Publications by authors named "Philip A Ades"

135 Publications

The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes.

J Cardiopulm Rehabil Prev 2021 Nov 24. Epub 2021 Nov 24.

Larner College of Medicine at the University of Vermont, Burlington (Drs Gaalema, O'Neill, and Bolívar and Ms Denkmann); Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington (Mr Savage and Drs Khadanga and Ades); and Department of Biostatistics, University of Vermont, Burlington (Dr Priest).

Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR.

Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate.

Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables.

Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.
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http://dx.doi.org/10.1097/HCR.0000000000000646DOI Listing
November 2021

Benchmarking Depressive Symptoms in Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2021 Nov 24. Epub 2021 Nov 24.

Vermont Center on Behavior and Health, Burlington (Mr Middleton and Drs Ades and Gaalema); Departments of Psychiatry (Dr Gaalema) and Psychology (Mr Middleton and Dr Gaalema), University of Vermont, Burlington; and Division of Cardiology, University of Vermont College of Medicine, Burlington (Messrs Savage and Rengo and Drs Khadanga and Ades).

Purpose: Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both.

Methods: Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified.

Results: Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P < .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P < .05).

Conclusion: Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.
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http://dx.doi.org/10.1097/HCR.0000000000000657DOI Listing
November 2021

Optimizing Training Response for Women in Cardiac Rehabilitation: A Randomized Clinical Trial.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Division of Cardiology, Department of Medicine, University of Vermont, Burlington.

Importance: Despite lower baseline fitness levels, women in cardiac rehabilitation (CR) do not typically improve peak aerobic exercise capacity (defined as peak oxygen uptake [peak Vo2]) compared with men in CR.

Objective: To evaluate the effect of high-intensity interval training (HIIT) and intensive lower extremity resistance training (RT) compared with standard moderate intensity continuous training (MCT) on peak Vo2 among women in CR.

Design, Setting, And Participants: This randomized clinical trial conducted from July 2017 to February 2020 included women from a community-based cardiac rehabilitation program affiliated with a university hospital in Vermont. A total of 56 women (mean [SD] age, 65 [11] years; range 43-98 years) participating in CR enrolled in the study.

Interventions: MCT (70% to 85% of peak heart rate [HR]) with moderate intensive RT or HIIT (90% to 95% of peak HR) along with higher-intensity lower extremity RT 3 times per week over 12 weeks.

Main Outcomes And Measures: The primary outcome was the between-group difference in change in peak Vo2 (L/min) from baseline to 12 weeks.

Results: Peak Vo2 increased to a greater degree in the HIIT group (+23%) than in the control group (+7%) (mean [SD] increase, 0.3 [0.2] L/min vs 0.1 [0.2] L/min; P = .03). Similarly, the change in leg strength was greater in the HIIT-RT group compared with the control group (mean [SD] increase, 15.3 [0.3] kg vs 6.4 [1.1] kg; P = .004).

Conclusions And Relevance: An exercise protocol combining HIIT and intensive lower extremity RT enhanced exercise training response for women in CR compared with standard CR exercise training. Women randomized to HIIT experienced significantly greater improvements in both peak Vo2 and leg strength during CR.

Trial Registration: ClinicalTrials.gov Identifier: NCT03438968.
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http://dx.doi.org/10.1001/jamacardio.2021.4822DOI Listing
November 2021

Reference Standards for Cardiorespiratory Fitness by Cardiovascular Disease Category and Testing Modality: Data From FRIEND.

J Am Heart Assoc 2021 Nov 8;10(22):e022336. Epub 2021 Nov 8.

Fisher Institute of Health and Well-BeingCollege of HealthBall State University Muncie IN.

Background The importance of cardiorespiratory fitness for stratifying risk and guiding clinical decisions in patients with cardiovascular disease is well-established. To optimize the clinical value of cardiorespiratory fitness, normative reference standards are essential. The purpose of this report is to extend previous cardiorespiratory fitness normative standards by providing updated cardiorespiratory fitness reference standards according to cardiovascular disease category and testing modality. Methods and Results The analysis included 15 045 tests (8079 treadmill, 6966 cycle) from FRIEND (Fitness Registry and the Importance of Exercise National Database). Using data from tests conducted January 1, 1974, through March 1, 2021, percentiles of directly measured peak oxygen consumption (VO) were determined for each decade from 30 through 89 years of age for men and women with a diagnosis of coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention, or heart failure. There were significant differences between sex and age groups for VO (<0.001). The mean VO was 23% higher for men compared with women and VO decreased by a mean of 7% per decade for both sexes. Among each decade, the mean VO from treadmill tests was 21% higher than the VO from cycle tests. Differences in VO were observed among the age groups in both sexes according to cardiovascular disease category. Conclusions This report provides normative reference standards by cardiovascular disease category for both men and women performing cardiopulmonary exercise testing on a treadmill or cycle ergometer. These updated and enhanced reference standards can assist with patient risk stratification and guide clinical care.
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http://dx.doi.org/10.1161/JAHA.121.022336DOI Listing
November 2021

Financial Analysis of Cardiac Rehabilitation and the Impact of COVID-19.

