation.

Purpose: The study aimed to improve attendance of a CR and PR program by utilizing a brief, no cost behavioral intervention (goal setting, problem-solving and motivational interviewing) compared to a retrospective control group (RCG). Patients in the behavioral intervention group (BIG) were hypothesized to attend CR or PR significantly more than the matched RCG. A secondary hypothesis was that patient performance improvements would be correlated with their subjective rating of goal improvements.

Design: A rolling recruitment of participants into a 12-week rehabilitation program occurred. The BIG consisted of 32 patients (7 PR and 25 CR). The RCG group consisted of a randomized matched pairs design based on age, gender, and principle diagnosis of a retrospective database. The BIG received a weekly behavioral intervention, with each exposure lasting <3 minutes. Patients in the BIG were asked to rate their perceived progress toward their goal at each exposure utilizing a 1-5 Likert scale. Performance was assessed via individual change in METs over the 12-weeks.

Methods: The mean attendance rate for BIG and RCG was analyzed using an independent t-test. This same method was used to analyze mean attendance rates of BIG and RCG subgroups. The relationship between change in performance and Likert rating was analyzed for within group differences and between groups via an ANOVA and linear regression analysis.

Results: A non-statistically significant difference was observed between the mean attendance rates of the BIG and RCG (p=0.09). Subgroup analysis revealed there to be a non-significant difference between attendance in the BIG CR subgroup and RCG CR subgroup (p=0.15). Analysis of the BIG PR subgroup and RCG PR subgroup revealed a non-significant difference in mean attendance rates (p=0.42). ANOVA analysis revealed a non-significant difference between Likert ratings and performance improvement (p=0.81). Linear regression analysis revealed a correlation (r=.78) between patient's change in performance and Likert scale ratings.

Conclusions: The differences between the BIG and RCG were not statistically significant but suggested a trend toward this behavioral intervention improving attendance for CR and PR programs. This study illustrated that the time commitment of interventions can be minimal and effective. Subgroup analysis revealed the BIG CR subgroup witnessed a greater improvement compared to the BIG PR subgroup. This may illustrate differing population responses to behavioral interventions such as goal setting, problem solving and motivational interviewing. A correlation between Likert scale rating, attendance and performance was witnessed, implying that one's perception of progress may factor into adherence and performance.

Abstract ID: S129

Title: A Novel Bai Factor Structure In Patients With Cardiovascular Disease

Track: Behavior Change Author(s): Rosemarie Basile, Ph.D., Katherine Russell, Ph.D., Meghan Leghuga, M.A., Anne Marie McDonough, BSN, MPH, FACHE, Anita Solan, Ph.D., Seleshi Demissie, DrPH, Janelle Eloi, Psy.D.

Institution(s): Staten Island University Hospital, Staten Island, NY, USA.

Introduction: Anxiety is common in cardiovascular disease (CVD), affecting up to 25% of patients (Celano, 2016). Elevated rates of anxiety have been associated with poor adherence to treatment, including cardiac rehabilitation (CR), and negative outcomes. The Beck Anxiety Inventory (BAI) is widely used to assess anxiety across patient groups (Beck et al., 1988), and previous work has shown differences in the components of anxiety by population. Yet, little research has focused on the unique presentation of anxiety symptoms in patients with CVD. Clark et al. (2016) found that a four-factor BAI model consisting of cognitive, autonomic, neuromotor, and panic components best fit their sample of patients receiving CR. Given the BAI's heavy focus on psychophysiological symptoms, and past observation that atypical cardiac symptoms are often found in patient with CVD and co-morbid anxiety, a greater understanding of the characters of anxiety in cardiac patients can improve diagnostic sensitivity and accuracy.

Purpose: This study sought to explore the factor structure of the BAI in patients enrolled in a phase II CR program.

Design: In this retrospective cohort study, the sample included adults who recently experienced a cardiac event and were enrolled in a phase II CR program. Each completed the BAI and other measures upon enrollment into the program.

Methods: Confirmatory factor analyses (CFA), based on Clark et al. (2016), were run on BAI responses (N=105). An exploratory factor analysis (EFA) was conducted to investigate factor structures that more accurately identified anxiety symptom profiles in patients receiving CR.

Results: CFA results did not support the previously proposed 4-factor model. EFA yielded a novel three-factor model of Fear, Autonomic, and Vestibular explaining 85% of the variance and adequate fit (KMO=.77; BTS Approx. χ2=130.41, p<.0001).

Conclusions: Results suggest a three-factor model more sufficiently captures anxious symptoms in patients with CVD, and offers an alternate approach in interpreting the BAI. Psychological distress makes completion of CR difficult, utilizing advanced personalization in interpreting symptoms on the BAI in CVD can aide in risk stratification, management and secondary prevention.

Abstract ID: S130

Title: Improving Access And Participation To Cardiac Rehabilitation Through Group Evaluations

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Bari DiUbaldo, M.Ed, CCRP, Tara Encarnacion, MS, M.Ed, ACSM-CEP.

Institution(s): Lehigh Valley Health Network, Allentown, PA, USA.

Introduction: The Millions Heart initiative aims at prevention of one million acute cardiovascular events by 2022 with a national goal of 70% participation in cardiac rehab for eligible patients. Access to timely appointments for evaluation into a cardiac rehabilitation program is one method that can increase a patient's participation and success in cardiac rehab. Group evaluations have been one way in which we can improve access and get eligible patients started sooner following their cardiac events.

Purpose: To set established group evaluations in our weekly schedule in order to improve on our departments time to consult from 21 days or more to under 7 days. Benefits and barriers to group evaluations must also be evaluated and adjusted to help improve the efficiency.

Design: Evaluation Study to determine the benefits and barriers of the group evaluations in order to improve the time to consult and the efficiency.

Methods: Our department has conducted 169 group evaluations which have consisted of 2 person, 3 person and 4 person groupings. Staff performed different approaches to the group evaluation process in order to help stream line general information and education as well as to be able to discuss HIPPA relevant information in private. A power point presentation including risk factor education along with general instructions for the cardiac rehab program was created. This serves as the introduction to the program as well as an introduction to staff. Cardiac outcome tools were given to patients to complete upon their arrival. This serves to help a patient remain engaged while staff completes a one- on one session with other patients. A recent upgrade to the EPIC charting system allows us to go from same day charting to a pre chart option to complete objective information prior to the evaluation. After completion of the one on one evaluation additional staff is available to complete the exercise portion of the assessment while the patient completing the paper work is now meeting with staff.

Results: After completion of multiple group evaluations staff was more aware of different approaches that are needed between the 2-3 person group evaluation and the 4 person group. Staffing needs were higher with the 4 person group needing at least 2-3 people to complete efficiently where the 2 -3 person group needed 1-2 staff members. Patients needing interpretation were limited to the 2 person grouping in order to meet their needs due to language barriers. Pre charting evaluations allows staff to reallocate time during the evaluation in order to complete the appointment in approximately an hour.

Conclusions: Group evaluations have been an effective tool in improving timely access to our cardiac rehab program. Subjective information from treatment providers regarding staffing and patient issues that may arise are an important factor to utilize in order to perform the group evaluations more efficiently and more frequently.

Abstract ID: S131

Title: Implications Of Urban Intervention: Modifications For Rural Cardiac Rehabilitation

Track: Behavior Change

Author(s): Kelly L. Wierenga, PhD, RN1, Jody Hill, RN, NE-BC, CCRN2, Marci Pittman, BSN, RN-BC2, Ronald Bridges, ASN, RN2, Kelly Freeman, MSN, AGPCNP-BC, DipACLM1, Shirley M. Moore, PhD, RN, FAAN3.

Institution(s):1Indiana University, Indianapolis, IN, USA, 2Indiana University Health, Bedford Hospital, Bedford, IN, USA, 3Case Western Reserve University, Cleveland, OH, USA.

Introduction: Cardiac rehabilitation is important to improve physical activity and reduce cardiovascular disease risk factors among people who have experienced a major adverse cardiac event. Many cardiac rehabilitation interventions do not address emotion regulation nor the unique needs of rural populations. Our team designed a new emotion regulation cardiac rehabilitation intervention to improve self-management of exercise and nutrition. Yet, given that this intervention was developed in an urban setting, changes are necessary to adapt to the needs of rural populations.

Purpose: The purpose of this study was to identify changes needed to expand an emotion regulation cardiac rehabilitation program to a rural setting.

Design: We used a prospective qualitative analysis of content with a directed approach to assess the feasibility of the emotion regulation intervention in an urban cardiac rehabilitation setting. We then conducted a literature review to identify rural population needs and assess the potential for scalability.

Methods: We interviewed 14 urban cardiac rehabilitation patients who had enrolled in 5-weekly 1-hour intervention sessions. Using a modified guide for assessing feasibility, we coded interviews for acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited efficacy. A literature search was conducted screening titles and abstracts for content including interventions in rural cardiac patient populations. Findings from the literature review were compared to those identified in the feasibility analysis and used to identify changes needed to expand the emotion regulation intervention to a rural setting.

Results: The average age of participants was 61 years (SD 7). Seventy-one percent were men, and 71% completed at least some college. According to participants, strengths of the emotion regulation intervention included acceptability, demand, adaptation, integration, and implementation. Areas that needed improvement were practicality, expansion, and efficacy. Upon analyzing the results from the interviews and literature, the emotion regulation intervention needed to be adapted in practicality, expansion, and efficacy for scalability to a rural setting.

Conclusions: Our study yielded three insights. First, practicality was a concern. Access to resources is a primary concern for rural patients. With regard to cardiac rehabilitation in rural settings, there are difficulties with transportation, limited cell and internet coverage, and poor access to indoor and outdoor physical activities. Given the concerns about practicality, ensuring adequate resources will be important for expanding cardiac rehabilitation programs that target emotion regulation to rural settings. Second, expansion, as it relates to the generalizability of intervention strategies, needs to be addressed. With urban participants reporting difficulties expanding content to individual needs, particular attention should be directed toward individualizing content while also incorporating modifications for rural populations. Finally, concerns over the efficacy of the intervention and its ability to make a lasting difference suggest that an increased dose may be necessary for both urban and rural populations.

Abstract ID: S132

Title: Effect Of Resistance Exercise With 3 Different Intensity On Baroreflex Sensitivity Function In Health Men

Track: Physical Activity/Exercise

Author(s): Akira Shōbo, Ph D1,2.

Institution(s):1Bunkyo GakuinUniversity, fujimino, Japan, 2Graduate School of Health Care Science, Bunkyo Gakuin University, Tokyo, Japan.

Introduction: Baroreflex sensitivity (BRS) has been known to decrease in patients with hypertension, diabetes and ischemic heart disease. BRS has been found to be a predictor of sudden death in individuals having had a myocardial infarction according to the cardiovascular trial database ‘Autonomic Tone and Reflexes After Myocardial Infarction’. Baroreflex activation therapy has recently focused on BRS function to improve autonomic nervous activity, cardiac function and exercise tolerance in patients with heart failure.

Purpose: The aim of this study was to examine the effect of resistance exercises on BRS function using three different intensities in healthy men.

Design: Experimental research.

Methods: The participants were 27 healthy men with a mean age of 19.9 years, mean body mass of 63.4kg, mean height of 171.7cm and a body mass index of 21.5kg/m2. The arm of the Leg Extension machine was placed on the distal end of the tibia for resisted quadriceps exercise and analogue loaded. The maximum strength of the left and right quadriceps femoris was defined as one-repetition maximum (1RM). The percentage of 1RM was calculated from the number of excursions per maximum repetitions. The participants performed 20 alternate knee extensions in sitting with a 20, 50 and 80% 1RM with each excursion consisting of a 5-sec contraction and 5-sec rest. Autonomic nervous activity and BRS were recorded during the exercise using impedance cardiography. At the same time, heart rate, systolic BP, diastolic BP, stroke volume, cardiac output and total peripheral resistance were measured. From the continuous R-R series taken of the heart rate, spectral powers were quantified for the regions of high (HF) and low frequencies (LF). Also, LF/HF of the R-R interval variability power ratio and HF normalized unit (HFnu) were calculated as indicators for sympathetic and parasympathetic nerve activity, respectively. BRS was calculated by the spontaneous sequence method. Statistical analysis was carried out for changes in BRS before and after exercise. Comparison among the three intensities was made using the Shapiro-Wilk test. Wilcoxon's ranking reconciliation was determined, for changes that did not follow normal distribution. This study was approved by the Bunkyo Gakuin University Ethics Committee (Approval No. 2017-0042).

Results: For all three exercise intensities, post-exercise sympathetic nerve activity was significantly decreased (20%: P=0.002, 50%: P=0.0001, 80%: P=0.001), but parasympathetic nerve activity was significantly increased (20%: P=0.0001, 50%: P=0.0001, 80%: P=0.0001). There was a significant increase in post-exercise BRS for 20% 1RM (P=0.046), but no significant change for 50% (P=0.4) and 80% 1RM (P=0.068).

Conclusions: Although no change occurred in BRS at 50% 1RM, it is possible that it may have increased at 80% 1RM with a larger number of subjects. Low intensity resistance exercise may play a role in improving BRS function. Further studies need to be carried out on cardiac patients.

Abstract ID: S133

Title: Influence Of Muscle Quality Versus Quantity On Health Related Quality Of Life In Women With Heart Disease

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Helen L. Graham, PhD, MSN, RN-BC, CNS, FAACVPR, Melissa J. Benton, Phd, RN, FACSM, FGSA.

Institution(s): University of Colorado Colorado Springs, Colorado Springs, CO, USA.

Introduction: Cardiac rehabilitation guidelines include resistance exercise for maintenance of muscular strength (quality). Maintenance of muscle mass (quantity) is not routinely considered, although muscle influences functional independence and mobility. Moreover, inflammation that accompanies heart disease has a catabolic effect that can result in muscle loss and sarcopenia, which in turn can influence strength, mobility, and health-related quality of life (HRQOL).

Purpose: The purpose of this study was to evaluate the relationship between lean (muscle) mass, strength, mobility, and HRQOL in women with heart disease.

Design: This was a cross-sectional, observational study.

Methods: Twenty-eight women (74.4 ± 1.7 years) who self-reported a diagnosis of heart disease using the U.S. Behavioral Risk Factor Surveillance System definition (“heart disease,” “coronary heart disease,” “heart attack,” “myocardial infarction,” “angina,” or “other heart problems”) completed one-time measurement of lean mass (multi-frequency bioelectrical impedance analysis), upper body strength (Arm Curl test), lower body strength (Chair Stand test), mobility (Timed Up and Go test), and HRQOL (RAND-36). Lean mass index (LMI) was calculated using the formula: lean mass (kg) ÷ height2 (m2), and sarcopenia was defined as LMI <15.0 kg/m2. Participant characteristics were analyzed using descriptive statistics and relationships were identified using Pearson correlation analysis. For consistency between analyses, Pearson r-values for Timed Up and Go correlations were converted to positive numbers so all positive correlations indicate better or greater strength, mobility and HRQOL.

