Original Investigation
The Impact of Reduced Cardiac Rehabilitation on Maximal
Treadmill Exercise Time
A RANDOMIZED CONTROLLED TRIAL
Alejandra Farias-Godoy, MD, PhD; Sammy Chan, MD; Victoria E. Claydon, PhD;
Andrew Ignaszewski, MD; Joanna Mendell, MPH; Julie E. Park, MMath; Joel Singer, PhD;
Scott A. Lear, PhD
Purpose: Cardiac rehabilitation programs (CRPs) remain un-
derutilized partly because of access barriers. We therefore eval-
uated a CRP with fewer center-based sessions (rCRP) compared
with standard CRP (sCRP) with respect to changes in exercise
capacity and cardiac risk factors.
Methods: In this randomized controlled noninferiority trial,
primary and secondary prevention patients at low and moderate
risk were randomized to an sCRP (n = 60) or an rCRP (n =
61). Over 4 months, sCRP and rCRP participants attended 32
and 10 on-site cardiac rehabilitation sessions, respectively. The
primary outcome was the difference in the change in exercise
capacity from baseline at 4 and 16 months between the groups
measured in seconds from a maximal treadmill exercise test.
Noninferiority of the rCRP was tested with mixed-effects model
analysis with a cut point of 60 seconds for the upper value of
the group estimate.
Results: Attendance was higher for the rCRP group (97% ±
63% vs 71% ± 22%, P = .002). Over 16 months, exercise test
time increased for the sCRP (524 ± 168 to 604 ± 172 seconds,
P < .01) and the rCRP (565 ± 183 to 640 ± 192 seconds, P <
.01). The rCRP was not inferior to the sCRP regarding changes
in treadmill time (48.47 seconds, P = .454). The rCRP was not
inferior to the sCRP regarding metabolic and anthropometric
risk factors.
Conclusion: Our findings suggest that, for a selected group of
low-/moderate-risk patients, the number of center-based CRP
exercise sessions can be decreased while maintaining reduced
cardiovascular risk factors.
Key Words: cardiac rehabilitation • cardiovascular disease
prevention • exercise • risk factors
C ardiac rehabilitation programs (CRPs) provide compre-
hensive management of patients with, and at risk for,
cardiovascular disease.1–4 Evidence has shown that CRPs
decrease all-cause and cardiovascular mortality by 20%
and 26%, respectively, as well as reducing risk of recurrent
Author Affiliations: Department of Biomedical Physiology and Kinesiology
(Drs Farias-Godoy, Claydon, and Lear) and Faculty of Health Sciences
(Ms Mendell and Dr Lear), Simon Fraser University, Burnaby, British Columbia,
Canada; Division of Cardiology, Providence Health Care, Healthy Heart
Program, St Paul’s Hospital, Vancouver, British Columbia, Canada (Drs Chan,
Ignaszewski, Singer, and Lear); School of Population and Public Health,
University of British Columbia, Vancouver, Canada (Ms Park and Dr Singer).
All authors have read and approved the article.
The authors declare no conflicts of interest.
Correspondence: Scott A. Lear, PhD, Healthy Heart Program, St Paul’s
Hospital, 180-1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada (slear@
providencehealth.bc.ca).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/HCR.0000000000000269
www.jcrpjournal.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
myocardial infarction.1–5 Despite current recommendations,6
CRPs are vastly underused, with as little as one-third of el-
igible patients participating.7 This is due to transportation
issues, financial cost, and time constraints.7–9 Furthermore,
the standard CRP often treats a wide variety of cardiovascu-
lar patients, from low- to high-risk patients in a “1-size fits
all” fashion, without triaging on the basis of disease severity.
In an attempt to overcome CRP utilization barriers, alter-
native programs with fewer CRP sessions have been devel-
oped and compared with center-based programs.10–12 How-
ever, many of these included only low-risk patients, focused
only on exercise, and utilized resources that are not usually
provided by CRPs such as home exercise equipment and
supervised home training. Importantly, these studies lacked
follow-up after intervention completion and were designed as
superiority trials in which a nonsignificant test could wrong-
ly be interpreted as proof of no difference between groups.13
To overcome these gaps, we designed a comprehensive CRP
with fewer center-based supervised sessions (rCRP) to eval-
uate and compare its effectiveness with the standard CRP
(sCRP) in primary and secondary prevention patients using
a noninferiority single-blinded randomized controlled trial.