J Cardiopulm Rehabil Prev 2021 09;41(5):308-314

Vermont Center on Behavior and Health, University of Vermont, and Department of Psychiatry, Larner College of Medicine, University of Vermont, Burlington (Drs Melbostad, Gaalema, and Ades and Ms Mahoney); University of Vermont Medical Center, Burlington (Mr Savage and Dr Ades); and The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Dr Shepard).

Purpose: Provision of phase 2 cardiac rehabilitation (CR) has been directly impacted by coronavirus disease-19 (COVID-19). Economic analyses to date have not identified the financial implications of pandemic-related changes to CR. The aim of this study was to compare the costs and reimbursements of CR between two periods: (1) pre-COVID-19 and (2) during the COVID-19 pandemic.

Methods: Health care costs of providing CR were calculated using a microcosting approach. Unit costs of CR were based on staff time, consumables, and overhead costs. Reimbursement rates were derived from commercial and public health insurance. The mean cost and reimbursement/participant were calculated. Staff and participant COVID-19 infections were also examined.

Results: The mean number of CR participants enrolled/mo declined during the pandemic (-10%; 33.8 ± 2.0 vs 30.5 ± 3.2, P = .39), the mean cost/participant increased marginally (+13%; $2897 ± $131 vs $3265 ± $149, P = .09), and the mean reimbursement/participant decreased slightly (-4%; $2959 ± $224 vs $2844 ± $181, P = .70). However, these differences did not reach statistical significance. The pre-COVID mean operating surplus/participant ($62 ± $140) eroded into a deficit of -$421 ± $170/participant during the pandemic. No known COVID-19 infections occurred among the 183 participants and 14 on-site staff members during the pandemic period.

Conclusions: COVID-19-related safety protocols required CR programs to modify service delivery. Results demonstrate that it was possible to safely maintain this critically important service; however, CR program costs exceeded revenues. The challenge going forward is to optimize CR service delivery to increase participation and achieve financial solvency.
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http://dx.doi.org/10.1097/HCR.0000000000000643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436146PMC
September 2021

The Treatment of Obesity in Cardiac Rehabilitation: A REVIEW AND PRACTICAL RECOMMENDATIONS.

J Cardiopulm Rehabil Prev 2021 09;41(5):295-301

Division of Cardiology, Department of Medicine, The University of Vermont, Larner College of Medicine, Burlington.

Background: Cardiac rehabilitation (CR) programs have evolved from exercise-only programs designed to improve cardiorespiratory fitness to secondary prevention programs with a broader mandate to alter lifestyle-related behaviors that control cardiac risk factors and, thereby, reduce overall cardiovascular risk. As the obesity epidemic has evolved in the late 20th and early 21st centuries, the prevalence of type 2 diabetes mellitus and the metabolic syndrome have soared and blunted the otherwise expected downturn in deaths from coronary heart disease related to better control of risk factors. In that the causes of obesity are behavioral in origin, the most effective treatment strategy requires a comprehensive, behavioral-based approach.

Purpose: In this review, we outline optimal lifestyle approaches that can be delivered in the CR setting to assist cardiac patients with their long-term goals of reducing weight and improving cardiac risk factors while concurrently improving cardiorespiratory fitness. We also performed a survey of CR program throughout the United States and found that only 8% currently deliver a behavioral weight programs.

Conclusions: Cardiac rehabilitation programs need to take on an important challenge of secondary prevention, which is to develop behavioral weight loss programs to assist cardiac patients to lose weight and, thereby, improve multiple risk factors and long-term prognosis.
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http://dx.doi.org/10.1097/HCR.0000000000000637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522194PMC
September 2021

A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE.

J Cardiopulm Rehabil Prev 2021 Aug 24. Epub 2021 Aug 24.

Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Dr Keteyian); University of Vermont Larner College of Medicine, Burlington (Dr Ades); Department of Epidemiology and Biostatistics and Division of Cardiology, University of California San Francisco, San Francisco (Dr Beatty), Northwest Community Healthcare, Arlington Heights, Illinois (Ms Gavic-Ott); Abt Associates, Rockville, Maryland (Dr Hines); GRQ Consulting, Alexandria, Virginia (Ms Lui); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland (Dr Schopfer); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (Dr Thomas); and Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia (Dr Sperling).

Purpose: This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR.

Review Methods: To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations.

Summary: A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.
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http://dx.doi.org/10.1097/HCR.0000000000000634DOI Listing
August 2021

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS.

J Cardiopulm Rehabil Prev 2021 07;41(4):207-213

Department of Medicine, Division of Cardiology, University of Vermont, Burlington (Drs Khadanga and Ades and Mr Savage); Departments of Psychiatry and Psychology, University of Vermont, Burlington (Dr Gaalema); and Vermont Center on Behavior and Health, University of Vermont, Burlington (Drs Gaalema and Ades).