Results: Overall, body mass was 68.4 ± 2.1 kg (43.4 ± 1.2% fat and 56.6 ± 1.2% lean), body mass index (BMI) was 27.4 ± 0.9 kg/m2, and LMI was 15.3 ± 1.5 kg/m2. Thirty-nine percent (n=11) met the criteria for sarcopenia. Neither age nor time since diagnosis (8.7 ± 2.1 years) were related to any variable. Lean mass relative to body mass (LM%) or relative to height (LMI) was not related to strength, although it was related to mobility (LM%: r =0.54, p <0.01; LMI: r =−0.38, p <0.05). Furthermore, LMI was negatively related to both overall HRQOL (r =−0.44, p <0.05) and its physical function sub-scale (r =−0.57, p <0.01), although LM% was positively related to the physical function sub-scale (r=0.44, p <0.05). In contrast, mobility was positively related to overall HRQOL (r =0.38, p <0.05) and lower body strength was positively related to perceived changes in health over the past year (r =0.41, p <0.05). In addition, upper and lower body strength, and mobility were positively and significantly (p <0.05) related to the physical function sub-scale of HRQOL (r =0.39, r =0.38, and r =0.46, respectively).

Conclusions: In this group of older women with heart disease, HRQOL was positively related primarily to strength and mobility, rather than lean mass. Based on our findings, muscle quality (measured as strength and mobility) exerts a greater influence on HRQOL and its physical function sub-scale than muscle quantity (measured relative to body mass and height). The current focus on muscle strength during cardiac rehabilitation is supported by the relationships we have identified.

Abstract ID: S134

Title: Women Show Equal Benefit From Intensive Cardiac Rehab

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Sydney Suzanne Stripling, MS, Seth Boynton, LCSW, Holly Konrady, MEd, RYT, Rachael Swartz, RD, LD, Jennifer Joseph, RN, BSN, Michael Perretta, RN, Jeffrey Soukup, PhD.

Institution(s): New Hanover Regional Medical Center, Wilmington, NC, USA.

Introduction: Data demonstrating improvements in cardiovascular (CV) risk, health-related quality of life (HR-QOL), and functional capacity are well-established for men following outpatient cardiac rehab (CR). Yet much less is known about how outpatient CR impacts women. Furthermore, limited data has been reported on the effect of intensive cardiac rehabilitation (ICR). To that end, we set out to compare gender differences in program outcomes following ICR.

Purpose: To compare changes in cardiovascular (CV) risk, HR-QOL and functional capacity between men and women following 9-weeks of outpatient ICR.

Design: Forty subjects (20 male, 20 female) who participated in a 9-week ICR program and completed all phases of pre- and post-program testing to include blood lipids, HR-QOL (SF-36) and the six-minute walk test (6MWT) were placed into two groups (MALES and FEMALES) for comparison of outcomes.

Methods: A priori power analysis modeling with a moderate effect size and a Power of .90 using two groups with repeated measures ANOVA, revealed that 40 subjects were needed. Female subjects were selected first based on completeness of data with identity blinding. Then male subjects were selected using age and intervention-matching to their female counterparts. Independent samples t-tests were used to determine group differences at baseline while a 2×2 repeated measures ANOVA was used to determine differences between groups over time. All statistics were performed using SPSS version 26 (IBM, Armonk, NY). Significance was set at p<0.05.

Results: Men were significantly taller than women, and although men were heavier, there were no significant differences in weight or BMI. Both groups were comprised of 15 subjects who had percutaneous coronary interventions, 1 subject who had coronary artery bypass grafting, and 4 subjects with stable angina. Males had a higher occurrence of myocardial infarction than women (MALES = 11 vs. FEMALES = 5). During CR, adherence to program guidelines and overall attendance were similar among groups. At baseline, there were no significant differences between groups for weight, cholesterol (CHOL), low-density lipoproteins (LDL), high-density lipoproteins (HDL), triglycerides (TRIG), systolic blood pressure (SBP), diastolic blood pressure (DBP) or mental composite HR-QOL. Women had a significantly lower six-minute walk distance (6MWD) and physical composite HR-QOL at baseline and the difference remained following ICR. There were significant reductions in weight, CHOL, LDL, HDL and TRIG following ICR for both groups while mental composite HR-QOL, physical composite HR-QOL, and 6MWD significantly increased. Both SBP and DBP were decreased following ICR but the reduction did not reach statistical significance.

Conclusions: The beneficial changes that result from ICR are conferred to both men and women equally when participation and adherence are similar.

Abstract ID: S135

Title: Behavioral Activation For Depression In Cardiovascular Rehabilitation: A Case Study

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Brooke R. Leonelli, M.A.1, Tyler Kuhn, M.A.1, Heather Y. Neifert, B.A.1, Richard Josephson, M.S., M.D.2, Joel W. Hughes, Ph.D.1.

Institution(s):1Kent State University, Kent, OH, USA, 2Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA.

Introduction: Individuals with cardiovascular disease (CVD) have higher rates of depression than the general population. Patients with comorbid CVD and depression experience significantly worse outcomes in secondary prevention programs, such as phase-II cardiovascular rehabilitation (CR), compared to non-depressed patients.

Purpose: This case study demonstrates the use of behavioral activation (BA), an empirically-based treatment, for comorbid depression and CVD.

Design: Treatment consisted of five psychotherapy sessions over nine weeks. In session one, psychoeducation was provided on the high rate of depression in CVD and causes of depression, including loss of pleasant activities. During session two, the client arranged for ongoing therapy with the first author under the last author's supervision. Treatment in this and subsequent sessions sought to increase the client's engagement with naturally reinforcing experiences by identifying behaviors aligned with her values. Smoking cessation support and stress management were also provided.

Methods: The client, Dana, was a 51-year-old married White woman status post-myocardial infarction (MI). She reported a history of recurrent depression and a current sertraline prescription. At intake, she was smoking one cigarette daily and vaping a 3% nicotine solution, and smoked one pack daily before the MI. Dana was referred for therapy with the last author in her third week of CR after scoring a 26 (severe depression) on the Patient Health Questionnaire-9 (PHQ-9). She reported sadness, anxiety, fatigue, guilt, anger, anhedonia, irritability, as well as poor sleep and appetite. She reported loss of pleasant activities due to new limitations (e.g., decreased work hours), increased interpersonal difficulties, and difficulties with smoking cessation. She appeared tearful, stressed, and irritable. She consented to ongoing therapy with a masters-level clinician in the Cardiopulmonary Behavioral Medicine Practicum (i.e., the first author).

Results: At the end of treatment, Dana's PHQ-9 score had decreased to a 2 (minimal depression). She reported greater engagement in activities. Her values of work and relationships provided target behaviors, and she reported enjoyment from completing assigned activities. She also reported increased interpersonal effectiveness, feeling happier, “loving” her job again, and engaging in stress-management techniques more regularly. At termination of treatment, Dana reported continued struggles with smoking. However, she endorsed a high motivation to quit, set a new quit date, and adhered to preparatory plans, indicating that stress-management skills from therapy made her more ready to quit. Two weeks after termination, Dana called the first author to report she had stopped smoking.

Conclusions: A brief, targeted intervention for depression in CR is feasible. Masters-level mental health professionals can provide BA. The combined treatment effects of BA and CR preclude attributing the result to BA alone, as CR is also an effective treatment for depression. Future research should examine the extent to which BA can be abbreviated in CR settings while remaining effective.

Abstract ID: S136

Title: Post Event-Cardiovascular Risk Perception Survey: In Cardiac Rehabilitation Patients

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Melanie Faulkender, RN1, Kelsey Loy, MS, RCEP1, Kathy Prue-Owens, PhD, RN, CCRN2, Helen Graham, PhD, RN-C, CNS, FAACVPR2, Keston Lindsay, PhD, CSCS2, Mythreyi Ramesh, BSN-studen3.

Institution(s):1Penrose-St.Francis Health Services, Colorado Springs, CO, USA, 2University Colorado Colorado Springs, Colorado Springs, CO, USA, 3Helen and Arthur E Johnson Beth-El College of Nursing and Health Sciences, Colorado Springs, CO, USA.

Introduction: Cardiovascular Disease (CVD) remains the number one killer of Americans in the United States. Efforts to decrease CVD risk factors have been extensive. Cardiac rehabilitation (CR) reduces morbidity, improves quality of life and appears to facilitate secondary prevention. However, perception of CVD post-event in CR patients is unknown.

Purpose: The purpose of this study was to determine patients' perception of risk after having a recent hospitalization for coronary artery disease, myocardial infarction, coronary artery bypass surgery, stable/unstable angina and stent/percutaneous transluminal coronary angioplasty (PTCA). If there is perceived risk, then a major benefit would be to implement individual heart healthy changes based on perceived risk for CVD during CR.

Design: Patients enrolled in traditional cardiac rehabilitation phase II or intensive cardiac rehabilitation at Penrose-St. Francis Health Services (PSF) that are diagnosed with CAD, MI, CABG, stable angina, or PCI were invited to participate. Participants answered a questionnaire to determine their views regarding CVD risk perception. The questionnaire was based on review of the literature, the Health Belief Model and known cardiovascular risk factors. The items addressed participants' chances of having the following conditions: high blood pressure (HBP), high cholesterol (HC), diabetes (DM), overweight (OW), and demographic predictors of heart disease [age/gender (AG), ethnicity (ET), family history (FH), stress (ST)].

Methods: This is a descriptive, cross-sectional design study. A sample of 190 post-event participants were recruited. An analysis was conducted using the Post Event- Cardiovascular Risk Perception Survey (PE-CRPS), a newly developed scale derived from the original 10-item Likert scale Cardiovascular Risk Perception Survey (CRPS). Data were analyzed using SPSS version 26. Descriptive and exploratory factor analyses were the methods used to analyze the data and factors.

Results: The higher the mean score, the higher the individual risk perception. Risk factors with a mean greater than 1.5 indicated a higher risk perception in this sample. Perceived risk factors included high blood pressure, high cholesterol, diabetes, gender/age, ethnicity, family history and stress. The higher risk perception occurred in high blood pressure, diabetes, and family history. Spearman correlations showed moderate relationships were shared with high blood pressure (HBP) & high cholesterol (HC); and HBP & stress. Moderate relationships were also seen between HBP with overweight (OW). Aside from HBP, OW also shared moderate relationships with diabetes (DM). Strong relationships were shared with ethnicity & gender/age; and ethnicity & family history (FH). In addition, strong relationships were seen between FH & gender/age and stress & gender/age.

Conclusions: The participants' post-event cardiovascular risk perception is evident in this study. Participants had the strongest relationship to high blood pressure, diabetes, and family history. By understanding the participants perception of risk, CR can empower the patient by promoting cardiovascular knowledge, behavioral changes, and positive health outcomes.

Abstract ID: S137

Title: Survey Of An Online Pulmonary Wellness And Rehabilitation Program In People With Chronic Respiratory Disease

Track: Pulmonary Rehabilitation & Medicine

Author(s): Noah Greenspan, PT, DPT, CCS, EMT-B1, Marcella Debidda, PhD2, Marion Mackles, PT, LMT1, Donna Frownfelter, PT, DPT, MA, CCS, RRT, FCCP3, Mark Mangus, RRT, RPFT, FAARC4, Akua Adu-Labi, MS, EP1, Aastha Joshi, PT, MS, EP1, Wai Chin, EP1, Patricia Rocco, MS, PT1, Mackenzie Doerstling, MPH, EP2.

Institution(s):1Pulmonary Wellness and Rehabilitation Center, New York, NY, USA, 2Pulmonary Wellness Foundation, New York, NY, USA, 3Rosalind Franklin University of Medicine and Science, Chicago, IL, USA, 4Pulmonary Wellness and Rehabilitation Center, San Antonio, TX, USA.

Introduction: Pulmonary rehabilitation is an effective and validated intervention to increase quality of life (QoL) and functional capacity in patients with CRD, however its availability is limited. In this study, we tested the implementation of an online open access pulmonary rehabilitation intervention.

Purpose: The purpose of this study is to pilot the feasibility of conducting a 42-day online pulmonary wellness and rehabilitation program in people with chronic respiratory disease (CRD).

Design: The SF-36 survey was administered to online participants for self-reported outcomes pre and post intervention.

Methods: 47 participants with CRD underwent a 42-day online pulmonary rehabilitation program with 4 components: thoughts and motivation; aerobic exercise; breathing, balance, flexibility and strength training; online peer and professional support groups.

Results: Differences between pre- and post-program SF-36 surveys were assessed using the Wilcoxon signed-rank test. Participants improved significantly in all 8 SF-36 scaled-score responses: physical functioning 23.33% (p=0.002), role limitations due to physical health 105.56% (p=0.002), role limitations due to emotional problems 49.38% (p<0.001), energy/fatigue 36.50% (p<0.0001), emotional wellbeing 14.29% (p<0.0001), social functioning 23.12% (p=0.002), pain 8.74% (p=0.045), and general health 12.88% (p=0.027). No serious adverse events (SAEs) were reported.

Conclusions: Participants increased QoL without SAEs and the program was rated feasible by participants. A multi-center, sufficiently powered online study of the intervention is planned to test safety and efficacy.

Abstract ID: S138

Title: Increasing Physician Attitudes Towards Cardiac Rehabilitation At UHealth Tower

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jessica Firmeza, DNP, APRN1, Sharon Andrade-Bucknor, MD, FACC2, Sabine M, Gempel, PT, DPT, CCS2, Meryl Cohen, MS, DPT, CCS, FAPTA3, Lawrence P. Cahalin, PhD, PT3, Torin P. Thielhelm, BS2.

Institution(s):1University of Miami Hospital, Miami, FL, USA, 2University of Miami Miller School of Medicine, Miami, FL, USA, 3University of Miami Miller School of Medicine, Department of Physical Therapy, Coral Gables, FL, USA.

Introduction: Annually, over 735,000 Americans experience myocardial infarction (MI) or acute coronary syndrome (ACS). For 525,000 of these patients, this event represents a first MI/ACS, while 210,000 of these patients experience a repeat MI/ACS. It is projected that 1 in 2 Americans will have cardiovascular disease (CVD) by 2035, estimated at a cost of $1.1 trillion to our healthcare system. Cardiac Rehabilitation (CR) is a level 1A Practice Guideline Recommendation and is proven to improve survival and health outcomes and reduce readmission rate and recurrent cardiac events. However, CR is still widely underutilized, with only 10-30% of eligible patients participating nationwide. Many factors contribute to this underutilization, including lack of physician knowledge and endorsement or referral, inefficient referral systems, poor patient motivation, inadequate reimbursement, and geographic limitations.