We hypothesized that the rCRP was noninferior to the sCRP
for changes in total time on a treadmill exercise test and risk
factors at program completion (4 months) and at 1 year of
follow-up from program graduation (16 months).
METHODS
This study was a prospective, 2-group noninferiority
randomized controlled trial. Consecutive patients were
screened during the CRP intake clinic at St Paul’s Hospi-
tal, Vancouver, British Columbia, Canada, a tertiary care
center. Primary and secondary prevention patients at low
and moderate risk according to the American Association
of Cardiovascular and Pulmonary Rehabilitation risk strat-
ification criteria14 were eligible (ejection fraction ≥40%,
absence of rest or exercise-induced complex arrhythmias
or ischemia, functional capacity ≥5 metabolic equivalents
(METs), and normal exercise hemodynamics). Patients
were excluded if they had clinical congestive heart failure,
ejection fraction <40%, complex comorbid conditions
(poorly controlled diabetes or chronic kidney disease), cog-
nitive impairment, scheduled revascularization, depression,
or no understanding of the English language. This study
was approved by the Providence Health Care and Simon
Fraser University research ethics boards. All participants
provided written informed consent.
Potential participants were approached after the CRP
intake assessment. Consenting participants were strati-
fied by gender and randomized to either the sCRP or the
Reduced Cardiac Rehabilitation Program 1
rCRP group (Figure 1). Participants were allocated using
computer-generated block randomization (blocks of 4, 6,
and 8) programmed by a statistician not associated with
the trial. Randomization was accessed by telephone by the
study coordinator. Because of the nature of the study, the
CRP staff, study coordinator, and participants were not
blinded to group assignment. However, laboratory tech-
nicians involved with exercise tests and blood work were
blinded to group allocation.
Data from the CRP intake assessment were used for
participant baseline assessments. Intake assessment con-
sisted of an evaluation by a cardiologist, nurse, dietitian,
and exercise specialist in which data on sociodemograph-
ics, risk factors (fasting glucose, fasting lipid profile, and
blood pressure), exercise capacity (determined by a tread-
mill stress test), and lifestyle behaviors were collected. On
the basis of this assessment, patients were counseled on risk
factor and pharmacological management.
STANDARD CARDIAC REHABILITATION PROGRAM
The sCRP was the standard of care, consisting of twice
weekly medically supervised CR sessions for 16 weeks
(32 sessions in total), education, dietary counseling, smok-
ing cessation, psychosocial support, and risk factor man-
agement. Each participant was given an individualized
exercise prescription by an exercise specialist with a target
heart rate at 50% to 70% of heart rate reserve on the basis
of their intake exercise test.15 Participants were prescribed
exercise “most days of the week,” 2 of which were included
as part of the sCRP sessions.
A center-based exercise session consisted of a warm-up
(10-15 minutes), aerobic activity within the prescribed target
Figure 1. Diagram of study design. rCRP indicates reduced cardiac rehabilitation program; sCRP, standard cardiac rehabilitation program.
2 Journal of Cardiopulmonary Rehabilitation and Prevention 2017;00:1-7
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
heart rate (30-45 minutes), resistance training (10-20 minutes),
and a cool-down (10-15 minutes). During these sessions, par-
ticipants underwent ongoing review and counseling sessions
with the nurse, dietitian, and exercise specialist.
REDUCED CARDIAC REHABILITATION PROGRAM
The rCRP had the core elements of the sCRP, with the
only difference being the total number of center-based
supervised CR sessions—10 during the 4-month period
compared with 32 with the sCRP. rCRP sessions were con-
ducted simultaneously with the sCRP by the same CRP per-
sonnel to ensure consistency of delivery. As with the sCRP,
rCRP participants were prescribed individualized exercise
prescription. Typically, an rCRP participant attended a cen-
ter-based exercise session twice a week during the first 2
weeks, once a week during the next 2 weeks, once every 2
weeks during the second month, and monthly in the last 2
months of CRP. Participants were advised to exercise “most
days of the week,” with the majority occurring outside the
hospital setting. Educational topics were provided in writ-
ten form to cover those on-site sessions where rCRP partic-
ipants may not have been present and a logbook to serve
as written guidance and motivational tool on their exercise
program. An exit strategy was in place to allow CRP staff
to transfer rCRP participants to the sCRP group for safety
reasons only, determined by the onset of new arrhythmias
or acute coronary events. Participant choice to transfer was
also allowed.
At program completion (4 months), both sCRP and
rCRP participants underwent an exit exercise test and blood
work, which were assessed by a cardiologist who made
appropriate medical changes. Participants were discharged
www.jcrpjournal.com
to the care of their general practitioner. All participants re-
turned 12 months later for the final outcome assessment
(1-year follow-up).