Purpose: Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

Review Methods: The review examines original studies and meta-analyses regarding women in CR.

Summary: Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.
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http://dx.doi.org/10.1097/HCR.0000000000000629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243714PMC
July 2021

Assessment of the Early Disabling Effects of Coronary Artery Bypass Graft Surgery Using Direct Measures of Physical Function.

J Cardiopulm Rehabil Prev 2021 Mar 26. Epub 2021 Mar 26.

Division of Cardiology, Department of Medicine (Mr Rengo, Mr Savage, and Drs Ades and Toth) and Division of Cardiothoracic Surgery, Department of Surgery (Drs Hirashima and Leavitt), College of Medicine, The University of Vermont, Burlington.

Purpose: Coronary artery bypass graft (CABG) surgery is an important treatment option in patients with coronary artery disease. Despite its beneficial effects, CABG surgery and its subsequent hospitalization may reduce physical functional capacity in patients, contributing to physical disability. Our objective was to assess the early disabling effects of CABG surgery and its subsequent hospitalization using direct measurements of physical function.

Methods: Patients (n = 44) were assessed pre-surgery and at hospital discharge for physical function using the Short Physical Performance Battery (SPPB) and self-reported physical and mental health by questionnaire.

Results: The total SPPB score (P < .001) and all of its components (P < .01-.001) decreased markedly following CABG surgery and hospitalization, with greater reductions in total SPPB score (P < .05) and gait speed (P < .01) in patients with higher body mass index. While CABG surgery and hospitalization reduced patient-reported physical function, changes in these indices largely did not correlate with changes in SPPB outcomes.

Conclusion: Our results show the early disabling effects of CABG surgery and hospitalization on directly measured physical function, and that patients with higher body mass index had greater reductions. In addition, our results underscore the need to perform direct measurements of physical function to describe reductions in physiological functional capacity. These findings suggest the need for inpatient rehabilitation or early mobility programs to address this decline in physical function.

Abstract For Toc: This is the first study to evaluate the early disabling effects of coronary artery bypass graft surgery and hospitalization using direct measures of physical function. Although self-reported physical function also decreased, these changes largely did not correlate with direct measures of physical function.
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http://dx.doi.org/10.1097/HCR.0000000000000587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8464611PMC
March 2021

Improvement in Physical Function After Coronary Artery Bypass Graft Surgery Using a Novel Rehabilitation Intervention: A RANDOMIZED CONTROLLED TRIAL.

J Cardiopulm Rehabil Prev 2021 Nov;41(6):413-418

Division of Cardiology, Department of Medicine (Messrs Rengo and Savage Drs Ades and Toth) and Division of Cardiothoracic Surgery, Department of Surgery (Drs Hirashima and Leavitt), College of Medicine, The University of Vermont, Burlington.

Purpose: Cardiorespiratory and skeletal muscle deconditioning occurs following coronary artery bypass graft surgery and hospitalization. Outpatient, phase 2 cardiac rehabilitation (CR) is designed to remediate this deconditioning but typically does not begin until several weeks following hospital discharge. Although an exercise program between discharge and the start of CR could improve functional recovery, implementation of exercise at this time is complicated by postoperative physical limitations and restrictions. Our objective was to assess the utility of neuromuscular electrical stimulation (NMES) as an adjunct to current rehabilitative care following postsurgical discharge and prior to entry into CR on indices of physical function in patients undergoing coronary artery bypass graft surgery.

Methods: Patients were randomized to 4 wk of bilateral, NMES (5 d/wk) to their quadriceps muscles or no intervention (control). Physical function testing was performed at hospital discharge and 4 wk post-discharge using the Short Physical Performance Battery and the 6-min walk tests. Data from 37 patients (19 control/18 NMES) who completed the trial were analyzed. The trial was registered at ClinicalTrials.gov (NCT03892460).

Results: Physical function measures improved from discharge to 4 wk post-surgery across our entire cohort (P < .001). Patients randomized to NMES, however, showed greater improvements in 6-min walk test distance and power output compared with controls (P < .01).

Conclusion: Our results provide evidence supporting the utility of NMES to accelerate recovery of physical function after coronary artery bypass graft surgery.
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http://dx.doi.org/10.1097/HCR.0000000000000576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310525PMC
November 2021

Predictors of Cardiac Rehabilitation Participation: OPPORTUNITIES TO INCREASE ENROLLMENT.

J Cardiopulm Rehabil Prev 2021 09;41(5):322-327

Division of Cardiology, Department of Medicine (Drs Khadanga and Ades and Mr Savage), Vermont Center on Behavior and Health (Drs Khadanga, Gaalema, and Ades and Mr Savage), and Departments of Psychiatry and Psychology (Dr Gaalema), University of Vermont, Burlington.