Purpose: To determine initial physician attitudes toward CR and assess the efficacy of an educational session on subsequent attitudes and referral practices in order to increase CR referral and decrease secondary cardiac events following discharge from UHealth Tower.

Design: Quality Improvement.

Methods: Participating physicians were assessed initially using the Physician Attitudes Toward Cardiac Rehabilitation & Referral Scale (PACRRS), administered via Qualtrics. An educational session on CR practices and referral within UHealth was then held during Cardiac Grand Rounds, including information on automating CR referral in discharge order sets, patient navigators for patient education and enrollment, and overall clinical team and provider education. Physician attitudes after the education sessions were subsequently assessed using the PACRRS. Pre- and post-test scale ratings were statistically analyzed via paired and unpaired t-tests using SPSS Statistics 26 (IBM Corp., Armonk, NY) with the level of statistical significance set at p<0.05.

Results: Physician attitudes toward CR referral and the existing program showed statistically significant (p<0.05) improvements in post-test scores on several of the PACRRS items including clinical practice guidelines promoting referral to CR (92% versus 75% strongly agreeing), referral of patients to CR (38% versus 15% strongly agreeing), intent to refer patients to CR (85% versus 41% strongly agreeing), and prescribing an exercise regimen for patients independently (8% versus 30% strongly disagreeing).

Conclusions: CR is known to reduce risk of secondary cardiac events and readmission rates among post-MI/ACS patients. Increasing physician knowledge on the benefits of CR, the existing referral system, and the department practice of CR and CR referral may improve overall utilization and referral for CR in post-MI/ACS patients. Healthcare leadership and key stakeholders may consider implementing routine education of clinical staff regarding CR to improve physician attitudes and referral to CR, as well as patient outcomes. Long-term effects of such routine educational programs on CR referral and outcomes are in need of investigation, but preliminary results are promising.

Abstract ID: S139

Title: Clinical Nurses Incorporate Professional Guidelines To Increase Patient Independence And Confidence During Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Lisa Diane Berg, ADN, BA.

Institution(s): Eisenhower Health, Rancho Mirage, CA, USA.

Introduction: Routine telemetry application, removal and monitoring requires significant staff resource, lengthens time of exercise session and minimizes nursing/patient interaction.

Purpose: Would use of a risk stratification tool to determine continued need of telemetry monitoring in cardiac rehabilitation patients increase department volumes, improve patient confidence and allow for more focused attention on high-risk participants.

Design: The Cardiac Rehabilitation (CR) Unit Based Council conducted a literature review to determine how other CR programs had incorporated the American Association of Cardiovascular Pulmonary Rehabilitation (AACVPR) risk stratification tool. Research demonstrated accurately identifying lower risk patients and modifying their need for telemetry reduces the amount of direct supervision needed and freed staff to focus more closely on higher risk patients.

Methods: Telemetry monitoring reduction tool was developed and endorsed by Cardiac Rehabilitation Nursing Director, program Medical Director and Department of Cardiology. The new risk stratification with modification to telemetry was incorporated into the Nursing Standardized Procedure for Cardiac Rehabilitation. Practice for newly admitted patients to CR includes risk assessment for participation, scoring from low to high based on a risk score. Number of permitted sessions, required direct supervision and telemetry monitoring are based on this risk score/stratification. Lowest risk patients are telemetry monitored for a minimum of six sessions, if no significant events telemetry monitoring is discontinued. Highest risk patient may continue with telemetry monitoring throughout the course of cardiac rehabilitation.

Results: Cardiac Rehabilitation participant enrollment increased by 10%.

Conclusions: Telemetry risk stratification promotes patient confidence related to cardiac health and fitness as well as encourages patients to develop and engage in out of clinical setting exercise. Future research related to frequency of resumption of telemetry monitoring, quantifying patient confidence and ongoing engagement in exercise program would be helpful.

Abstract ID: S140

Title: Significant Other Attendance In ICR Education

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Ashley Cotta, RDN, LDN, Wen-Chih Wu, MD, Julianne DeAngelis, MS, CCRP.

Institution(s): The Miriam Hospital, East Greenwich, RI, USA.

Introduction: Partner support is an important factor in behavior change. So, when it comes to adopting a plant-based dietary approach, partner support may play an influential role.

Purpose: To identify if support from a significant other (SO)—either a spouse or a partner—assists in adoption of dietary changes, resulting in better nutrition-related outcomes in intensive cardiac rehabilitation (ICR) patients. We hypothesize that patients with SO support will have more optimal nutrition-related outcomes due to guidance in implementing dietary changes.

Design: Retrospective chart review of patients (n=308) at baseline and upon discharge of ICR during 2017-2020. Patients with complete data at baseline and discharge in weight (n=300), FFQs (n= 214) and lipid panels (n= 268) were included in this analysis.

Methods: Patients attended a 9-week ICR program consisting of four-hour sessions, twice a week. The four hours consisted of exercise, education on a whole-food-plant-based diet, group support and stress management. Prior to and upon discharge of ICR, data on patients was collected, including anthropometrics, lab work and Food Frequency Questionnaires (FFQs). T-tests were used to compare changes in weight, laboratory total- and LDL-cholesterol and triglyceride levels, and dietary intake of fat, cholesterol and fiber, before and after ICR, by gender, and between patients with and those without SOs in attendance during nutrition education in at least 50% of the sessions.

Results: A total of 280 patients (mean age = 68.5 SD 10.3 years) completed ICR without a SO, of which 63% were male and 37% were female. All patients who completed ICR with a SO (n=28) were male. Compared to baseline, there was a significant improvement in weight (−6.7 +/− 6.6 lbs), laboratory measured total-cholesterol (−25 +/− 40 mg/dL) LDL (−20 +/− 35 mg/dL), and triglyceride (−18 +/− 64 mg/dL) levels; and diet intake of fat (−42.3 +/− 50.5 g/day), cholesterol (−182.9 +/− 188 mg/day) and fiber (+6.1 +/− 10.5 g) after ICR (p<0.001). With the exception of a trend in weight (−5.8 +/− 5.3 in female vs −7.2 +/− 7.1 lbs in male, p=0.06), there were no significant gender differences in the above outcomes. Among men (n=176), those with a SO had a greater decrease in fat intake than those without a SO in attendance (−84.5 +/− −95.0 vs −37.6 +/− 39.6 g, p=0.02). There were no significant differences in the otehr outcomes.

Conclusions: There were significant and consistent improvements in weight, serum lipid profile, and dietary fat and fiber intake after completion of ICR in both men and women. Only men had SO attendance in the nutrition education sessions. A SO attendance further decreased dietary fat intake than those without. Further research is warranted to identify which motivators can help women achieve better outcomes after ICR.

Abstract ID: S141

Title: Effects Of Insurance Payer Status On Outcome Measures In A Federally Qualified Family Health Center Outpatient Cardiac Rehabilitation Program

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Matthew Bancone, PT, DPT, Kimberly Valdecantos, DNP, RN, FNP-C, CCRP, Enza Navarra, PT, DPT, Meghan Durney, PT, DPT, Swati Patel, PT, DPT, Heather Larkin, PT, DPT, Manuel Wilfred, PT, DPT, Jason Ramdeen, PT, DPT.

Institution(s): NYU Langone Brooklyn, Brooklyn, NY, USA.

Introduction: Safety-net hospitals (SNH) will treat patients regardless of their ability to pay, including those without insurance. SNH patients will have more health risks compared to those in other hospitals. Insurance status is a significant predictor of cardiac rehabilitation (CR) attendance, along with perceived lack of time.

Purpose: To further understand the impact of financial/insurance status on clinical outcomes within a federally qualified Family Health Center (FHC). This will involve observing patients' insurances as compared to patients' pre and post program results on the 6 Minute Walk Test (6MWT), Duke Activity Status Index (Duke) and Dartmouth COOP Functional Assessment Charts Tests (Dartmouth).

Design: This is a retrospective study.

Methods: We reviewed charts for 91 patients who were enrolled and completed CR at FHC at NYU Langone Hospital-Brooklyn between 2018-2019. This study entailed a retrospective chart review of patients' charts only. Data were analyzed using SPSS. Significance value was set at p <.05.

Results: A series of 3 × 2 mixed-model ANOVAs were calculated to examine the effects of insurance(Medicare, Medicaid, Private) and time (pre & post-test) on Duke scores, 6MWT scores, Dartmouth scale scores, and BMI. The main effect for insurance payer code was significant for the 6MWT and BMI. There was a significant difference in 6MWT and BMI scores between the three insurance payer groups. There was a significant large main effect for time for the Duke, 6MWT, Dartmouth scores, and BMI. Mean Duke and 6MWT scores were higher after completion of the CR program. Mean BMI and Dartmouth scale scores were lower after completion of the CR program.

Conclusions: This study was a retrospective analysis of the CR outcome measures for ninety-one patients with qualifying cardiac diagnoses insured by three insurance providers (Medicare, Medicaid, and Private) who completed CR at a FHC. Medicaid patients represent only 14% of the total patient population of this study, despite the clinic's location in a federally qualified FHC. Compared to patients with Medicare and private insurances, Medicaid patients presented with worse pretest baseline status as measured by lower Duke and 6MWT scores and higher BMI and Dartmouth scale scores. However, the magnitude of improvement was similar across patient groups regardless of insurance. Regardless of respective insurances, all three participant groups achieved comparable results. There was an overall significant increase in Duke and 6MWT scores and a decrease in BMI and Dartmouth scale scores. These results indicate that patients who successfully completed CR improved both physical fitness and quality of life, regardless of insurance payer. Although patients from different insurance groups made significant progress, after successful completion of CR it is worth noting that Medicaid patients had the lowest pretest baseline status and represented a small portion of the total patients. Further research should focus on ways to increase participation among Medicaid patients to improve their cardiac health outcomes.

Abstract ID: S142

Title: Correlation Of Cardiovascular Risk Factors With Cardiac Surgical Status In A Federally Qualified Family Health Center Outpatient Cardiac Rehabilitation Program

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Kimberly Valdecantos, DNP, RN, FNP-C, CCRP, Matthew Bancone, PT, DPT, Enza Navarra, PT, DPT, Meghan Durney, PT, DPT, Swati Patel, PT, DPT, Jason Ramdeen, PT, DPT.

Institution(s): NYU Langone Brooklyn, Brooklyn, NY, USA.

Introduction: Many cardiovascular surgeries, including percutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG), and valve surgery, are referred to cardiac rehabilitation (CR) to improve a patient's cardiac health. Cardiovascular risk factors include: patient's age, high blood pressure, high LDL or low HDL cholesterol levels, obesity, diet, smoking, and post-menopausal status. Through this study we have investigated if there is a relationship between cardiac risk factors and surgical versus non-surgical CR patients.

Purpose: To provide a greater understanding of the impact of cardiovascular risk factors and cardiac surgical status within a federally qualified Family Health Center (FHC).

Design: This is a retrospective study.

Methods: An electronic medical record review was performed for 91 patients that successfully completed the Phase II CR Program at NYU FHC between 2018 and 2019. A retrospective analysis was implemented for these chart audits. Data including surgical versus non-surgical participants and the presence of risk factors were analyzed using SPSS and included use of Pearson Chi-Square, Fisher's Exact, and Correlation coefficient. Significance value was set at p <.05.

Results: A chi square test of association was calculated comparing the surgical status of the patients based on ICD-10 codes and risk factors. A significant relationship was found between surgical status and hyperlipidemia χ2 (1, N = 91) = 11.59, p = .003, effect size= 0.35 and power= 0.92; as well as surgical status and hypertension χ2 (1, N = 91) = 15.16, p = .001, effect size= 0.40 and power= 0.97. For both hyperlipidemia and hypertension, p < .05 and hence we can say that a significant relationship was found and we can reject the null hypothesis. There is a correlation between the surgical status and 2 risk factors: hyperlipidemia and hypertension. The significant values indicate that there is a significant dependence of one variable on the other and that the presence of the risk factor (hyperlipidemia and hypertension) differed across surgical vs. non- surgical patients. 94.3 % of the surgical patients had hyperlipidemia compared to non-surgical patients where only 5.7% had hyperlipidemia. Similarly 94.5 % of the surgical patients had hypertension compared to non-surgical patients where only 5.5% had hypertension. No correlation was found between the surgical status and rest of the risk factors.

Conclusions: Surgical patients presented with significantly increased proportion of hyperlipidemia and hypertension compared to non-surgical CR patients. No other significant correlation was found between surgical status of the patient and other risk factors.

Abstract ID: S143

Title: Comparative Analysis: 3 Day Pulmonary Rehabilitation Program Versus 2 Day Pulmonary Rehabilitation Program

Track: Pulmonary Rehabilitation & Medicine

Author(s): Stacey LJ Papo, BS, CCRP, ACSM-CEP1, Kayla Mahoney, MS, CCRP, CSCS2, Loren Stabile, MS, FAACVPR3, Wen Chih Wu, MD, FAACVPR3.

Institution(s):1Lifespan-Newport Hospital, Newport, RI, USA, 2Lifespan-Miriam Hospital, Providence, RI, USA, 3Lifespan, Providence, RI, USA.

Introduction: Pulmonary Rehabilitation (PR) is often offered as a 90-minute session that meets twice weekly. With a lifetime maximum of 72 visits, patients often complete 20-24 sessions holding additional visits for future needs. Due to the population's comorbidities and health challenges, these programs are often extended to 18-24 weeks, well beyond the scheduled 12 weeks. The need to prolong the enrollment impacts throughput resulting in decreased access for newly referred patients. In an effort to improve patient outcomes, program throughput and decrease dropout rates a 3 day per week program was implemented with goal completion of 8 to 12 weeks.

Purpose: The aim of this study was to determine the impact of a 3 day per week PR program (PR3) on dyspnea, fatigue, health-related quality of life, dropout rate, completed sessions, and time from referral to enrollment versus those outcomes in a 2 day per week PR program (PR2).

Design: Retrospective chart review using registry data to compare patients enrolled at two affiliated PR facilities, one offering PR2 the other PR3. Data was collected for patients with enrollment after February 1st 2018 and completion prior to December 31st 2019.

Methods: Patients enrolled in PR2 (n=167) attended two 90-minute sessions per week, consisting of 60-minutes of supervised exercise and 30-minute education class. Patients in PR3 (n=67) attended three 60-minute supervised exercise sessions and two 30-minute education classes. The changes from baseline to discharge for depression (PHQ-9), quality of life (CRQ dyspnea and fatigue domains and COPD assessment test), dyspnea (MMRC), and functional status (six minute walk test) were compared within and between the PR2 and PR3 programs via T-tests. The referral to enrollment time, dropout rate, duration of the program, and number of sessions completed were also quantified between the programs.

