Safety in Cardiac Rehab – A Primer

A common question that we are asked when deploying the Movn Virtual Cardiac Rehab program is about patient safety. Given that patients are going home, natural questions arise as to how to handle potential adverse events and ensure that patients are getting effective care without increasing the risk for emergent situations.

Virtual and hybrid cardiac rehab (CR) approaches have gained immense traction during COVID-19. The proliferation of these approaches has provided an opportunity to further refine strategies to keep patients safe. In the rest of this article we share our learnings both from existing literature and from our own experience:

Adverse Events for CR in General are Low‍

Indirect support for the safety of home-based CR can be found in studies of Center Based Cardiac Rehab (CBCR) (including both lower- and higher-risk patients) that have reported that serious cardiovascular events occur rarely: ≈1 event per 50,000 patient-hours. These studies evaluated 25,420 patients undergoing CR at 65 different facilities. The event rate was 1 per 49,565 patient-hours of exercise training; the cardiac arrest rate was 1.3 per million patient-hours of exercise. No fatal complications or emergency defibrillations were reported. It will be important to set expectations of patient safety knowing these numbers.
 
For The Right Patients, Safety Outcomes are Favorable

Several meta-analyses and other controlled trials investigating hybrid, virtual, or remote CR report favorable safety data. Studies have shown that
with the right screening and monitoring procedures in higher-risk patients, home-based cardiac rehab (HBCR) can be feasible and safe, including in patients with stable heart failure (HF). An important data point for safety is the HF-action trial where the investigators assessed the safety of exercise training in 2,331 stable outpatients with chronic heart failure (mean ejection fraction 25%) and used a model of initially facility-based cardiac rehab followed by home-based cardiac rehab. For patients in the intervention during or within 3 hr after exercise there was no significant difference between the exercise and usual care groups for the rate of hospitalization (1.9 vs 3.2%, respectively) or death (0.4 vs 0.4%, respectively), and there was no significant difference in implantable cardioverter-defibrillator shocks between the two study groups (HR = 0.9: 95% CI, 0.7-1.2). A potential drawback in these trials is that not all of them were powered adequately to measure safety. Nevertheless, the data reported suggest safety.

Patients Should be Screened
Virtual and hybrid cardiac rehab options are not for every patient. We've found that by adequately screening patients for whom it is unsafe to exercise from their home requires caution. The types of patients who would be excluded from such an approach include those receiving continuous inotropic support, those having recently received a mechanical support device, and those who are symptomatic at very low workloads (≤2 metabolic equivalents of task). Otherwise, most patients with stable cardiovascular disease should be able to exercise on their own at a lower risk of complication.

An Exercise Test Further Helps Reduce Risk
Assessing the patient through a symptom-limited exercise test can further help staff ascertain if virtual options are safe for the patient. The test must be held around the time of starting the at-home component of cardiac rehabilitation as a means to screen for significant arrhythmia, symptoms, or electrocardiogram evidence of myocardial ischemia. As part of the exercise test, additional screening should also be made including the risk for falling and their ability to exercise independently. In our experience, most low-to-moderate patients do not need an exercise test. However, having the test as an option in case a patient is in a safety gray area can greatly alleviate risk.

Create an Emergency Plan
Once patient appropriateness for rehab is determine, an on-going component of safety is being able to handle patient issues that may arrive as part of the program. Central to this component is to agree upon an emergency plan. Staff should educate the patient to help them recognize potential symptoms of importance, know how to dial 911 and avail of emergency services. In addition, patients should be encouraged to have an emergency contact that can be reached and ideally have a friend or family member nearby. Contact information and location must be stored. The patient should demonstrate to staff knowledge of such by repeating the details of the plan. At the beginning of each synchronized audiovisual CR session, staff should always confirm the patient emergency contact information and location.

The emphasis within CR on in-person exercise training under continuous supervision by trained medical professionals has had unintended consequences for rehab participation as well. These consequences include making raising the concern of patients that exercise might be harmful or requires close supervision. It also suggests that the need to exercise ends after completion of a facility-based CR session and no further physical activity is beneficial. Given the right checks and balances, it is possible to ensure that patients get all the benefits of cardiac rehab while having a safe experience. Thus, it is important to provide patients the right information so
that they can make an informed choice.
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Disclaimer: This article is not meant to be medical advice. Always consult
with your physician to determine if an in-person or virtual cardiac rehab
program is the right option for you.