Purpose: Participation in cardiac rehabilitation (CR) is low despite proven benefits. The aim of this study was to assess medical, psychosocial, and behavioral predictors of participation in a phase 2 CR.

Methods: This was a prospective observational study. Participants hospitalized for an acute cardiac event and eligible for CR completed in-hospital assessments, and the primary outcome was CR participation over a 4-mo follow-up. Measures included age, sex, educational attainment, smoking status, medical diagnosis, ejection fraction, and electronic referral to CR. Data included General Anxiety Disorder, Patient Health Questionnaire, Medical Outcomes Study Short Form-36, Behavioral Rating Inventory of Executive Function, and Duke Social Support Index. Logistic regression and Classification and Regression Tree analysis were performed.

Results: Of 378 hospitalized patients approached, 294 (31% females) enrolled in the study and 175 participated in CR. The presence of electronic referral, surgical diagnosis, non/former smoker, and strength of physician recommendation (all Ps < .02) were independent predictors for CR participation. No differences were seen in participation by measures of anxiety, depression, or executive function. Males with a profile of electronic referral to CR, high school or higher education, ejection fraction >50%, and strong physician recommendation were the most likely cohort to participate in CR (89%). Patients not referred to CR were the least likely to attend (20%).

Conclusions: Lack of CR referral, lower educational attainment, nonsurgical diagnosis, current smoking, and reduced ejection fraction can predict patients at a highest risk of CR nonparticipation. Specific interventions such as electronic referral and a strong in-person recommendation from a medical provider may enhance CR participation rates.
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http://dx.doi.org/10.1097/HCR.0000000000000573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310538PMC
September 2021

Social Smoking Environment and Associations With Cardiac Rehabilitation Attendance.

J Cardiopulm Rehabil Prev 2021 01;41(1):46-51

Vermont Center on Behavior and Health (Drs Bolívar, Ades, and Gaalema, Ms Elliott, and Mr Middleton) and Departments of Psychiatry (Drs Bolívar and Gaalema and Ms Elliott) and Psychology (Mr Middleton and Dr Gaalema), University of Vermont, Burlington; Departments of Psychiatry and Behavioural Sciences (Dr Yoon and Ms Haliwa) and Cardiothoracic and Vascular Surgery (Dr Miller), University of Texas Health Science at Houston; College of Nursing, University of Kentucky, Lexington (Dr Okoli); and Division of Cardiology, University of Vermont College of Medicine, Burlington (Dr Ades).

Purpose: Continued cigarette smoking after a major cardiac event predicts worse health outcomes and leads to reduced participation in cardiac rehabilitation (CR). Understanding which characteristics of current smokers are associated with CR attendance and smoking cessation will help improve care for these high-risk patients. We examined whether smoking among social connections was associated with CR participation and continued smoking in cardiac patients.

Methods: Participants included 149 patients hospitalized with an acute cardiac event who self-reported smoking prior to the hospitalization and were eligible for outpatient CR. Participants completed a survey on their smoking habits prior to hospitalization and 3 mo later. Participants were dichotomized into two groups by the proportion of friends or family currently smoking ("None-Few" vs "Some-Most"). Sociodemographic, health, secondhand smoke exposure, and smoking measures were compared using t tests and χ2 tests (P < .05). ORs were calculated to compare self-reported rates of CR attendance and smoking cessation at 3-mo follow-up.

Results: Compared with the "None-Few" group, participants in the "Some-Most" group experienced more secondhand smoke exposure (P < .01) and were less likely to attend CR at follow-up (OR = 0.40; 95% CI, 0.17-0.93). Participants in the "Some-Most" group tended to be less likely to quit smoking, but this difference was not statistically significant.

Conclusion: Social environments with more smokers predicted worse outpatient CR attendance. Clinicians should consider smoking within the social network of the patient as an important potential barrier to pro-health behavior change.
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http://dx.doi.org/10.1097/HCR.0000000000000518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755730PMC
January 2021

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction.

Prev Med 2020 11 8;140:106245. Epub 2020 Sep 8.

Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States; University of Vermont Medical Center, Burlington, VT, United States.

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.
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http://dx.doi.org/10.1016/j.ypmed.2020.106245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680426PMC
November 2020

The Million Hearts Initiative: CATALYZING UTILIZATION OF CARDIAC REHABILITATION AND ACCELERATING IMPLEMENTATION OF NEW CARE MODELS.

J Cardiopulm Rehabil Prev 2020 09;40(5):290-293

Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (Mss Wall and Stolp and Drs Ritchey and Sperling); IHRC, Inc, Atlanta, Georgia (Ms Stolp); Office of the Surgeon General, US Department of Health and Human Services, Washington, District of Columbia (Dr Wright); Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (Dr Thomas); Division of Cardiology, University of Vermont College of Medicine, Burlington (Dr Ades); and Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia (Dr Sperling).