Results: The characteristics of patients were similar in PR2 (52%COPD) versus PR3 (55%COPD) with mean ages of 69.7±8.9 (PR2) versus 74.5±8.9 (PR3) years. Both groups completed an average of 22 PR sessions. Of the patients initially enrolled, there was a non-significant improvement in the referral to enrollment time (35.8±32.2 versus 29.5±32.5 days, p=0.18) and dropout rates (40% versus 28%, p=0.09) between the PR2 and PR3 programs, respectively. There was a significant improvement in PR completion time being achieved in 79.6±24.0 (PR3) versus 97.7±24.1 (PR2) days, p<0.01. Patient outcomes were significantly improved from baseline in both programs (all p's<0.05) with CRQ-Fatigue scores favoring PR3 versus PR2 (14.57±7.47 versus 12.05±9.06, p=0.03).

Conclusions: Implementation of a PR3 program had a significant improvement on fatigue ratings and program duration, with trends in dropout rate and referral to enrollment time among patients. A 3 day program would benefit PR facilities experiencing wait lists due to high referral volume and/or limited staffing or facility space and those struggling with high dropout rates.

Abstract ID: S144

Title: Improving Pediatric Cardiac Rehabilitation Metrics In Response To AACVPR Program Certification Alignment For Cardiac Transplant

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Justine D. Shertzer, MS, Wayne A. Mays, MS, Sandy K. Knecht, MS, Malloree C. Rice, MS, Andrea L. Grzeszczk, MS, Matthew J. Harmon, MS, Adam W. Powell, MD, Clifford Chin, MD, Samuel W. Wittekind, MD.

Institution(s): Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

Introduction: The standard operating procedures outlined by the AACVPR program certification process offer an excellent framework for a cardiac rehabilitation program's daily procedures and outcomes. We adopted these guidelines 3 years ago and we sought to evaluate the outcomes for our patients before and after this modification.

Purpose: To evaluate cardiac rehabilitation (CR) programmatic metrics in our cardiac transplant patients before and after preparation and submission to the AACVPR program certification process.

Design: We retrospectively reviewed individual cardiac rehabilitation (CR) sessions for our pediatric and young adult patients post cardiac transplant that completed their cardiac rehabilitation program during the period of January, 2014 to January, 2020.

Methods: Modification of our CR program was completed in November, 2017. The patients were divided into those participating in the program, pre November, 2017 (PCERT) and those post November 2017 (CERT). There were 18 patients in each group. All Cardiopulmonary Exercise Tests (CPET), 6 minute walk tests (6MWT) and individual treatment plan (ITP) assessments were reviewed. Results were characterized with means and standard deviations with comparisons made using the student T Test. Significance was set at p < 0.05.

Results: The number of CPETs (0.8 to 1.2), 6MWT (0.2 to 1.3) and ITPs (1.1 to 3.4) per patient significantly increased in the CERT group. Both groups (PCERT vs CERT) improved in aerobic capacity (VO2 indexed) (15 ± 2 to17 ± 8 vs 17 ± 6 to 23 ± 4, cc/kg/min) and meters covered in the 6MWT (379 ± 170 to 570 ± 140 vs 288 ± 114 to 402 ± 126). Only the CERT group improved in sit and reach (14 ± 2 to 16 ± 3) and arm curl (16 ± 7 to 20 ± 8, reps per minute).

Conclusions: Application of standard operating procedures outlined in the AACVPR cardiac rehabilitation program certification process resulted in significantly improved follow up and assessment in our cardiac transplant population. Both groups showed significant improvement in working and aerobic capacity. However, only the group participating in the CR program after adoption of the new standard operating procedures showed improvement in strength measures.

Abstract ID: S145

Title: Expanding And Improving Access Of Cardiac Rehabilitation Across Sites In The Veteran Affairs Healthcare System

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Rebecca Smith, MPT, MS1, Kimberly Timmerman, DPT2, Sean Karr, DPT2, Daniel Forman, MD1.

Institution(s):1VA Pittsburgh Healthcare System, Pittsburgh, PA, USA, 2VA Butler Healthcare System, Butler, PA, USA.

Introduction: While Cardiac Rehabilitation (CR) has AHA/ACC Class I endorsement for secondary prevention and risk reduction for coronary heart disease,1,2 enrollment of Veterans into CR has been remarkably low. In 2014, only 10.3% of eligible Veterans participated in CR after an ischemic heart event3 within the Veterans Health Administration (VHA) The VHA provides care for Veterans located in both urban and rural settings with distances between home and hospital often quite large. Schopfer et al. found that 68% of study participants cited travel issue or distance as major barriers to participation in CR within the VHA4.

Purpose: In this quality improvement project we sought to expand access to site-based cardiac rehabilitation by better integrating two contrasting VHA facilities, i.e., the VA Pittsburgh Healthcare System (VAPHS), a level 1A hospital with a comprehensive CR program staffed by an MD, nurses, PT, nutrition, social work, and exercise physiologists, to its affiliate site VA Butler Healthcare System (VABHS), a tertiary facility in a smaller city 60 miles away that had no CR available.

Design: The design of affiliate model begins with evaluation including six-minute walk test (6MWD) with telemetry to be completed by VAPHS CR staff. If it is determined a Veteran does not need additional telemetry sessions and also fulfills other criteria of low to moderate cardiac risk, then the Veteran can be enrolled in the program at VABHS. The VABHS program has all of the elements of CR, aerobic, strengthening, balance and risk factor education except for telemetry monitoring. The PTs at VABHS have completed onsite training in CR at VAPHS and site visits were conducted at VABHS. Both sites participate in a combined weekly meeting were Veteran's cases are discussed and care is coordinated, with all the VAPHS staff participating.

Methods: VAPHS and VABHS staff completed the same enrollment and discharge outcomes to allow complete pre and post data collection. VAPHS tracks the enrollment numbers and access to VABHS Veterans in CR in this affiliate site model.

Results: This model has been in place for the last 9 months. So far, 11 Veterans have enrolled in VABHS and 9 have completed the program. Compared to the prior 12 months, this has been a 50% increase in enrollment in CR in the affiliate model as compared to the few who previously utilized non-VA care. Veteran's completing the program at VABHS have had an avg 6MWD increase of 76.4m (pre 374.8m, post 451.2m). There have been 0 adverse events with Veterans exercising without telemetry.

Conclusions: The creation of the affiliate program has had a positive impact on access to CR. Training of current staff has allowed expanded services without increase in staff, and the outcomes are in line with the traditional site-based program.

Abstract ID: S146

Title: Cardiac Rehabilitation In Pediatric Patients With Acquired Or Congenital Heart Disease And Significant Physical Or Behavioral Limitations

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Matthew J. Harmon, MS, Wayne A. Mays, MS, Justine D. Shertzer, MS, Malloree C. Rice, MS, Sandra K. Knecht, MS, Andrea L. Grzeszczak, MS, Adam W. Powell, MD, Clifford Chin, MD, Samuel W. Wittekind, MD.

Institution(s): Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

Introduction: Cardiac rehabilitation may be modified to address the added burden of significant physical and/or behavioral limitations in pediatric patients with acquired or congenital heart disease. These modifications should be evaluated to assure their efficacy.

Purpose: To evaluate exercise responses and outcomes in patients with physical limitations versus behavioral limitations in a cardiac rehabilitation setting modified to address those limitations.

Design: We retrospectively reviewed individual cardiac rehabilitation (CR) sessions, exercise tests (CPET), 6 minute walk tests (6MWT) and CR assessments for our pediatric and young adult patients with acquired or congenital heart disease that participated in the cardiac rehabilitation program during the period of December, 2017 to February, 2019. The session routines were adapted for the patients to include game play, variable reward strategies and customized modifications.

Methods: The patients were divided into those with significant physical (PHY, N=9) versus behavioral (BEH, N=13) challenges. Results were characterized with means and standard deviations and comparisons were made with the student T test. Significance was set p < 0.05.

Results: PHY group consisted on 6 patients with musculoskeletal, 1 with balance/mobility and 2 with combined issues. BEH group consisted of 8 with adjustment disorder, 1 with PTSD, 3 with anxiety/panic/conversions disorder and 1 with ADHD. PHY and BEH groups significantly improved CPET total time (7.6 ± 2.5 to 9.3 ± 2.6 and 6.2 ± 2.7 to 8.9 ± 3.1 min, p < 0.03 and 0.003, respectively), indexed VO2 (19 ± 7 to 25 ± 6 and 16 ± 6 to 23 ± 8, cc/kg/min, p < 0.05 and 0.01, respectively), oxygen pulse (9.7 ± 4.7 to 11.5 ± 4.8 and 5.9 ± 2.6 to 8.4 ± 3.5, ml/beat, p < 0.03 and 0.005, respectively) and 6MWT distance (450 ± 181 to 532 ± 161 and 342 ± 115 to 393 ± 193 meters, p < 0.05 and 0.02, respectively). BEH group significantly increased sit to stand (16 ± 6 to 22 ± 7 reps/min, p < 0.03) and arm curls (17 ± 6 to 21 ± 6, reps per min, p < 0.01).

Conclusions: Utilizing a strategy of game play, variable reward and customized modifications of existing cardiac rehabilitation interventions, we were able to provide our service to patients with significant behavioral and physical limitations. There were significant aerobic and working capacity improvement in the PHY and BEH groups with additional muscular improvement in the BEH group.

Abstract ID: S147

Title: Regional Fat Mass And Protein Level Are Associated With Sarcopenia In Chinese Older Adults

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Lu Zhang, MS.

Institution(s): HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.

Introduction: Body fat and malnutrition, as well as sarcopenia, are common conditions in older adults and increases the risk of falls, disabilities and mortality.

Purpose: The aim of the present study was to explore the relationship between regional fat mass and protein level with sarcopenia in Chinese community-dwelling older adults.

Design: A Cross-sectional study.

Methods: Ningbo Community Study on Aging (NCSA) recruited Chinese community-dwelling participants aged ≥65 years from November 2016 to March 2017. Regional fat mass and blood sample tests, as well as comprehensive geriatric evaluation, were accessed in our study. Measures of sarcopenia included gait speed by 4 meter walk test, handgrip strength and skeletal muscle mass by performing bioelectrical impedance analysis.

Results: Data from 1021 participants were used for analysis, including 590 women (58.1%), with a mean age of 72.4 (±5.3) years. Multiple logistic regression analysis showed that higher total body fat and regional fat mass increased the odds of sarcopenia (P<0.01), body protein mass level accessing by bioelectrical impedance analysis and blood albumin-globulin ratio also were negative with sarcopenia after adjusting for sex, age and body mass index (P≤0.01). For further adjustment of smoking, drinking, education level, mean blood pressure, heart rate, the serum total-to-HDL cholesterol ratio, glycosylated haemoglobin, hypertension, diabetes mellitus and stroke, total body fat mass (OR = 1.33, 95% CI, 1.19-1.48), arm fat mass (OR = 4.76, 95% CI, 2.90-7.82), leg fat mass (OR = 1.76, 95% CI, 1.27-2.44) and trunk fat mass (OR = 1.73, 95% CI, 1.42-2.12) were associated with sarcopenia, whereas 1-SD increased in body protein mass and blood albumin-globulin ratio were associated with a 13% (CI, 3%-65%; P=0.01) and 8% (CI, 5%-14%; P<0.01) lower odds of being sarcopenia respectively.

Conclusions: Not only muscle mass, regional fat mass and protein are associated with Sarcopenia, these should be further considered in the future research and prevention of Sarcopenia.

Abstract ID: S148

Title: Comparison Of Total Body Recumbent Stepping Vs Treadmill Walking In A Rural Midwest Supervised Exercise Therapy Program For Peripheral Artery Disease

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Dereck L. Salisbury, PhD1, Rebecca JL Brown, MEd, MN, RN1, Kristin Elgersma, DM, MN, MM, RN1, Kayla Brown, BS2, Diane Treat-Jacobson, PhD, RN, FAHA, FSVM, FAAN1.

Institution(s):1University of Minnesota, Minneapolis, MN, USA, 2Lake Regions Healthcare, Fergus Falls, MN, USA.

Introduction: The national guidelines for treatment and management of symptomatic peripheral artery disease (PAD) recommend supervised exercise therapy (SET) as a first line of therapy. Treadmill walking is the most commonly studied exercise modality in the laboratory setting, however other modalities may be equally effective and more tolerable clinically.

Purpose: The purpose of this study was to compare the effectiveness and safety of a) treadmill walking (TM), b) total body recumbent cycling (TBRS) and, c) treadmill + total body recumbent cycling (TM+TBRS) for treatment of PAD in rural SET programs.

Design: This was a prospective, non-randomized pre-post study using standardized data collection methods to assess the effectiveness of a clinical SET program in the rural Midwest.

Methods: Participants enrolled in a 12-week SET program and were prescribed an exercise program based on current SET guidelines, clinical judgement of the team composed of therapists, nurses, exercise physiologist, and patient input. Clinical considerations included fall-risk assessment, baseline treadmill walking duration, and comfort. Pre and post physical function tests included: 4-meter walk (4mWT), repeated chair rise (RCR), 6-minute walk (6MWT), and Timed Up and Go (TUG) tests. Based on clinical prescription, 53 of the 95 SET participants were categorized into the following groups: TM, TBRS, or TM+TBRS. Thirty-six of the 53 completed all 12-week tests and were included in the analysis. Descriptive and inferential statistics were used to analyze demographic and primary outcome measures, respectively.

Results: The sample was predominantly Caucasian with 56% female representation, average age of 75.1 (7.9 years), and mild-moderate PAD (ABI 0.69 [0.8]). TBRS group (n=12) had significantly more comorbid conditions (p=.05) and poorer physical function at baseline including: 6MWT (p<.01), TUG test (p<.01), and 4mWT (p<.01) compared to TM group (n=10). At post-test, all groups showed improvement in peak walking distance on 6MWT (TM: 121.4 [139.4] vs. TBRS: 107.9 [142.8] vs. TM+TBRS: 121.4 [139.4] feet), however changes were non-significant across groups using non-adjusted and adjusted models. TBRS group showed the greatest (though non-significant) improvements in TUG (−1.1 [2.5] vs. −0.6 [0.7] vs. −0.7 [2.0] seconds], 4mWT (−0.5 [0.8] vs. 0.9 [2.3] vs. −0.4 [0.6] seconds), and RCR (−2.9 [4.4] vs. −1.6 [1.4] vs. −2.0 [3.2] seconds) tests compared to TM and TM+TBRS groups.

Conclusions: Results may be interpreted with caution due to 1) non-randomized design, 2) patients were recommended to TBRS group in part because they couldn't walk on treadmill, and 3) small sample size. Despite the limitations, 1) all groups improved walking capacity, 2) TBRS improved walking despite poorer baseline functioning, and 3) exercise modalities incorporating TBRS improve physical function in persons with PAD. Lastly, this study demonstrates the efficacy of rural SET programs following current guidelines and potential utilization of TBRS in SET programs for persons unable to perform treadmill exercise.

