Introduction
Coronary artery disease (CAD) is one of the most common cardiovascular diseases and becomes the major cause of morbidity and mortality worldwide until 2040 [
1,
2]. Percutaneous coronary intervention (PCI) is a surgical procedure involving the combination of coronary angioplasty with stenting and used to open clogged or narrow coronary arteries of the heart found in CAD [
3]. Although effective preventive medication is a priority, patients with stable CAD commonly undergo revascularization by virtue of PCI to reduce symptoms and prevent adverse events [
4]. Of note, CAD patients undergoing PCI are required to receive cardiac rehabilitation (CR) programs to optimize lifestyle, restore or increase physical abilities, and reduce major adverse cardiac events [
5]. Physical exercise represents a predominant part of CR and can improve prognosis and quality of life of CAD patients undergoing PCI [
6]. CR delivers a cost-effective and structured exercise, education, and risk reduction programme, which could contribute to an improvement of 5% of predicted fitness associated with a corresponding 10% reduced risk of cardiac hospitalization or all-cause mortality [
7]. Despite these benefits and recommendations in clinical practice guidelines, CR programs are available to only 38.8% of countries [
8]. Accordingly, exercise-based CR is highly recommended by all international guidelines for stable CAD patients after hospitalization in hospitals or outpatient centers.
On January 30, 2020, the World Health Organization declared the outbreak of a new Corona virus, SARS-CoV-2 which spread very rapidly throughout the world and impinged on economic, social, and health systems [
9]. The sustained coronavirus disease 2019 (COVID-19) pandemic leads to the saturation of hospital services, and rehabilitation centers in many institutes or specialized CR clinics had to close [
10]. The COVID-19 infection may contribute to a poor prognosis for stable CAD patients undergoing PCI or CABG, which has raised challenges and dilemmas to their functional recovery, even leading to severe cardiovascular events and deaths [
11]. The CAD patients, especially those older patients, may be more likely to infect SARS-CoV-2 virus in their travels to and assembly in hospital services and rehabilitation centers [
12]. Therefore, it is urgent to find an alternative CR delivery model to break these barriers, including COVID-19 quarantine, stay-home orders, and recreation facility closures in the local community and reduce the risk of COVID-19 infection for stable CAD patients undergoing PCI and requested to receive CR program. Remote delivery of CR program has been adapted from the existing center-based CR program to expand coverage and accessibility to these programs without increasing total costs [
13]. This CR delivery model consists of remote supervision on exercise training and group or individual education meetings for cardiac prevention and management heart disease by videoconference [
14]. Importantly, a previous systematic review demonstrated a very low risk of the incidence of adverse events during remote CR program and encourage cardiac patients to be more active in their environment and practice physical exercise regularly [
15]. This study aims to investigate outcomes of exercise capacity, quality of life, mental health, and family burden of stable CAD patients with low-to-moderate risk by a cohort comparison of in-person vs. remote CR program.
Discussion
This study examined the exercise capacity, quality of life, mental health, and family burden of stable CAD patients undergoing PCI requested to receive in-person CR program compared to remote CR program. The main findings of this work support remote delivery as a feasible and safe model for stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic.
Exercise capacity is considered as a predictor of cardiovascular death in patients with CAD [
23,
24]. Some stable CAD patients undergoing PCI are afraid of stent detachment due to exercise. Over time, their cardiac function gradually weakened, which has a serious impact on the long-term efficacy of patients. Exercise can help to maintain blood pressure control, improve cardiorespiratory fitness, enhance the function of vascular endothelial cells, and prevent the development of atherosclerosis [
25]. Similar to our study, Candelaria et al. analyzed the patient experience while exercising between in-person and remote-delivered CR exercise interventions during the COVID-19 pandemic [
26]. Although they thought remote-delivered CR program during the COVID-19 pandemic had equivalent patient experience, sometimes better HRQL outcomes than in-person model, the rapid transition from in-person to remote delivery in the same group of patients may contribute to less careful planning and testing of remote interventions, creating a further cross-sectional study. In the study reported by Batalik et al., they endorsed the feasibility of remote delivery as an alternative delivery model for CR program, focusing on 200 m fast walking test after 8-week intervention to reflect exercise capacity of CAD patients [
27]. However, only 19 participants and the absence of a control group in the above study means a further investigation in a larger-scale comparative study during the COVID-19 pandemic. Montoye et al., also demonstrated improved mental health and physical fitness by virtual exercise program during the COVID-19 pandemic for adults with chronic disease [
28]. In our study, we compared the exercise capacity results between 45 patients completing the in-person CR program and 47 patients completing the exercise intervention by remote delivery. The data showed that in-person delivery of CR program and remote delivery of CR program both can improve the exercise capacity of stable CAD patients undergoing PCI and their exercise capacity did not differ between in-person delivery of CR program or remote delivery of CR program.