Million Hearts and partners have been committed to raising national cardiac rehabilitation participation rates to a goal of 70%. Quality improvement tools, resources, and surveillance models have been developed in support. Efforts to enhance research programs and collaborative initiatives have created momentum to accelerate implementation of new care models.
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http://dx.doi.org/10.1097/HCR.0000000000000547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529047PMC
September 2020

Response to Exercise Training During Cardiac Rehabilitation Differs by Sex.

J Cardiopulm Rehabil Prev 2020 09;40(5):319-324

Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington (Messrs Rengo and Savage and Drs Khadanga and Ades); and University of Vermont College of Medicine, Burlington (Drs Khadanga and Ades).

Purpose: Directly measured peak aerobic capacity or oxygen uptake is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) with lower and their response to training, compared with men, is equivocal. We analyzed at entry and exit in patients participating in CR and improvements by diagnosis to assess training response. We also identified sex differences that may influence change in .

Methods: The cohort included consecutive patients enrolled in CR between January 1996 and December 2015 who performed entry exercise tolerance tests. Data collected included demographics, index diagnosis, , and exercise training response.

Results: The cohort consisted of 3925 patients (24% female). There was a significant interaction between baseline and diagnosis (P < .001), with percutaneous coronary intervention and myocardial infarction greater than other diagnoses. Surgical patients demonstrated greater improvement in than nonsurgical diagnoses (n = 1789; P < .001). Women had lower than men for all diagnoses (P < .02) and demonstrated less improvement (13 vs 17%, P < .001). Percent improvement using estimated metabolic equivalents of task (METs) were similar for women and men (33 vs 31%, P = NS). Despite overall increases in , 18% of patients (24% women, 16% men) failed to demonstrate any improvement (exit ≤ entry ).

Conclusions: While there were no differences in training effect estimated by METs, directly measured showed a significantly lower training response for women despite adjusting for covariates. In addition, 18% of patients did not see any improvement in . Alternatives to traditional CR exercise programming need to be considered.
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http://dx.doi.org/10.1097/HCR.0000000000000536DOI Listing
September 2020

Effects of Behavioral Weight Loss and Weight Loss Goal Setting in Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2020 11;40(6):383-387

Divisions of Endocrinology, University of Vermont Medical Center, and Larner College of Medicine, University of Vermont, Burlington (Dr Barrett); and Divisions of Cardiology, University of Vermont Medical Center, and Larner College of Medicine, University of Vermont, Burlington (Mr Savage and Dr Ades).

Purpose: Obesity is prevalent among participants in cardiac rehabilitation (CR). Establishing a weight loss goal is an important strategy for promoting weight loss. We evaluate the association between a pre-program weight loss goal and change in weight during CR.

Methods: Body weight was measured at CR entry and at exit from CR. Overweight/obese participants were categorized as having: (1) established a weight loss goal and attended behavioral weight loss sessions (G + BWL); (2) set a weight loss goal but did not attend BWL (G); (3) and neither set a weight loss goal nor attended BWL (NoG).

Results: The cohort consisted of 317 overweight/obese participants; 52 of whom set a weight loss goal and attended BWL, 227 patients set a goal but did not attend BWL, and 38 did neither. The G + BWL group lost more weight than the G group (-6.8 + 4.3 vs -1.1 + 3.5) (P < .0001). Both groups that established a weight loss goal lost more weight than the NoG group.

Conclusions: For overweight/obese individuals in CR, participating in BWL classes and setting a weight loss goal leads to more weight loss than G alone. Setting a weight loss goal alone leads to greater weight loss than not setting a weight loss goal.
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http://dx.doi.org/10.1097/HCR.0000000000000510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647951PMC
November 2020

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in the Evolution of Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2020 01;40(1):2-8

University of Vermont College of Medicine, Burlington (Dr Ades); Preventive Cardiology, Boston Medical Center, and Boston University School of Medicine, Massachusetts (Dr Balady); The LifeCare Company, and Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California (Ms Berra); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Dr Franklin); Cardiovascular Medicine and Orthopedics/Sports Medicine, Stanford University School of Medicine, California (Dr Froelicher); Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia (Dr Hamm); Clinical Exercise Physiology, Ball State University, Muncie, Indiana (Dr Kaminsky); and Cardiology, Creighton University School of Medicine, Omaha, Nebraska (Dr Williams).

The maturing of a clinical discipline necessitates the ability to document scientific advancements and state-of-the-art reviews with a focus on clinical practice. Such was the case for the field of cardiac rehabilitation in 1981. Whereas a growing body of literature was demonstrating benefits of exercise in cardiac patients with regard to clinical, psychologic, and quality-of-life outcomes,, there were still concerns about the safety of exercise and whether it could be widely adapted in clinical care. Since this was a time period when searches of online databases such as PubMed had not yet been established (began in 1996), there was a great value of concentrating much of the cardiac rehabilitation literature in a single journal.This commentary describes the conceptualization and implementation of the Journal of Cardiopulmonary Rehabilitation and Prevention from 1981 to the present and its acceptance as the official journal of the American Association of Cardiovascular and Pulmonary Rehabilitation and later the Canadian Association of Cardiac Rehabilitation. The commentary also highlights the journal's inclusion in Index Medicus in 1995, its receipt of an impact factor from International Scientific Indexing in 2007, and its publication of many important scientific statements, often in collaboration with major scientific organizations such as the American Heart Association and the American College of Cardiology.
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http://dx.doi.org/10.1097/HCR.0000000000000494DOI Listing
January 2020

The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention.