Abstract ID: S149

Title: Impact Of A Phase II Cardiac Rehabilitation Program On Circulatory And Ventilatory Power Variables In Patients With Heart Failure

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Henry S. Barrera, MD1,2, Juan M. Sarmiento, MD2,1, Alberto Lineros, MD1, Jenny C. Sanchez, Fst2.

Institution(s):1Universidad El Bosque, Bogota DC, Colombia, 2Fundacion Clinica Shaio, Bogota DC, Colombia.

Introduction: Heart failure (HF) syndrome has high morbidity rates. Despite new pharmacological treatments, cardiovascular devices and cardiac rehabilitation (evidence IA), mortality remains to be high between 40-50% to five years. The maximum oxygen consumption is used as a prognostic factor and mortality in HF. There are others that allow a more accurate prognosis in the evaluation of an intervention to measure changes, such as the VE/VCO2 slope, OUES, PETCO2 and the ventilatory oscillatory pattern. Also as circulatory power (maximum systolic blood pressure x peak VO2) and ventilatory power (maximum systolic blood pressure/VE/VCO2 slope) with special relevance in HF patients with B-Blocker, since they are not widely modified. Therefore, the application of circulatory and ventilatory power is opened as a response parameter to exercise intervention. However, we cannot use them as their behavior due to exercise intervention is not precisely known.

Purpose: Determine the impact of a phase II cardiac rehabilitation program in terms of circulatory and ventilatory power, in order to provide the basis for the integration of these variables into the multiparametric evaluation to serve as a basis as a tool to define its usefulness in risk re-stratification systems in this population.

Design: pseudo-experimental retrospective analytical study.

Methods: A total sample of 35 patients diagnosed with cardiac failure with reduced ejection fraction who completed phase II cardiac rehabilitation program with a minimum of 36 sessions of exercise, 21 patients performed high-intensity interval training and 14 developed moderate-continuous training. Ergospirometry was performed at the beginning of the program and after completing the program, measurements were obtained from: VO2peak, VE/VCO2, Peak systolic blood pressure, circulatory and ventilatory power.

The quantitative variables were described using averages and standard deviation. Variables with normal distribution according to the Shapiro-Wilk test; otherwise, they were described using medians and interquartile ranges. Qualitative variables were described using proportions. Comparison of quantitative variables before and after the program, a t-student test was used for paired data when the data were distributed in a normal or non-parametric statistical defect (Wilcoxon rank sum for paired data). To compare qualitative variables, a Pearson's χ2 test was conducted when the expected values in the cells were> 5, otherwise Fisher's exact test was performed. The data analysis was conducted using the statistical software Stata®, the statistical tests were significant at an α≤0.05 level.

Results: There were changes with statistical significance in both circulatory and ventilatory power, for the first of these, there is an increase of 21.6% and in the second variable of 9.3% associated with significant changes in VO2peak and VE/VCO.2

Conclusions: This study demonstrated the favorable impact of Phase II cardiac rehabilitation in terms of circulatory and ventilatory power, showing an improvement in cardiovascular and respiratory responses to exercise. In addition to this the potential use of these variables in post-intervention multiparametric evaluation with cardiac rehabilitation.

Abstract ID: S150

Title: Daily Step Counts In Participants With And Without Symptomatic Peripheral Artery Disease

Track: Physical Activity/Exercise

Author(s): Polly Montgomery, MS1, Ming Wang, PhD1, Biyi Shen, MS1, Shangming Zhang, MD1, William Pomilla, MD1, Marcos Kuroki, MD, PhD1, Ana Casanegra, MD2, Fedirico Silva-Palacios, MD3, Omar Esponda, MD4, Andrew Gardner, PHD1.

Institution(s):1Penn State COM, Humelstown, PA, USA, 2Mayo Clinic, Rochester, MN, USA, 3Univ. of Oklahoma HSC, Oklahoma City, OK, USA, 4Hospital Perea, Mayaguez, PR, USA.

Introduction: Many individuals with Peripheral Arterial Disease (PAD) may not have access to or desire to participate in formal structured exercise programs, but they could nevertheless benefit by incorporating a greater amount of walking into their daily routine.

Purpose: We compared the prevalence of participants with and without symptomatic PAD who meet the recommendations of attaining more than 7,000 and 10,000 steps/day, and we determined whether PAD status was significantly associated with meeting the daily step count recommendations before and after adjusting for demographic variables, comorbid conditions, and cardiovascular risk factors.

Design: cross-sectional.

Methods: Participants with PAD (n=396) and those without PAD (n=396) who were matched on age and sex were assessed on their walking for seven consecutive days with a step activity monitor attached to the ankle.

Results: The PAD group took significantly fewer steps/day than the non-PAD control group (6,722±3,393 vs. 9,475±4,110 steps/day; p<0.001). Only 37.6% and 15.7% of the PAD group attained the recommendations of walking for at least 7,000 and 10,000 steps/day, respectively, whereas 67.9% and 37.4% of the control group attained these recommendations (p<0.001 for each recommendation). In multivariable logistic regression models, having PAD was associated with a 62% lower chance of attaining 7,000 steps/day than compared to the control group (OR=0.383, 95% CI= 0.259-0.565, p<0.001), and a 55% lower chance of attaining 10,000 steps/day (OR=0.449, 95% CI=0.282-0.709, p<0.001). Significant covariates (p<0.01) included age, current smoking, diabetes, and body mass index (only for the 10,000 step/day recommendation).

Conclusions: Participants with symptomatic PAD had a 29% lower daily step count compared to age- and sex-matched controls, and were less likely to attain the 7,000 and 10,000 steps/day recommendations. Additionally, participants who were least likely to meet the 7,000 and 10,000 daily step count recommendations included those who were older, currently smoked, had diabetes, and had higher body mass index.

Abstract ID: S151

Title: Impact In Morbidity And Mortality In Heart Failure Patients With Reduced Ejection Fraction After A Cardiac Rehabilitation Program

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Juan P. Martinez, MD1, Juan M. Sarmiento, MD2,1, Oscar Ortiz, MD1, Alberto Lineros, MD1.

Institution(s):1Universidad El Bosque, Bogota DC, Colombia, 2Fundacion Clinica Shaio, Bogota DC, Colombia.

Introduction: Cardiac rehabilitation (CR) is one of the non-pharmacological tools that have benefits in patients with heart failure (HF). However, there is currently no clear consensus on the decrease in decompensating hospitalizations and mortality in patients with HF in the short, medium or long term.

Purpose: To determine the impact on morbidity and mortality and the maintenance of physical activity in patients with HF with reduced ejection fraction (REF), between six and twelve months of having participated in a cardiac rehabilitation program (PCR) and correlate the number of sessions of CR (CRS) performed with mortality, number of hospitalizations and maintenance of physical activity, in patients who have participated in a CRP.

Design: Quantitative, observational, analytical retrospective cohort study.

Methods: One hundred twenty six patients with HF-REF, were divided into two cohorts according to the number of CRS performed <30 or ≥30, were followed by telephone between six and twelve months after participating in a CRP phase II. The information obtained was in questionnaire format including IPAQ. The outcomes evaluated were mortality, cardiovascular mortality, hospitalizations, cardiovascular hospitalizations, physical activity and sitting time. The variables are expressed as means ± standard deviation, compared to the t-test. student or Mann-Whitney U-Test. Categorical variables are expressed in frequencies and percentages and compared with the chi square test. To analysis of the results of morbidity and mortality and the maintenance of physical activity, Odds Ratio was used by the Mantel-Haenszel method. A multivariate logistic regression was performed for the outcome of hospitalizations and the covariates considered were level of physical activity at the time of follow-up, minutes per day of sitting and the cohort to which the patient belonged (complete vs. incomplete cardiovascular rehabilitation program). Cumulative survival curves for the outcome of general hospitalizations during the follow-up time were performed using the Cox method. For all statistical tests, a significance level of p≤0.05 was established. The SPSS Statistics ® software was used for statistical analysis.

Results: Sixty-four patients were analyzed (65.48 ± 2.96 years; 52 men). Patients who did not complete ≥30 CRS have a higher risk of general hospitalizations (OR=3,988; p=0.027), which disappears when adjusted for physical activity level (OR=3.22; p=0.1). Inactive patients (<1000 METS-min / week) have a higher risk of general hospitalizations (OR=5.8; p=0.013), which remains significant when performing a multivariate logistic regression adjusting for termination or not of a program of rehabilitation and sitting time (OR=4.67; p=0.037).

Conclusions: More than 30 sessions of CR reduces the risk of presenting general hospitalizations in patients with HF between six and twelve months of having performed a phase II of cardiac rehabilitation, however, this effect is lost when the patient is not physically active (>1000 METS-min / week). Physical inactivity (<1000 METS-min / week) is an independent risk factor for general hospitalizations in patients with heart failure with reduced ejection fraction.

Abstract ID: S152

Title: Acculturation & Healthy Behaviours Among Arab Individuals At Higher Risk Or Diagnosed With Cardiovascular Diseases: Findings From A Cross Sectional Study In Ottawa, Ontario

Track: Behavior Change

Author(s): Hussein Baharoon, PhD Candidate, Judy King, PhD, MHSc, BHSc (PT) Associate Professor.

Institution(s): University of Ottawa, OTTAWA, ON, Canada.

Introduction: Adopting healthy lifestyle behaviours is the target of primary and secondary prevention in cardiac rehabilitation programs to prevent cardiovascular diseases. Cultural and religious beliefs are considered challenges that influence healthy behaviours among immigrants in host countries. These cultural and religious beliefs are rarely addressed in the research among Arab Canadians and immigrants living with cardiac events or cardiovascular disease risk factors.

Purpose: This study aims to describe the level of religious/spiritual beliefs and coping strategies, acculturation, perceived stress, and healthy lifestyle behaviours among Arab people diagnosed with cardiac events or at high risk for cardiovascular diseases living in the region of Ottawa, Ontario, Canada.

Design: A cross-sectional survey.

Methods: This study was conducted with 63 individuals either diagnosed with cardiac events or at high risk for cardiovascular diseases from Arab communities living in the region of Ottawa. Participants completed an English/Arabic sociodemographic questionnaire as well as five validated questionnaires measuring the level of religious/spiritual beliefs and coping strategies, acculturation, perceived stress, and healthy lifestyle behaviours. Data collected were analyzed using SPSS. All sociodemographic information was analyzed using the statistical descriptive analysis based on frequencies and proportions for categorical variables, and by using means with standard deviations for continuous variables.

Results: Of the 63 participants, 38% were women, 62% were men. From this sample, 87% were 45 years old or older, 59% were immigrants, and 35% were refugees. The majority of participants were Muslim, with only two Christian participants. All participants were from the first generation, and 62% of participants had lived in Canada for more than 15 years. 21 participants had suffered a cardiac event and 42 participants had been diagnosed with cardiovascular disease risk factors. Study data indicate the mean positive religious coping score was 3.82 (SD = 0.20) while the mean negative religious coping score was 1.30 (SD = 0.34). Most participants are more oriented toward their Arabic culture, as the total mean score of acculturation-Arabic dimension was 5.26 (SD = 0.42) while the total mean score of acculturation-Canadian dimension was 3.48 (SD = 0.82). More attention was paid by participants toward nutrition (M = 2.48, SD = 0.58) than toward physical activity (M = 1.76, SD = 0.64) in their behaviours. There was no significant difference among participants' mean scores based on age, gender, length of residence time in Canada, or health status.

Conclusions: While these individuals may be more religious and less acculturated, their lifestyle health behaviours related to physical activity, nutrition and stress management may be influenced by their health status, religious beliefs, and practices from their culture of origin. Findings from this study will inform the next step in this research, a qualitative study with participants who have suffered cardiac events to understand religious coping in their experiences and the impact of their culture on their rehabilitation following cardiac events.

Abstract ID: S153

Title: Are Rural-dwelling Nigerian Adults Aware Of Stroke?

Track: Behavior Change

Author(s): Marufat Oluyemisi Odetunde, PhD1, Timilehin Gabriel Ademuwagun, BMR(Physiotherapy)1, Nurain Akinjide Odetunde, MBBS2, Adebimpe Olayinka Obembe, Ph. D3.

Institution(s):1Obafemi Awolowo University, Ile Ife, Osun state, Nigeria, 2General Out-patient Department, General Hospital, Gusau, Zamfara State, Nigeria, Gusau, Zamfara state, Nigeria, 3Department of Occupational Therapy, College of Saint Mary, Omaha, NE, USA.

Introduction: Evaluation of public's knowledge or awareness of stroke risk factors and warning signs is key to preventive approach on reducing the incidence of stroke, however, there is still limited information needed for policy and actions among rural dwellers in Nigeria.

Purpose: This study assessed awareness and knowledge of stroke risk factors and warning signs among Nigerian rural community dwellers.

Design: This was a cross-sectional survey that involved 322 community dwelling adults selected systematically from every second house in Ipetumodu, Osun State, Southwestern Nigeria.

Methods: Method: Adults aged 18 years and older who were residents of Ipetumodu participated in this survey, after obtaining their written informed consent. A validated four-section questionnaire was used to collect data on socio-demographic information, stroke risk factors and warning signs awareness, action respondents will take first if a stroke occurs and sources of information on stroke. Descriptive statistics of frequency and percentage; and inferential statistics of Kruskal-Wallis test and logistic regression were used to analyze data. Alpha level was set at p<0.05.

Results: A total of 322 respondents (176 males and 146 females) consented for this survey. Majority of the respondents were in the 20-40 years age group (65.8%) and had tertiary education (56.5%). Rate of correct identification of ‘at least two risk factors and warning signs of stroke’ (i.e. awareness) were 79.5% and 61.2%. The rates of identification of ‘more than 50% of’ stroke risk factors and warning signs (i.e. knowledge) were 80.4% and 13.7%. The most identified stroke risk factor and warning signs were hypertension (44.4%) and numbness (46.9%). Family histories of stroke and lack of exercises were significant predictors of awareness of risk factors (R2= 0.301, p<0.05), and warning signs (R2= 0.259, p<0.01) while family history of stroke and secondary level education were significant predictors of awareness of all the warning signs of stroke (R2= 0.153, P<0.01). Male gender, family history of stroke, lack of exercise (R2= 0.090, p<0.01) and past smoker, 60 years old or less (R2= 0.325, p<0.05) were significant predictors of knowledge of stroke risk factors and warning signs respectively.

Conclusions: There is high level of awareness of stroke risk factors and warning signs, largely influenced by family history of stroke, secondary level education and lack of exercises. Also, there is a high and low level of knowledge of stroke risk factors and warning signs respectively among Nigerian rural community dwellers.