Following 8-week and 12-week CR program whether in-person or remote model, the HRQL scores were increased in all domains of physical and mental composites both, indicating the overall equivalence in HRQL between groups was expected, concurring with other previous reports [
29,
30]. Similar have also been noted in other conditions such diabetes, and remote monitoring of physiological, symptom, and self-care behavior data did not improve or have a deleterious effect on quality of life or psychological outcomes compared to those did not receive remote model [
31]. CR is a complex intervention with many interacting elements. It is therefore difficult to pinpoint the active programme components, which could also differ for each patient’s perspective. Specifically, in our study, the patients receiving remote CR program exhibited higher HRQL scores in domains of the mental composite compared to in-person CR program after 8 weeks, suggesting that CAD patients undergoing PCI requested to receive CR program may benefit more from remote delivery especially on mental health during the COVID-19 pandemic. The additional benefits for mental health in remote CR program may have been a result from pandemic-related isolation distress [
32], and thus remote delivery for CR program may be an effective and timely intervention as it was individualized. During the remote delivery for CR program, patients have one-on-one contacts to raise specific recovery concerns and receive more personalized counselling and motivational support than in-person delivery [
33]. The patients receiving in-person CR exercise could engage with the nursing staff through incidental conversations and questions and obtain encouragement from the exercise professionals during exercise. For remote-delivery CR participants, they appreciated remote delivery due to easy accessibility from the home, less travel time, direct engagement and encouragement from their lives. Individualized and personal contacts with cardiovascular specialists regularly in the remote CR program make participants feel more flexible and less stressed than in the in-person CR program. As previously reported by Su et al., actionable CR guidance, increased awareness, and professional support in early post-discharge consultation could significantly reassure patients [
34]. Therefore, remote delivered CR program was demonstrated to be a suitable alternative model for patients who are unable to participate in the in-person program, particularly as other studies have demonstrated that low-risk patients could be safely managed without requiring ongoing biochemical evaluations [
35].
For stable CAD patients undergoing PCI, depression and anxiety are associated not only with a poorer prognosis and increased long-term mortality, but also with reduced productivity owing to evidently increased disability rates in the working population and increased medical care costs [
36]. After PCI, fear of disease recurrence, unknown prognosis and high medical costs will increase psychological burden and induce depression in stable CAD patients undergoing PCI. Anxiety and depression are independent risk factors in the pathophysiological progress of CAD, which run through the whole process of disease treatment, rehabilitation and prevention, and increase the risk of patient death [
37]. In this study, remote CR program was as effective as the in-person CR program in improving anxiety and depression symptoms, functional capacity, and quality of life. More specifically, the patients receiving remote CR program showed lower SAS and SDS scores compared to those receiving in-person CR program for 8 weeks. Exercise together with educational and psychological interventions in remote CR program had a positive impact on the psychological state of the patients.
After PCI, patients suffered from in stent restenosis repeatedly, and the high medical costs brought a heavy economic burden to patients’ families. The economic burden has a negative impact on the physiological health and emotional functions of the caregivers, especially during the COVID-19 pandemic [
38]. Remote delivered CR program in the home environment represent an opportunity to increase overall utilization as most evidence found strong evidence that remote CR program was cost-effective [
13]. Scherrenberg et al. analyzed the effectiveness of a home-based mobile CR program in elderly patients that were unable or not willing to receive center-based CR from a health-economic point of view, demonstrating the home-based mobile CR program was cost-effective alternative to improve cardiorespiratory fitness [
39]. In addition, due to the illness of patients after PCI, their spouses have more psychological problems due to the disorder of family and marriage life and the lack of sexual life, which leads to greater psychological burden [
40,
41]. Through positive psychological suggestion to patients, regular telephone calls and home visits, the remote CR program enables patients and their families to obtain relevant knowledge about diseases at any time outside the hospital, helps patients and their families to maintain an optimistic attitude and positive coping style, instructs their families how to carry out family self-rescue, and improves the preventive intervention ability of caregivers. This service concept is based on continuous nursing, extending the patient-centered service concept to families, so that patients can receive continuous treatment and rehabilitation guidance, and provide seamless nursing services for patients. Development of remote CR program into regular practice not only during the COVID-19 pandemic is the next step to yield the same results as would be conferred by the standard rehabilitation process and to overcome potential staff deficiencies and geographical barriers [
42]. Future investigations should focus on how to effectively enhance the adherence of patients and the implementation of alternatives based on smart devices to ensure data reliability.
There are several limitations of this study that should be noted. Although the remote CR program was delivered in a fixed format, there is no fidelity test to ensure that the curriculum was delivered exactly as it should be. In the in-person CR group, the participants voluntarily attended the drop-in center, but their family members did not receive any assistance from the drop-in center, unlike the experimental group families who received family psychoeducation. Thus, the benefit of remote CR program may be due to the potential Hawthorne effects, because services offered to the remote CR group were more intensive. Besides, the patient recruitment occurred at two different time points, January 2019 to December 2019 and May 2020 to May 2021 due to the COVID-19 pandemic, creates a critical need for further prospective studies investigating the outcomes after two delivery models of CR program at the same period to validate the remote delivery as an alternative delivery model for CR program.
In conclusion, our study demonstrates that both in-person or remote CR programs could effectively improve exercise capacity, quality of life, mental health, and reduced the family burden of low-to-moderate-risk, stable CAD patients undergoing PCI who were requested to receive CR program. This investigation showed that CR by a remote delivery might become a relevant alternative to conventional center-based CR. This innovative healthcare delivery method appears to be a feasible, tolerable, safe, cost-effective solution, and is likely to facilitate the continuity of care for people who encounter geographical or social accessibility difficulties. In future research, this study should be replicated with a larger sample size, validation of the curriculum, and a comparable intervention intensity control group. For the outcome assessments, areas such as employment, community functioning, personal empowerment, and sense of purpose should be included rather than merely focusing on symptom management and social functioning.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.