Prev Med 2019 11 26;128:105865. Epub 2019 Oct 26.

University of Vermont, United States of America; University of Vermont Medical Center, United States of America; Vermont Center on Behavior and Health, Burlington, VT, United States of America.

Participation in secondary prevention programs such as cardiac rehabilitation (CR) reduces morbidity, mortality, and hospitalizations while improving quality of life. Executive function (EF) is a complex set of cognitive abilities that control and regulate behavior. EF predicts many health-related behaviors, but how EF interacts with interventions to improve treatment adherence is not well understood. The objective of this study is to examine if EF predicts CR treatment adherence and how EF interacts with an intervention to improve adherence. Data were collected from 2013 to 2018 in Vermont, USA. 130 Medicaid-enrolled individuals who had experienced a qualifying cardiac event were enrolled in a controlled clinical trial and randomized 1:1 to receive financial incentives for completing secondary prevention sessions or to usual care. In this secondary analysis, effects of EF on CR adherence (defined as completing ≥30/36 sessions) were examined in 112 participants (57 usual care, 55 intervention) who completed an EF battery. Delay-discounting, a measure of impulsivity, predicted CR adherence (p = 0.01) and interacted with the incentive intervention, such that those who exhibited greater discounting of future rewards benefitted more from the intervention than those who discounted less (F(1, 104) = 5.23, p = 0.02). Better cognitive flexibility, measured with the trail-making-task, also predicted CR adherence (p = 0.02). While EF has been associated with adherence to a variety of treatment regimens, this interaction between an incentive-based intervention to promote treatment adherence and EF is novel. This work illustrates the value of considering individual differences in EF when designing and implementing interventions to promote health-related behavior change.
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http://dx.doi.org/10.1016/j.ypmed.2019.105865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939881PMC
November 2019

Resistance Training for Older Adults in Cardiac Rehabilitation.

Clin Geriatr Med 2019 11 3;35(4):459-468. Epub 2019 Jul 3.

Department of Medicine, Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, 62 Tilley Drive, South Burlington, VT 05403, USA.

Cardiac rehabilitation plays a key role in the care of older patients after a coronary event. Hospitalizations are prevented and quality of life, exercise capacity, and physical function are improved. Almost 50% of cardiac rehabilitation participants are older adults (>65 years), many of whom are frail or deconditioned. Resistance training, as a component of cardiac rehabilitation, improves muscle strength, endurance, and physical function. The purpose of this review is to describe the effects of resistance training in cardiac rehabilitation for older adults with a particular focus on physical function.
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http://dx.doi.org/10.1016/j.cger.2019.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237336PMC
November 2019

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products.

Prev Med 2019 11 27;128:105757. Epub 2019 Jun 27.

Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, United States of America; Departments of Psychiatry, University of Vermont, Burlington, VT, United States of America.

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.
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http://dx.doi.org/10.1016/j.ypmed.2019.105757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248643PMC
November 2019

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial.

JACC Heart Fail 2019 07 8;7(7):537-546. Epub 2019 May 8.

Division of Cardiology, University of Vermont Medical Center, Burlington, Vermont.

Objectives: This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).

Background: Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.

Methods: A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.

Results: Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).

Conclusions: Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).
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http://dx.doi.org/10.1016/j.jchf.2018.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599560PMC
July 2019

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015.

J Cardiopulm Rehabil Prev 2019 07;39(4):266-273

University of Vermont College of Medicine, Burlington (Drs Gaalema, Naud, Priest, and Ades); and University of Vermont Medical Center, Burlington (Messrs Savage and Rengo and Drs Leadholm and Ades).

Purpose: Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr.

Methods: To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects.

Results: Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels.

Conclusions: Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.
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http://dx.doi.org/10.1097/HCR.0000000000000390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594875PMC
July 2019

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association.

Circulation 2019 05;139(21):e997-e1012

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.
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http://dx.doi.org/10.1161/CIR.0000000000000679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603804PMC
May 2019

A Systematic Review of the Diagnostic Accuracy of Depression Questionnaires for Cardiac Populations: IMPLICATIONS FOR CARDIAC REHABILITATION.

J Cardiopulm Rehabil Prev 2019 11;39(6):354-364

Department of Psychology, University of Oviedo, Oviedo, Spain (Ms González-Roz); Department of Psychiatry, University of Vermont, Burlington (Drs Gaalema and Pericot-Valverde and Ms Elliott); and Division of Cardiology, University of Vermont College of Medicine, Burlington (Dr Ades).