Abstract ID: S154

Title: Quality Of Life, Exercise Capacity And Muscle Strength In Coronary Patients Participating In Cardiac Rehabilitation, Compared With The General Population In Chile

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Pamela Seron, PhD1, María-José Oliveros, MSc.1, Gabriel N. Marzuca-Nassr, PhD1, Claudia Román, MSc.2, Manuel Galvez, PT3, Rocío Navarro, PT4, Gonzalo Latin, PT5, Tania Marileo, PT6, Juan P. Molina, PT7, Sherry L. Grace, PhD8,9.

Institution(s):1Universidad de La Frontera, Temuco, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile, 3Complejo Hospitalario San José, Santiago, Chile, 4Hospital Clínico Universidad de Chile, Santiago, Chile, 5Hospital San Borja Arriarán, Santiago, Chile, 6Hospital Regional de Antofagasta, Antofagasta, Chile, 7Hospital San Juan de Dios, Santiago, Chile, 8York University & University Health Network, Toronto, ON, Canada, 9University of Toronto, Toronto, ON, Canada.

Introduction: Ischemic heart disease is the second leading cause of disability-adjusted life years affecting functionality and quality of life.

Purpose: This report aims to compare health-related quality of life (HRQL), exercise capacity and muscle strength in coronary artery disease patients participating in Cardiac Rehabilitation in relation to the general population in Chile.

Design: Cross-sectional Study.

Methods: Baseline data from participants recruited into a randomized, multi-center, non-inferiority clinical trial conducted in Chile (Hybrid Cardiac Rehabilitation Trial, HYCARET) was used. The EuroQol-5 dimensions (EQ-5D) questionnaire, Six Minute Walk Test (6MWT), and grip strength assessed by dynamometer were applied. Comparative parameters were obtained from the Social Valuation of EQ-5D Health States in Chile for HRQL, from references values in healthy subjects in Chile for 6MWT, and from data obtained in the Chilean sample of the PURE Study for grip strength. Test statistics for one-sample proportions and means, were used to compare sample estimates to population values in the same age range and gender.

Results: 204 participants have been recruited in HYCARET between May 2019 and February 2020 (average age=58.6±9.9 years; 24.51% female; 69.12 revascularized). The most impacted HRQL dimensions were pain/discomfort (72.4% affected) and anxiety/depression (43.75%), proportions greater than those of the general population in Chile (39.6%, p<0.0001 and 30.9%, p<0.0001, respectively). Regarding exercise capacity, HYCARET participants walked on average 480.1±112 meters in 6 minutes, which was less than the healthy population who walked 562.5±29.7 meters (p<0.0001). Finally, HYCARET female participants had on average more muscle strength than the general population (20.1±6.15 vs 17.4±6.2 Kg, p<0.005) while in male there were no differences.

Conclusions: Quality of life and exercise capacity are very affected in the Chilean population with coronary artery disease when compared with the general population, at the same age strata and sex, however, the muscle strength in the sample studied was not lower than the data available from the general population. Clearly cardiac rehabilitation is warranted in this population, and this trial will determine whether participation can improve these key outcomes, and even bring them closer to healthy population values.

Abstract ID: S155

Title: Suitability And Acceptability Of A Self-efficacy Counseling In A Cardiac Rehabilitation Context In Chile

Track: Behavior Change

Author(s): Pamela Seron, PhD1, María-José Oliveros, PhD1, Daniela Gómez, PhD1, Gladys Morales, PhD1, María-José Arancibia, PT1, Tania Marileo, PT2, Rocío Navarro, PT3, Juan P. Molina, PT4, Gonzalo Latin, PT5, Manuel Galvez, PT6.

Institution(s):1Universidad de La Frontera, Temuco, Chile, 2Hospital Regional de Antofagasta, Antofagasta, Chile, 3Hospital Clínico Universidad de Chile, Santiago, Chile, 4Hospital San Juan de Dios, Santiago, Chile, 5Hospital San Borja Arriarán, Santiago, Chile, 6Complejo Hospitalario San José, Santiago, Chile.

Introduction: Education is one of the essential components in a cardiac rehabilitation program. There are several educational strategies and principles behind it, including counseling.

Purpose: To evaluate the suitability and acceptability of a self-efficacy-based counseling strategy in the context of a cardiac rehabilitation program in Chile.

Design: Cross-sectional Study.

Methods: In the context of a clinical trial on cardiac rehabilitation for patients with coronary disease (HYCARET Study), a counselling strategy was designed for the participants assigned to the experimental intervention. This counseling considered: (1) the theory of self-efficacy as a basis for lifestyle changes; (2) the use of an accompanying manual entitled “How can I live better?” designed with thematic sections (coronary disease, self-efficacy, physical activity, diet, smoking and adherence to drug therapy), key messages, and progress checklists; and (3) progressive dialogue between therapist and patient during face-to-face exercise sessions. At the end of the exercise sessions, the participants answered a survey that included 12 questions about the accompanying manual and 3 questions related to the dialogue established with the therapist. Data collected were analyzed in a descriptive way.

Results: 55 participants (22% female) from 6 cardiac rehabilitation centers in Chile were included. Mean age was 58.4+9.98 years, 31% have primary education or less. 98.15% of the participants considered that the accompanying manual was easy to understand and allowed them to know much more about their disease and treatment. 100% considered that the manual will be useful for future doubts, is well designed in terms of colors and figures, is recommended for people with coronary disease, has been important for their treatment, captured their attention by reading it, contained suggestions applicable to daily life, and was easily understandable. In addition, 69.1% of the participants stated that they had reviewed the manual after the face-to-face exercise sessions, and there were some suggestions that it could include even more content or that it should be deeper or suggest further reading and that the letters should be larger. The overall rating for the accompanying manual, on a scale of 1 to 7, was 6.69±0.59. Regarding interaction with the therapist, it was recognized that there was a dialogue on each topic contained in the manual 94.8% of the time, with 98.18% of the participants rating the manual as useful to support the dialogue within the exercise session. Additionally, 93% considered that the time dedicated to the dialogue was adequate and 98.18% considered that the dialogue was carried out in an atmosphere of trust and always their doubts were solved. Finally, 98.18% of the participants declared that they were satisfied with the counseling.

Conclusions: A counseling strategy based on self-efficacy was acceptable and suitable to implement in the context of a cardiac rehabilitation program in Chile.

GRANT: Fondecyt N° 1181734

Abstract ID: S156

Title: Systematic Review Of Interventions Designed To Maintain Or Increase Physical Activity Post-cardiac Rehabilitation Phase II

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Helen L. Graham, PhD, RN-BC, CNS, FAACVPR, Kathy Prue-Owens, PhD, RN, Jessica Kirby, PhD, Mythreyi Ramesh, RN, BSN.

Institution(s): University of Colorado Colorado Springs, Colorado Springs, CO, USA.

Introduction: CVD continues to be the number one cause of death in the US and globally. Individuals with a history of a cardiac event are at increased risk for a repeat event. Physical inactivity creates health problems for individuals with chronic heart disease. Evidence shows exercise which is a central component of Cardiac Rehabilitation Phase II (CRII), decreases hospital readmission and mortality up to 50%. Adherence to exercise is lacking within months following CRII completion.

Purpose: The purpose of this review was to evaluate interventions designed to assist individuals diagnosed with Myocardial Infarction (MI), Coronary Artery Bypass Graft (CABG), Coronary Artery Disease (CAD), and Percutaneous Coronary Intervention (PCI) to maintain physical activity (PA) post-CRII. Secondary aims include an update of prior reviews and to inform health care providers of effective PA maintenance interventions available.

Design: Systematic Review.

Methods: This review was designed according to the Preferred Items for Systematic Reviews and Metanalysis Guidelines (PRISMA). Multiple databases for the literature search included PubMed, PsychInfo, Cinahl, Medline, Cochrane, and Scopus. Key words included exercise, physical activity, adherence, maintenance, cardiac rehabilitation, and intervention. Primary research articles published in English with participants 18 years and older who completed a CRII program and participated in an intervention study to maintain or increase PA were eligible for inclusion. Review papers and studies with patients enrolled in CRI or CRIII were excluded. Two individuals reviewed all studies meeting inclusion criteria and agreed on the selection. A third individual was involved when there was a lack of consensus. Quality and risk for bias were assessed according to the Downs and Black Checklist.

Results: A systematic search of electronic databases including a hand-search of peer-reviewed articles published between 2000 and 2019 yielded 19 randomized control trials retained for descriptive analysis. The study interventions were categorized in to one of three domains; 1) cognitive behavioral interventions 2) physical activity interventions, and 3) combined cognitive & physical activity intervention. Thirteen (68%) of the studies reported significant PA outcomes following participation in an intervention. The average age was 61.3 years, and 76.8% were males. Most studies were published outside the US. Objective outcome measurements were used for approximately half of the studies and self-reported PA outcomes for most of the studies. The outcome measurements used varied considerably.

Conclusions: Interventions designed to help individuals maintain PA post- CRII appear promising. The interventions studied varied widely. Most studies included interventions designed according to a cognitive-behavioral theory. Healthcare providers should consider encouraging patients to enroll in an intervention designed to maintain PA post-CRII.

Abstract ID: S157

Title: Determinants Of Compliance With The Global Recommendation On Physical Activity In Chilean Adult Population

Track: Physical Activity/Exercise

Author(s): Maria Jose J. Oliveros, MSc PT1, Pamela Seron, PhD MSc PT1, Shrikant Bangdiwala, PhD2.

Institution(s):1Universidad de La Frontera, TEMUCO, Chile, 2Population Health Research Institute, McMaster, Hamilton, ON, Canada.

Introduction: Physical activity levels are low in Chile and around the world. Neighbourhood conditions and personal characteristics play an important role in primordial prevention.

Purpose: To evaluate the impact of neigbourhood and individual characteristics in the physical activity global recommendation accomplishment in adults from Temuco city between 2009 and 2017.

Design: Cohort Study.

Methods: This analysis was carried out on a cohort assembled between 2006 and 2008, of adults between 35 and 70 years of age from different neighborhoods in the city of Temuco, Chile, in the context of the Prospective Urban and Rural Epidemiology (PURE) Study, including measurements taken between 2009 and 2017. In this period, 3 measurements of physical activity were made over time using the IPAQ short form, which determined whether or not participants met the WHO physical activity recommendation at each time in the study. The potential variables determining compliance with physical activity recommendations were: At the level of the neighborhood's environment: population density and implementation of healthy squares, for which an index was constructed dividing the number of blocks in a neighborhood by the number of squares. At the individual level: being older or not, sex, socioeconomic level, educational level, suffering from major health events, and BMI. A multilevel regression analysis was performed. The PURE study protocol was approved by the SSAS ethics committee and participants signed informed consent upon entering the study, re-consenting during follow-up.

Results: 3495 observations were analyzed, corresponding to 1773 adults living in 15 neighborhoods in Temuco. The average age at the time of recruitment was 52.04 years + 9.7 (26.8% were over 60). 69% were women. The population density explains the variability among the neighborhoods. Age, educational level, and the presence of a major health event explain the variability among subjects in the same neighborhood. By having one more block assigned to an available space, the probability of meeting the physical activity recommendation decreases by 0.58%. Being male increases the probability of meeting the recommendation by 39.5%.

Conclusions: Healthy squares appear to have a marginal positive impact on compliance with the PA recommendation, while being male is significantly associated with increased likelihood of compliance with the global physical activity recommendation.

Abstract ID: S158

Title: Nursing Autonomy Bridging The Gap: Improvisation Of The Referral Process To Outpatient Cardiac Rehabilitation Enhancing Transitional Care

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jonathan DAVID, MSN, RN, CCRP, NE-BC, ONC

Institution(s): STANFORD HEALTH CARE, STANFORD, CA, USA.

Introduction: Challenges in chronic disease management are ubiquitous, health care organizations, providers, community partners, patients, and families look toward a smooth and effortless transitional care process. Patients following MI, PCI, CABG, heart valve surgery, heart transplant, and heart failure strongly benefit from early enrollment to outpatient cardiac rehabilitation. The emphasis is on referring to outpatient cardiac rehabilitation before discharge from the hospital and clinic to support early enrollment. Acute care inpatient settings have struggled with the barriers in implementing and sustaining referral rates over 70% among eligible patients. At Stanford health care, driven by nursing autonomy, a quality improvement method was adopted to bridge the gap in the outpatient cardiac rehabilitation referral process and overall enhance transitional care.

Purpose: Translating scientific evidence into daily practice is essential, especially in caring for individuals requiring chronic disease management. Most of the cardiovascular illnesses heavily depend on the effectiveness of chronic disease management processes to improve clinical outcomes. At Stanford health care, driven by nursing autonomy, a quality improvement method was adopted to bridge the gap in the outpatient cardiac rehabilitation referral process and overall enhance transitional care.

Design: The methodology consisted of the quality improvement method using Plan-Do-Study-Act to explore the cause and effect systematically. Interventions were aligned to overcome barriers using the driver diagram and A3 tool.

Methods: An electronic referral system was developed within the EHR, which enabled attachment of clinical documents and electronically sent to multiple providers in one sitting. The introduction of the electronic referral method enhanced the rate of referral significantly. The referral date was captured by screening patients with the eligible ICD code 10 and rated against the percentage referred to OPCR before discharge.

Results: The descriptive findings of the Plan-Do-Study-Act study revealed several barriers, including the lack of education on the need for cardiac rehabilitation following discharge, and it was up to the outpatient cardiologist, lack of documentation in electronic health records (EHR) on referrals faxed manually via the physical fax device. The referral rate at baseline for the period January 2012 to January 2019 was at 3.7% in both inpatient and outpatient settings. Implementation of the revised referral process yielded a significant increase in the rate of referral over 70%, consistently meeting the stretch of 90%.

Conclusions: The combination of nursing autonomy and improving the process of referral benefitted patients, families, and providers to experience a smooth transitional care process and enabling referral before discharge among all eligible patients.

Abstract ID: S159

Title: Effect Of Simple Quality Improvement Projects On Cardiac Rehabilitation Referrals, Enrollment, And Adherence

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jessica Firmeza, DNP, APRN1, Mary Hooshmand, PhD, MS, RN2, Sharon Andrade-Bucknor, MD, FACC3, Sabine M. Gempel, PT, DPT, CCS3, Meryl Cohen, MS, DPT, CCS, FAPTA4, Torin P. Thielhelm, BS3, Camille Go, MD5, Lawrence P. Cahalin, PhD, PT4.

Institution(s):1University of Miami Hospital, Miami, FL, USA, 2University of Miami School of Nursing and Health Studies, Coral Gables, FL, USA, 3University of Miami Miller School of Medicine, Miami, FL, USA, 4University of Miami Miller School of Medicine, Department of Physical Therapy, Coral Gables, FL, USA, 5Kendall Lakes Health and Rehabilitation, Miami, FL, USA.