SAMPLE SIZE DETERMINATION
The primary outcome, difference in the change in ex-
ercise capacity between the 2 groups from baseline to
4-and 16-month follow-up, was measured as total time (in
seconds) on the treadmill for a symptom-limited exercise
treadmill test using the Bruce protocol.16 The study was
powered to detect the minimal clinically relevant difference
of 60 seconds between the 2 groups for total treadmill time
change over the 16-month study duration. Using noninferi-
ority power calculation software (StudySize, Creorstat), a
standard deviation of 103 seconds on the basis of prelim-
inary data and a power of 0.80, a total of 47 participants
were required in each group. Accounting for a dropout rate
of 25%, 118 participants were determined to be needed in
the total study cohort. A difference of 60 seconds in the
change in total treadmill time between the groups corre-
sponds to approximately 1 MET on the Bruce protocol, and
is equivalent to a 12% reduction in mortality.17,18 A differ-
ence below this noninferiority cut point is associated with
minimal clinical benefit.17,19
SECONDARY OUTCOME MEASURES
Secondary outcomes consisted of changes in risk factors,
from baseline to 4- and 16-month follow-up between the
2 groups, as well as participant program adherence. Non-
inferiority cut points were decided upon consultation with
experts and considering the threshold below which risk factor
Figure 2. Flow diagram of study participants through different phases of enrollment, allocation, follow-up, and analysis. CRP indicates cardiac
rehabilitation program.
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Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
changes elicited insignificant clinical benefits according to
existing literature.20–24 Blood samples were collected after
a 12-hour fast and 72-hour cessation of alcohol use and
were analyzed by standardized laboratory procedures for
total cholesterol (TC), high-density lipoprotein cholesterol
(HDL-C), triglycerides (TGs), and fasting blood glucose.
Low-density lipoprotein cholesterol (LDL-C) was calculat-
ed using the Friedewald calculation.25 Waist circumference
was measured to the nearest 0.1 cm following a normal ex-
piration at the point of maximal narrowing of the trunk.
Body mass index was calculated as weight in kilograms
divided by height in meters squared. Blood pressure was
recorded using a manual sphygmomanometer and the av-
erage of 2 measures taken 5 minutes apart after 5 minutes
of seated rest. Program adherence was measured as self-re-
ported physical activity with the 4-week modified Minneso-
ta Leisure Time Physical Activity questionnaire26 in kcal per
week, as well as percent attendance, which was calculated
from the total number of center-based CR sessions attended
divided by the number of sessions participants were expect-
ed to attend according to their group assignment.
STATISTICAL ANALYSES
Statistical analyses were conducted with the statistician
blinded to treatment group. All variables were tested for
normality pre-analysis using quantile-quantile plots. Non-
normally distributed variables were log transformed and
reported as median and interquartile ranges. The presence
of outliers was noted for further sensitivity analyses.
The primary outcome analysis was performed to assess
the difference in total treadmill time (seconds) between the
Reduced Cardiac Rehabilitation Program 3
sCRP and rCRP groups at 4 and 16 months of follow-up, at 4 months. From 4 to 16 months, TC, HDL-C, and TG
using a mixed-effects model. The 4-month and 16-month increased in the sCRP. At 16-months follow-up there was
data were adjusted for baseline data. The same analyses a deterioration of TC and TG for the sCRP group. There
were used for the secondary outcomes. was no change across time for fasting blood glucose, blood
To conduct within-group comparisons of continuous pressure, and anthropometric measurements. For TC and
variables, a 2 (group) by 3 (time) repeated measures anal- LDL-C, the upper bound of the 95% confidence interval
ysis of variance was performed. Where appropriate, post of the group effect was slightly greater than their nonin-
hoc multiple comparisons were conducted using the Bon- feriority cut point; therefore, noninferiority for the rCRP
ferroni correction. To test for within-group comparisons of compared with the sCRP group in regard to TC and LDL-C
categorical variables, McNemar tests with multiple testing was not shown.