Purpose: Depression is overrepresented in patients with cardiovascular disease and increases risk for future cardiac events. Despite this, depression is not routinely assessed within cardiac rehabilitation. This systematic review sought to examine available depression questionnaires to use within the cardiac population. We assessed each instrument in terms of its capability to accurately identify depressed patients and its sensitivity to detect changes in depression after receiving cardiac rehabilitation.

Methods: Citation searching of previous reviews, MEDLINE, PsycInfo, and PubMed was conducted.

Results: The Beck Depression Inventory-II (BDI-II) and the Hospital Anxiety and Depression Scale (HADS-D) are among the most widely used questionnaires. Screening questionnaires appear to perform better at accurately identifying depression when using cut scores with high sensitivity and specificity for the cardiac population. The BDI-II and the HADS-D showed the best sensitivity and negative predictive values for detecting depression. The BDI-II, the HADS-D, the Center for Epidemiological Studies-Depression Scale, and the 15-item Geriatric Depression Scale best captured depression changes after cardiac rehabilitation delivery.

Conclusions: The BDI-II is one of the most validated depression questionnaires within cardiac populations. Health practitioners should consider the BDI-II for depression screening and tracking purposes. In the event of time/cost constraints, a briefer 2-step procedure (the 2-item Patient Health Questionnaire, followed by the BDI-II, if positive) should be adopted. Given the emphasis on cut scores for depression diagnosis and limited available research across cardiac diagnoses, careful interpretation of these results should be done. Thoughtful use of questionnaires can help identify patients in need of referral or further treatment.
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http://dx.doi.org/10.1097/HCR.0000000000000408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318783PMC
November 2019

Cardiac Rehabilitation Utilization During an Acute Cardiac Hospitalization: A NATIONAL SAMPLE.

J Cardiopulm Rehabil Prev 2019 01;39(1):19-26

Division of Cardiovascular Medicine (Drs Pack and Atreya and Mr Berry), Department of Internal Medicine (Drs Pack, Lagu, and Lindenauer), and Institute for Healthcare Delivery and Population Science (Drs Pack, Lagu, Pekow, and Lindenauer and Ms Priya), Baystate Medical Center, Springfield, Massachusetts; University of Massachusetts Medical School at Baystate, Springfield (Drs Pack, Lagu, and Lindenauer); School of Public Health and Health Sciences, University of Massachusetts, Amherst (Ms Priya and Dr Pekow); Division of Preventive Cardiology, Henry Ford Hospital, Detroit, Michigan (Mr Berry); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (Dr Atreya); and Division of Cardiology, Department of Medicine, The University of Vermont, Burlington (Dr Ades).

Background: Inpatient cardiac rehabilitation (ICR) programs provide important services to hospitalized patients by delivering risk factor education, daily ambulation, and facilitation of referral to outpatient cardiac rehabilitation. However, little is known about ICR utilization or practice patterns.

Methods: We examined the use of ICR, between January 2007 and June 2011, in a geographically and structurally diverse sample of US hospitals (Premier, Inc).

Results: Among 458 hospitals, there were 1 343 537 admissions with a qualifying diagnosis for outpatient cardiac rehabilitation. Formal ICR was available at 223 (49%) of these hospitals. Overall, patient utilization of ICR was low (21.2%) and varied by indication. Utilization was highest in those undergoing cardiac surgery (43.3%) and lowest in patients with medically managed myocardial infarction (15.6%) or heart failure (10.6%). A larger bed count, the presence of cardiac interventional services, and Midwest location were associated with increased likelihood of a hospital having an ICR program. In multivariable hierarchical analysis adjusting for known hospital characteristics among hospitals that provided ICR, multiple patient factors were associated with a lower likelihood of ICR utilization, including older age, more comorbidities, female sex, and Medicare insurance, but unspecified hospital characteristics explained the vast majority of the variability.

Conclusions: We found substantial variation in the delivery of ICR across US hospitals and by patient condition. Overall, only a minority of eligible patients ever received ICR and fewer than half of hospitals treating cardiac patients provided formal ICR services. This substantial gap in the secondary prevention of heart disease warrants further investigation and intervention.
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http://dx.doi.org/10.1097/HCR.0000000000000374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310017PMC
January 2019

Quadriceps Lipid Content Has Sex-Specific Associations With Whole-Muscle, Cellular, and Molecular Contractile Function in Older Adults.

J Gerontol A Biol Sci Med Sci 2019 11;74(12):1879-1886

Department of Kinesiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst.