Introduction: Referral (REF), enrollment (ENROLL), and adherence (ADHER) to cardiac rehabilitation (CR) is poor due to several factors including underuse and lack of physician endorsement, inefficient REF systems, poor patient motivation, inadequate reimbursement, and geographic limitations. Quality improvement projects (QIPs) have been found to improve aspects of REF, ENROLL, and ADHER with implementation of automatic CR REF discharge order sets and providing a patient navigator (PN) to educate patients and assist with ENROLL processes. Little is known on the effects of simple QIPs.

Purpose: To examine the effects of simple QIPs on REF, ENROLL, and ADHER to CR.

Design: QIP.

Methods: The simple QIPs included automating CR referrals in the electronic health record (EHR) discharge checklist diagnosis-related order sets and standardizing CR orders by adding “hard stop” alerts (a computer-required question) to capture qualified diagnoses for CR. The PN then met with qualified patients and their families for education prior to discharge or placed phone calls to patients after REF orders were received from the EHR work queue. Included in this initial education session, a 6-item pretest and post-test were administered to the patients. The PN assisted patients in person or via phone with pre-ENROLL processes and provided initial evaluation appointments after insurance verification was confirmed. The PN also conducted in-services to cardiac units' staff with a 7-item pre- and post-knowledge test to examine the effects of education on these staff members.

The CR team conducted an educational presentation during cardiology grand rounds entitled, “Cardiac Rehab: Why Bother?”. Cardiologists received a pre- and post-presentation survey, “Physician Attitude towards Cardiac Rehabilitation and Referral Scale” (PACRRS). This survey consists of 19 items on a Likert scale, to assess physicians' attitudes and beliefs about CR and REF. The 20th question is an open-ended item asking physicians to list the most important factors that influence their decision to refer a patient to CR.

Results: The effects of simple QIPs over a 12-week period included a 58% increase in REFs and 15% increase in ADHER. However, ENROLL was not found to increase. The patient and clinical staff education test results found a 48% and 30% improvement, respectively. Cardiologist responses to the open-ended question included concerns related to insurance, cost, time, REF process, and ease of patient access.

Conclusions: Simple QIPs over a 12-week period improved many key metrics of CR but did not improve ENROLL. Potential reasons for this lack of improvement in ENROLL include insurance coverage, high copay requirements, distance and transportation to CR, and return to work. The reasons for improvement in other key metrics include automating CR REF, coordination of inpatient and outpatient CR by PNs, patient and provider education, and appointments for initial evaluation within 30 days of discharge. Further investigation of the role of a PN appears warranted.

Abstract ID: S160

Title: Exercise Awareness Smile Therapy: Flow In Cardiac Rehabilitation And Implications For Sustainable Lifestyle Changes

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Anand Chockalingam, MD, FACC, FAHA, FASE1,2.

Institution(s):1University of Missouri, Columbia, MO, USA, 2Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA.

Introduction: Cardiovascular diseases (CVD) are the leading cause of mortality globally. Majority (over 80%) are sedentary accounting for 250,000 deaths in the US alone. Flow inducing physical activities (FPA) are well described in athletes and may enhance exercise compliance in cardiac patients. We appear to be the only program prospectively targeting flow in cardiac rehabilitation.

Purpose: To evaluate scope for Exercise Awareness Smile Therapy (EAST), a novel meditative exercise tool targeting FPA in sedentary STEMI patients post coronary revascularization.

Design: Education and motivational training aimed at FPA in cardiology group clinic setting.

Methods: The Flow phenomenon is an intrinsically enjoyable, exceptionally positive state of mind. Cardiac patients engage in weekly session of 30 minutes didactics, 15 minutes tailored exercise training and 15 minutes exploring various self- inquiry meditative tools during physician-led cardiac wellness group clinics. Based on Modified Borg Dyspnea Scale 0-10 rating of perceived exertion (RPE), patients attempt safe yet increasingly challenging levels of exertion (exercise awareness) at home. Smile therapy is relaxation, self-suggestion of being ‘lighter’ and consciously smiling while actively exercising. Post exercise, patients grade their experience on 1-5 FPA scale, 1) ‘looking back, I performed Beyond my expectations’, 2) ‘things happened Effortlessly & I felt weightless’, 3) ‘it was a Fun & rewarding experience, I look forward to’, 4) ‘the sense of self “I” was lost, yet there was intuitive awareness’ and 5) ‘Time just stopped, long periods feeling like a blur or a moment’.

Results: We report the FPA EAST experience with two of our cases. A 50-year-old sedentary engineer developed anterior STEMI and ventricular fibrillation arrest, was revascularized and completed cardiac rehabilitation (CR) as well as our cardiac wellness program. His exercise tolerance improved steadily over 3 months. At constant treadmill speed of 3.7mph, most sessions would forcibly terminate due to exhaustion at 30-40 minutes on reaching RPE 10. However, on some occasions his heart rate would stabilize at about 133bpm, and importantly, RPE would drop to 2 as he felt ‘relaxed’ and ‘weightless’ and continued running an additional 15 -20 minutes comfortably (FPA 22). A 68-year-old sedentary professor required emergent revascularization for inferior STEMI and completed 3 months CR along with our cardiac wellness program. From a baseline 2-3 blocks tolerance, he progressively increased in exercise capacity. He started competitive running for the first time at the age of 69 years and completed a 5K run in 45 minutes. With FPA increasing from 14 to 18, he has begun weight training to enhance athletic performance in future athletic events.

Conclusions: Sedentary cardiac patients willing to learn simple exercise self-monitoring tools can safely explore the limits of their physical capacity after coronary events. Targeting flow may increase compliance with exercise prescription. EAST may inspire cardiac patients to engage in physical activities beyond rehabilitation requirements, finding this a fulfilling and deeply rewarding exercise.

Abstract ID: S161

Title: Impaired Ventricular Wall Motion After Percutaneous Coronary Intervention Is Associated With Greater Response To Cardiac Rehabilitation In Patients With Preserved Ejection Fraction

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Wei Yuan, M.D1, Harry B. Rossiter, Ph.D2, Shan Nie, M.D1, Jia Nan, B.D1, Pei-jun Gui, Ph.D1, Dongxing Zhao, Ph.D3, Asghar Abbasi, Ph.D2, Nicholas B. Tiller, Ph.D2, Janos Porszasz, Ph.D2, Haoyan Wang, Ph.D1.

Institution(s):1Beijing Friendship Hospital affiliated of Capital Medical University, Beijing, China, 2The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA, 3First affiliated Hospital of Guangzhou Medical University, Guangzhou, China.

Introduction: Cardiac rehabilitation (CR) ameliorates symptoms and increases peak oxygen uptake (VO2peak) during recovery from acute coronary syndrome (ACS), despite preserved left ventricular ejection fraction (LVEF). Whether other measures of cardiopulmonary function are associated with CR benefit is unclear.

Purpose: To identify baseline patient characteristics that associate with increases in cardiopulmonary function after CR.

Design: Eighteen acute coronary syndrome (ACS) patients (16 male; 55 ± 11 years) were studied after percutaneous coronary intervention (baseline) and after completion of 3-month CR (follow-up) in a prospective, intention-to-treat study design.

Methods: Stable patients attended CR after hospital discharge. LVEF, LV end-diastolic diameter (LVEDD), early/late diastolic filling velocity ratio (E/A) and wall motion score (WMS) were assessed by echocardiography at rest. VO2peak and other exercise variables were measured by cardiopulmonary exercise test (CPET). Patients were stratified by ventricular wall motion at baseline: Group A= normal wall motion; Group B= regional wall motion abnormality. Ischemia was quantified by WMS. Pre/post CR measures were compared by t-test. Multiple liner regression was used to identify baseline characteristics associated with the change in VO2peak following CR.

Results: All 18 participants completed the 3-month CR and CPET assessments, while 11 underwent echocardiography after CR. In all subjects, there was no change in LVEF (62±5 vs. 63±7%; p=0.78) or LVEDD, but E/A (1.18±0.34 vs. 1.05±0.20; p=0.040) and WMS (18.1±1.5 vs. 16.7±1.3; p=0.035) were reduced following CR. Peak work rate (116±20 vs. 133±22 W; p=0.020), lactate threshold (12.9±2.6 vs. 14.9±2.4 ml/kg/min; p=0.022) increased, and VO2peak tended to increase (20.3±3.0 vs. 22.5±3.6 ml/kg/min; p=0.065) after CR. Subgroup analysis showed there were no significant increases in echocardiography or CPET variables in Group A (normal WMS), whereas peak work rate, ventilation at peak and heart rate recovery at 3 minutes post exercise were increased (p<0.05) in Group B (abnormal WMS). Multivariate regression analysis revealed significant associations of WMS (standardized β=0.82; p=0.014), LVEF (β=0.79; p=0.02) and VO2peak (β=-0.53; p=0.016) with the increased in VO2peak following CR (R2 =0.57). There were no serious adverse events during the study.

Conclusions: During recovery from ACS, worse baseline ventricular wall motion score, greater LVEF and lower VO2peak after percutaneous coronary intervention was associated with greater response to CR in the form of increased VO2peak. Wall motion score was significantly associated with the efficacy of cardiac rehabilitation in patients with preserved ejection fraction.

Abstract ID: S162

Title: Exercise Intensity Predicts Outcome Of Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Stephanie Gerlach, Ph.D.1, Micah Zuhl, Ph.D.2.

Institution(s):1Missouri Western State University, Saint Joseph, MO, USA, 2Central Michigan University, Mount Pleasant, MI, USA.

Introduction: Improvement in functional capacity (FC) measured as oxygen utilization (ml*kg−1*min−1) is the primary physical outcome variable among cardiovascular disease patients enrolled in cardiac rehabilitation (CR). Positive changes in FC as a result of CR have been linked to decreased mortality and re-hospitalization rates for patients. Functional capacity is often measured in peak METs due to the ease of use, where 1 MET equals 3.5 ml*kg−1*min−1. In addition, METs is often used to established and progress a patient's workload throughout CR. Evidence suggests that patients who exercise at higher exercise workloads (measured in METs) throughout CR achieve higher peak METs in an exercise test post CR. However, it is unknown how exercise workloads obtained every 12 sessions of CR influence MET changes among coronary artery disease (CAD) patients. Evaluating the impact of intensity measured in METs at every 12 sessions interval of CR will direct clinicians towards designing and implementing effective exercise programs for every 12 sessions for a standard 36 session CR program.

Purpose: To evaluate the impact of treadmill walking intensity every 12 sessions of CR on the total change in METs over 36 sessions of CR among CAD patients.

Design: A retrospective database study between the years 2014 to 2018.

Methods: Data was extracted for 150 CAD patients from a clinic located in Albuquerque, NM. Exercise intensity for each patient was obtained from the in-house clinical database. Outcome data (FC - measured as change in peak metabolic equivalents, METs, from pre- to post-CR) was extracted from the AACVPR registry. Intensity was based on treadmill exercise workload throughout CR. Session intensity was average (11-13;23-25;34-36) to represent an estimate of METs for every 12 sessions (12,24,36). A repeated measures ANOVA was completed to check for changes between every 12 sessions of CR. Data was used to develop a multiple linear regression model to predict the impact of intensity on the improvement in FC during CR. The predictors in the model were exercise intensity at sessions 1, 12, 24 and 36. Age and sex were the confounding variables in the model.

Results: A repeated measures ANOVA indicated a significant increase in intensity for each twelve sessions of CR among patients (p< 0.001). The regression model identified that significant proportion (49%) of the total change in FC was predicted by intensity for every 12 sessions (1, 11-13, 23-25, 34-36), age, and sex. Intensity at the end of CR (36; β=1.142, p<0.001) was a significant predictor in the model.

Conclusions: Among a cohort of CAD patients, exercise workload is a main predictor in outcomes of CR. Exercise intensity towards the end of a standard 36 session CR program is a significant predictor in FC and therefore outcome of CR and change in mortality risk. It is important to ensure continues increases in workload over the course of a 36 session CR program.

Abstract ID: S163

Title: Systematic Changes And Dashboard Monitoring Increased Cardiac Rehabilitation Referral, Enrollment, And Participation In Hospitalized Patients With Cardiac Events

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Lue Lao, MD, MPH, Xuan-Khoi Dang, BS, Eddie Eabisa, BA, Francis Sitorus, BS, Dana Carrington, MS, Armon Hosseini, MSN, Duncan Warren, BA, MA, Susan Stewart, PhD, Radhika Bukkapatnam, MD, MAS, Javier López, MD, MAS.

Institution(s): University of California-Davis, Sacramento, CA, USA.

Introduction: Cardiac Rehabilitation (CR) improves mortality and re-hospitalization. The current guidelines recommend patients with acute myocardial infarction (AMI), CABG, percutaneous coronary intervention (PCI), systolic heart failure (sHF) and valvular repair/replacement (VR) to participate in CR. However, CR is nationally underutilized with a participation rate at 20%.

Purpose: To assess the efficacy of interventions that were implemented in August 2019 as part of a Quality Improvement project. Interventions included EMR modification (CR referral single order, built-in CR referral order into the discharge ordersets), Dashboard monitoring, and staff education.

Design: Retrospective study and chart review.

Methods: Retrospective study on hospitalized patients at the University of California-Davis Medical Center from 6/1/2017 - 3/31/2020. SAS was used to compute p-value.

Results: The baseline referral rates for AMI, PCI, AMI with PCI, CABG, VR and sHF were 2.59%, 46.40%, 47.72%, 75.63%, 10.10%, and 4.20%. The referral rates for AMI, PCI, AMI with PCI, CABG, VR, and sHF increased by 7.62%, 13.41%, 35.89%, 3.16%, 26.84%, and 7.38%, respectively (p-value being <0.05, except PCI or CABG). Baseline enrollment rates for PCI, AMI with PCI, sHF, VR and CABG were 18.86%, 19.30%, 2.19%, 1.68%, and 33.07%. Enrollment rates for PCI, AMI with PCI and VR increased by 5%, 7.57%, 3.24%, respectively. Baseline participation rates for PCI, AMI with PCI and VR were 18.01%, 17.54%, 2.01%, 1.68%, and 30.71%. Participation rates for PCI, AMI with PCI and VR increased by 5.85%, 9.33%, 3.24%, respectively. Baseline completion rates for PCI, AMI with PCI and VR were 14.61%, 9.09%, 0.00%, respectively. Completion rates for PCI, AMI with PCI and VR increased by 13.96%, 24.24%, 33.33%, respectively.

Conclusions: The systematic changes improved the workflow of CR referral, which resulted in more and appropriate referrals being made. The Dashboard allowed remote tracking of the referral rate and alerted the UC Davis CR team to intervene when the rate was below goal.

Abstract ID: S164

Title: Self-reported Outcomes Following Covid-19 Triggered Transition To Virtual Cardiac Rehabilitation

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Kevin Manwaring, BS1, Natalie Holdaway, BS2, Amy Johnson, BS2, Brittany Pruden, RN BSN2, Michelle Milano, RN BSN2, Dawn Young, RN BSN, BA2, William Western, BS2, Paola Rampton, BA2, Amanda Markie, MS, RDN, LD2, Lillian Khor, MB.BCh, Ms2.

Institution(s):1University of Utah Health, Salt lake city, UT, USA, 2University of Utah Health, salt lake city, UT, USA.

Introduction: On March 11th, 2020 the World Health Organization declared COVID-19 a pandemic, prompting the closure of our comprehensive and traditionally center-based Cardiac Rehabilitation (CCR) gyms and a rapid transition to a novel Virtual Cardiac Rehabilitation (VCR) platform for our CR program.

Purpose: The effectiveness of a rapid transition to virtual cardiac rehabilitation is unknown and the purpose of this study was to assess the relative effectiveness of VCR by 1) comparing the relative completion rates to VCR as compared to our traditional center-based program; 2) resting blood pressure (BP) changes; and 3) compare the outcome measures of self-reported anxiety and depression, functional capacity, and diet quality with CCR when staffed by the same providers.

Design: Prospective observational case-controlled cohort study of VCR patients enrolled between March 23 and April 19th, 2020.

Methods: Prospectively recruited VCR patients' completion rates, relative changes in resting BP, self-reported measures of anxiety and depression, functional capacity, and diet were compared with a retrospective control cohort of CCR patients from our institutional American Association of Cardiovascular and Pulmonary Rehabilitation registry (AACVPR) between 2013-2019 using two-tailed t-test.

Results: Following our gym closure, 42 new patients were recruited to VCR with a pending completion rate as compared to a completion rate of 52% from the 785 patients who completed CCR between 2013-2019. Upon orientation, the average resting blood pressure in both VCR and CCR cohorts were normal and not statistically different. The reported functional capacity by the Duke Activity Score Index (DASI) was 5.89 metabolic equivalents (METs) in the VCR group, which was not statistically significant to our respective control cohort of 785 CCR patients who had an average DASI of 5.54 METs upon orientation. The average Rate your plate score in our VCR cohort was 55.52 as compared to 56 and the PHQ-9 score was similar at 6.2 and 5.7 respectively. At the end of 8 weeks of VCR the completion rates and same outcome measures will be compared with our CCR cohort.

Conclusions: Completion rates from VCR are expected to be higher than CCR when compared to retrospective completion data by our AACVPR registry, but at the cost of a lesser improvement in functional capacity and anxiety and depression is more modest in VCR. The reasons behind these differences deserves further investigation.

Abstract ID: S165

Title: Oxygen Uptake Efficiency Slope Changes After Cardiac Rehabilitation In Heart Failure Patients

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Nicolas Arellano, MD1, Juan M. Sarmiento, MD2,1, Alberto Lineros, MD1, Fabian Cortes, BSN2, Jenny C. Sanchez, PT2.

Institution(s):1Universidad El Bosque, Bogota DC, Colombia, 2Fundacion Clinica Shaio, Bogota DC, Colombia.

Introduction: Oxygen uptake efficiency slope (OUES) has potential diagnostic, prognosis and follow-up value in patients with heart diseases. Although there is methodological consensus for the OUES calculation and interpretation as compared with other cardiopulmonary exercise testing (CPET) variables, much is yet to be elucidated about it and additional investigation is needed to define its truly utility.

Purpose: In this study, we assessed the oxygen uptake efficiency slope and its changes before and after a cardiovascular rehabilitation program (CVRP) in patients with heart failure with reduced ejection fraction, in order to provide more information on the behavior of this variable. We hypothesized an increase in OUES value after the cardiovascular rehabilitation program. Additionally, we searched for correlation between OUES and V˙o2 peak and for similarity in OUES values when calculated in different moments of the CPET.

Design: Analytical, retrospective and pseudo-experimental study.

Methods: Thirty-six medical records corresponding to patients with heart failure with reduced ejection fraction were eligible for the study. Patients had attended a cardiovascular rehabilitation program of at least 36 sessions of exercise and had undergone two CPETs (before and after CVRP). V˙o2 peak and OUES were calculated for each of the 72 CPETs (OUES at different moments of the test) and statistical analyses were driven. A frequentist approach of descriptive and inferential statistics was used. Student's t test was used for comparisons of pre and post intervention OUES values; Pearson correlation coefficient was used for association between OUES and V˙o2 peak ; and ANOVA was used for comparisons between OUES values in different CPET moments.

Results: Pre-intervention oxygen uptake efficiency slope was 1521 ± 462 mL · min-1 (mean ± standard deviation) and an improvement of 188 mL · min-1 with 95%CI of 105 - 273 (p <0.001) post-intervention was seen. There was a correlation rho > 0.9 between oxygen uptake efficiency slope and V˙o2 peak (p <0.001). ANOVA showed no statistical differences between OUES values when calculated at different moments of CPET.

Conclusions: Oxygen uptake efficiency slope is significantly diminished in patients with heart failure with reduced ejection fraction. The results of this study suggest that this variable presents significant improvements after a cardiovascular rehabilitation program. Statistical analyses show a good correlation between the OUES and the V˙o2 peak in this population. Calculation of the OUES in different moments of CPET demonstrated no significant differences between them. Therefore, given previous evidence and the results of this study, we propose that this cardiopulmonary exerciser testing variable should be systematically used in the assessment and follow-up of patients with heart failure with reduced ejection fraction.

Abstract ID: S166

Title: Cardiopulmonary Exercise Test (CPET) Guided Intensive Cardiac Rehabilitation in Patients Post Acute Coronary Syndrome (ACS)

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Rituparna Shinde, MD DNB FACC, Asawari Page, MPTH, Ashwini Joshi, MD, Suresh Shinde, MD.

Institution(s): Aloha Lifestyle Reversal Studio, Pune, India.

Introduction: CPET has been shown to be useful in exercise prescription and prognostication of cardiac patients for intensive Cardiac Rehabilitation (CR). We are studying usefulness of CPET guided CR in post ACS patients.

Purpose: To objectively demonstrate usefulness and confirm utility of CPET in post ACS patients going for intensive CR.

Methods: Retrospective analysis of 19 patients who underwent CR post ACS was done. Patients underwent a CPET prior to and after 36 sessions of Intensive CR. Duration of exercise, Total load, Peak oxygen uptake (pVO2), percentage of predicted PVO2, Minute ventilation to CO2 production (VE / VCO2) slope, O2 pulse at peak and in percentage of predicted, Heart Rate maximum (HRmax) at peak and Vo2 work slope are compared pre and post CR. Clinical examination, ECG and 2D Echocardiography were done prior and post CR.

Results: We analyzed 19 patients, 14 (73 %) male and 5 (27%) females. Mean Left Ventricular ejection fraction 42.3 %. Significant improvement was observed in duration of exercise and peak load achieved pre and post CR. Peak VO2 was mild to moderately reduced pre CR (mean 74% of predicted), which showed significant improvement post CR to 79% of predicted. O2 pulse showed significance improvement post CR (72% vs 84% of predicted). Maximum Heart Rate (HRmax) also showed improvement post CR. VE/VCO2 slope and VO2 / WR slope showed nonsignificant improvement post CR.

Conclusions: Patients post ACS show significant improvement in functional capacity and cardiac circulatory markers in CPET after intensive exercise based cardiac rehabilitation. CPET is an important tool to objectively assess the cardiovascular circulatory status and usefulness of CR.

Abstract ID: S167

Title: Resistance Training Following Median Sternotomy: A Systematic Review With Meta-analysis

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jacqueline Marie Stacey Pengelly, PhD, MClinExPhys, MTeach, BExSpSci1,2, Michael John Stacey Pengelly, MAppSpSci; BExSpSci3, Kuan-Yin Lin, PhD4, Colin Royse, MD5,6, Alistair Royse, MD5,7, Adam Bryant, PhD5, Gavin Williams, PhD5, Doa El-Ansary, PhD1,5.

Institutions: 1Swinburne University of Technology, Melbourne, Australia, 2Charles Sturt University, Bathurst, Australia, 3Central Queensland University, Cairns, Australia, 4National Cheng Kung University, Tainan, Taiwan, 5University of Melbourne, Melbourne, Australia, 6Outcomes Research Consortium Cleveland Clinic, Cleveland, OH, USA, 7Royal Melbourne Hospital, Melbourne, Australia.

Introduction: Despite no evidence to suggest that restricting upper limb and trunk movements improves bone healing and prevents sternal complications, sternal precautions are typically prioritised over exercise for 8 to 12 weeks following surgery. Resistance training may play a role in the reduction of inflammation, cognitive dysfunction and sarcopenia, which can persist for several months after surgery. Furthermore, resistance training augments improvements in cardiovascular fitness, muscle strength, quality of life and the ability to perform activities of daily living. However the disconnect between current sternal precautions, cardiac rehabilitation resistance training guidelines and emerging evidence is problematic for clinicians delivering evidence-based exercise interventions.

Purpose: To determine how resistance training is defined, applied, progressed and evaluated in the median sternotomy cardiac population; and its subsequent effect on physical and functional recovery.

Design: A systematic review with meta-analysis.

Methods: Five electronic databases were searched for relevant key terms. Studies eligible for inclusion were published in English and evaluated the effect of resistance training on physical and functional recovery in adults (≥18 years) undergoing cardiac surgery via median sternotomy (valve surgery and/or coronary artery bypass grafting). Two independent researchers assessed articles for relevance and eligibility prior to data extraction and quality appraisal, with a third independent reviewer for overall agreement. Data extraction was undertaken using the Law and MacDermid Quantitative Review form and guidelines, whilst study quality and risk of bias was assessed using a modified Downs and Black tool.

Results: Quality appraisal of the 18 included studies found that the definition of ‘resistance’ was primarily defined as callisthenic or range of motion-type exercises. No studies met all ACSM resistance training guidelines and the inadequate reporting of the weights and exercises used in the resistance training interventions did not allow for interpretation. However, session frequency (2-3 days/week) and program duration (4-6 months) were met by ten and five studies, respectively. Meta-analysis was performed on seven studies investigating the effects of resistance training alone after cardiac involving median sternotomy. When comparing aerobic and resistance training interventions, there was no statistically significant improvement in cardiopulmonary capacity measures of VO2peak and treadmill time (mean difference= 0.24; 95% CI= −0.32-0.80; p=0.40; I2=58%) or anthropometric measures of body mass index and body weight (mean difference= −0.06; 95% CI= −0.36-0.24; p = 0.91; I2 = 0%). However, the addition of resistance training to standard care showed a trend toward 6-minute walk distance improvement (mean difference= 13.76m; 95% CI= −4.07-31.59; p=0.13; I2=54%).

Conclusions: Resistance training shows potential in optimising patient physical and functional recovery following cardiac surgeries via median sternotomy through improved neurogenesis, neuromuscular control and muscle activation patterns. However, the effect of early resistance training on sternal healing remains unknown and further research to inform clinical guidelines in required.

Abstract S168

Title: Cardiac Rehabilitation Following Median Sternotomy In The Elderly: A Systematic Review With Meta-analysis

Track: Cardiovascular Rehabilitation & Clinical Cardiology

Author(s): Jacqueline Marie Stacey Pengelly, PhD, MClinExPhys, MTeach, BExSpSci1,2, Michael John Stacey Pengelly, MAppSpSci; BExSpSci3, Kuan-Yin Lin, PhD4, Roshan Karri, BBMed5, Colin Royse, MD5,6, Alistair Royse, MD5,7, Adam Bryant, PhD5, Gavin Williams, PhD5, Doa El-Ansary, PhD1,5.

Institutions: 1Swinburne University of Technology, Melbourne, Australia, 2Charles Sturt University, Bathurst, Australia, 3Central Queensland University, Cairns, Australia, 4National Cheng Kung University, Tainan, Taiwan, 5University of Melbourne, Melbourne, Australia, 6Outcomes Research Consortium Cleveland Clinic, Cleveland, OH, USA, 7Royal Melbourne Hospital, Melbourne, Australia.

Introduction: More than 1.5 million cardiac operations are performed annually, worldwide. Patients undergoing these procedures are typically elderly with multiple co-morbidities, which places them at a higher risk of post-operative cognitive and functional decline. Whilst exercise has beneficial effects on effects on exercise capacity, inflammation, autonomic function, muscular strength, the exercise prescription and outcome measures used in elderly cardiac patients following median sternotomy are unknown.

Purpose: To identify the exercise parameters (frequency, duration, intensity and mode) and outcome measures used in cardiac rehabilitation programs, in elderly patients following median sternotomy and their compliance with international cardiac rehabilitation guidelines.

Design: A systematic review with meta-analysis.

Methods: Five electronic databases were searched for relevant key terms. Studies eligible for inclusion were published in English between 1997- September 2018, evaluating the physiological or cognitive effects of post-operative cardiac rehabilitation exercise interventions in elderly patients (≥65 years) following cardiac surgeries via median sternotomy (valve surgery and/or coronary artery bypass grafting). Two independent researchers assessed articles for relevance and eligibility prior to data extraction and quality appraisal, with a third independent reviewer for overall agreement. Data extraction was undertaken using the Law and MacDermid Quantitative Review form and guidelines, whilst study quality and risk of bias was assessed using a modified Downs and Black tool.

Results: Study quality appraisal was undertaken on 11 studies. Exercise parameters for the included studies ranged from 1 week to 6 months in program duration, 1-7 days/week, for 30-120 minutes at a light-moderate intensity. Aerobic training interventions in seven studies, met two out of three cardiac rehabilitation guidelines (Australian, American and/or European). However, the eight studies stating inclusion of resistance training interventions, lacked sufficient detail to establish adherence. Meta-analysis was performed using two randomised controlled trials, with outcome measure variability limiting study inclusion suitability. A higher volume of exercise was shown to have a positive effect on functional capacity, assessed using the 6-minute walk test (6MWT) (mean difference = 26.97 m; 95% confidence interval [CI], 6.96-46.97; p = 0.008; I2 = 0%). Furthermore, the addition of resistance exercise to traditional aerobic programs may lead to more significant improvements in functional capacity than aerobic exercise alone. No significant improvement was shown between additional exercise compared to standard care in improving VO2peak, maximal power output or quality of life. No studies evaluated the impact of exercise on cognitive recovery, thus it remains unknown.

Conclusions: In the elderly cardiac population, higher volume of exercise training improves physical recovery beyond that of standard care. Whilst the physiological benefits of aerobic exercise have been extensively researched, there is a lack of evidence surrounding resistance training following cardiac surgery. The high prevalence of cognitive impairment warrants investigation into the effects of exercise on cognitive recovery.

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