Increased adiposity is associated with reduced skeletal muscle function in older adults, but the mechanisms underlying this relationship remain unclear. To explore whether skeletal muscle properties track with adiposity, whole-muscle, cellular, and molecular function were examined in relation to adiposity measured at various anatomical levels in healthy older (60-80 years) men and women. Although women had greater absolute and relative body and thigh fat than men, quadriceps muscle attenuation, an index of intramuscular lipid content, was similar between sexes. At the whole-muscle level, greater quadriceps attenuation was associated with reduced knee extensor function in women, but not men. In women, decreased myosin heavy chain I and IIA fiber-specific force was associated with higher intramuscular lipid content, which may be explained, in part, by the reduced myofilament lattice stiffness found in myosin heavy chain IIA fibers. Longer myosin attachment times in myosin heavy chain I fibers from men and women were associated with greater amounts of adipose tissue, suggesting that fat deposits lead to slower myosin-actin cross-bridge kinetics. Our results indicate greater quantities of adipose tissue alter myofilament properties and cross-bridge kinetics, which may partially explain the adiposity-induced decrements in single-fiber and whole-muscle function of older adults, especially women.
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http://dx.doi.org/10.1093/gerona/gly235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6853688PMC
November 2019

Tobacco use in cardiac patients: Perceptions, use, and changes after a recent myocardial infarction among US adults in the PATH study (2013-2015).

Prev Med 2018 12 8;117:76-82. Epub 2018 May 8.

Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA; Psychological Science, University of Vermont, Burlington, VT, USA.

Smoking status following cardiac events strongly predicts future morbidity and mortality. Using a nationally representative sample of United States adults, aims of this study were (1) to estimate use of, and attitudes towards, tobacco products as a function of level of cardiac risk, and (2) to explore changes in attitudes and tobacco use among adults experiencing a recent myocardial infarction (MI). Data were obtained from the first and second waves of the Population Assessment of Tobacco and Health (PATH) study. Use and attitudes towards tobacco products were examined at Wave 1 among adults with no chronic health condition (n = 18,026), those with risk factors for heart disease (n = 4593), and those who reported ever having had an MI (n = 643). Changes in perceived risk of tobacco and use between the two waves and having an MI in the last 12 months (n = 240) were also examined. Those who reported lifetime MI were more likely to believe that smoking/using tobacco was causing/worsening a health problem. Having had a recent MI event increased perceived tobacco-related risk and attempts at reduction/quitting, but did not significantly impact combusted tobacco cessation/reduction or uptake of non-combusted tobacco products. Sociodemographic characteristics and use of other tobacco products were associated with change in use of tobacco products. Those who have an MI are sensitized to the harm of continued smoking. Nonetheless, having an MI does not predict quitting combusted tobacco use or switching to potentially reduced harm products. Intense intervention is necessary to reduce combusted use in this high-risk population.
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http://dx.doi.org/10.1016/j.ypmed.2018.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195824PMC
December 2018

Geographic Variations in Cardiac Rehabilitation Use: Regional Variations in Medical Care or in Patient Behaviors?

Circulation 2018 05;137(18):1909-1911

Psychiatry (D.E.G.), College of Medicine, University of Vermont Larner College of Medicine, Burlington.

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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.033255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935129PMC
May 2018

Age-related reduction in single muscle fiber calcium sensitivity is associated with decreased muscle power in men and women.

Exp Gerontol 2018 02 13;102:84-92. Epub 2017 Dec 13.

Department of Molecular Physiology and Biophysics, University of Vermont, Health Science Research Facility 127, 149 Beaumont Avenue, Burlington, VT 05405, USA. Electronic address:

Age-related declines in human skeletal muscle performance may be caused, in part, by decreased responsivity of muscle fibers to calcium (Ca). This study examined the contractile properties of single vastus lateralis muscle fibers with various myosin heavy chain (MHC) isoforms (I, I/IIA, IIA and IIAX) across a range of Ca concentrations in 11 young (24.1±1.1years) and 10 older (68.8±0.8years) men and women. The normalized pCa-force curve shifted rightward with age, leading to decreased activation threshold (pCa) and/or Ca sensitivity (pCa) for all MHC isoforms examined. In older adults, the slope of the pCa-force curve was unchanged in MHC I-containing fibers (I, I/IIA), but was steeper in MHC II-containing fibers (IIA, IIAX), indicating greater cooperativity compared to young adults. At sub-maximal [Ca], specific force was reduced in MHC I-containing fibers, but was minimally decreased in MHC IIA fibers as older adults produced greater specific forces at high [Ca] in these fibers. Lessor pCa in MHC I fibers independently predicted reduced isokinetic knee extensor power across a range of contractile velocities, suggesting that the Ca response of slow-twitch fibers contributes to whole muscle dysfunction. Our findings show that aging attenuates Ca responsiveness across fiber types and that these cellular alterations may lead to age-related reductions in whole muscle power output.
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http://dx.doi.org/10.1016/j.exger.2017.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411279PMC
February 2018

What do we tell patients with coronary artery disease about marijuana use?

Coron Artery Dis 2018 01;29(1):1-3

Department of Medicine, Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington, Vermont, USA.

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http://dx.doi.org/10.1097/MCA.0000000000000567DOI Listing
January 2018
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