corrections were performed. Analyses were governed by
an intent-to-treat as per randomization and per-protocol
according to treatment completed (for patients who used DISCUSSION
the exit strategy).13 Imputation of missing data was not per- In this randomized, single-blinded study, we observed that a
formed as the method of analysis allowed missing data.27 CRP with one-third of the on-site sessions significantly im-
The P value for significance was set at .05 and statistical proved exercise capacity, HDL-C, and physical activity, and
analyses were conducted using SPSS version 17 (IBM) and was not inferior across a range of metabolic and anthropo-
SAS (SAS Institute). metric risk factors in low- and moderate-risk patients. In
addition, rCRP participants attended a greater proportion
of their CR sessions than the sCRP group. These findings
RESULTS suggest that the number of center-based CRP sessions could
A total of 121 participants were recruited and random- be reduced for these patients.
ized (Figure 2). After 16 months, 5 participants withdrew Although several studies with alternative CRP delivery
from the study (2 from the sCRP group) and 12 were lost modes have been evaluated,10–12 these studies used superi-
to follow-up (5 from the sCRP). There was 1 participant ority trial designs and incorrectly interpreted nonsignifi-
from each group who underwent revascularization during cant findings as proof of no difference between groups.13
CRP participation and were excluded from data analyses.
Therefore, a total of 102 participants were included in the
final analyses. Those who were lost to follow-up had sig- Table 1
nificantly higher body mass index (30.1 ± 6.2 vs 27.9 ± Baseline Comparison of Participant Demographics,
3.8 kg/m2, P < .05), higher waist circumference (106.6 ± Medical History, and Risk Factor Variables Between sCRP
16.4 vs 96.8 ± 10.9 cm, P < .05), and a higher waist-to-hip and rCRP Groupsa
ratio (0.96 ± 0.07 vs 0.96 ± 0.08, P < .05) than those who
sCRP (n = 60) rCRP (n = 61)
remained in the study.
Baseline demographic and clinical characteristics of the Males 48 (80) 50 (82)
sCRP and rCRP groups are shown in Table 1. The 2 groups Age, y 60.6 ± 10.7 61.6 ± 10.5
had similar demographic characteristics, baseline time on Family history of IHD 30 (50) 26 (43)
the treadmill, and risk factors. Attendance at their respec- Post-menopausal 11/12 (92) 10/11 (91)
tive center-based CR sessions was significantly higher for the Primary prevention 14 (23) 19 (31)
rCRP group (97.3% ± 62.6% vs 70.5% ± 22.0%, P ≤ .01). Presence of diabetes 7 (12) 7 (12)
Within-group comparisons showed that both groups had IHD presentation
a significant improvement in total treadmill time at program Myocardial infarction 17 (28) 19 (31)
completion (4 months) of 106 seconds in the sCRP group Coronary artery bypass graft 20 (33) 18 (30)
(P < .01) and 90 seconds in the rCRP group (P < .01) Percutaneous transluminal 24 (40) 28 (46)
(Table 2). The sCRP group had a significant decline of coronary angiography
26 seconds in total treadmill time from 4 to 16 months of
Smoking status
follow-up (P < .05). The rCRP had a nonsignificant decline
Never smoked 51 (85) 56 (92)
of 15 seconds in total treadmill time from 4 to 16 months
Ex-smokers 2 (3) 2 (3)
of follow-up. For both groups, the 16-month total treadmill
Current smokers 7 (12) 3 (5)
time was significantly higher than baseline by 80 seconds
(P < .01) and by 75 seconds (P < .01), for the sCRP and Exercise capacity, METs 9.1 ± 2.1 9.2 ± 2.3
rCRP groups, respectively (Figure 3). TC, mmol/L 4.14 ± 1.07 4.16 ± 1.17
Table 3 shows the mixed-effects model analysis for the LDL-C, mmol/L 2.28 ± 0.89 2.25 ± 0.86
difference of total treadmill time between the sCRP and HDL-C, mmol/L 1.19 ± 0.30 1.27 ± 0.32
rCRP groups at the 4- and 16-month follow-ups adjust- Triglycerides, mmol/L 1.24 (0.93, 1.90) 1.38 (0.94, 1.65)
ed for baseline treadmill time. Participants in the sCRP TC/HDL-C 3.59 ± 1.00 3.41 ± 1.03
group had higher change in treadmill time of 13.3 seconds
Fasting glucose, mmol/L 5.6 (5.3, 6.2) 5.5 (5.1, 6.1)
compared with participants in the rCRP across the 2 time
points. The upper value of the 2-sided 95% confidence in- BMI, kg/m2 28.1 ± 3.7 28.4 ± 4.6
terval for the group estimate was lower than the 60-second Waist circumference, cm 97.4 ± 11.0 98.2 ± 12.8
cut point (48.47 seconds, P = .454); therefore, the rCRP LTPA, kcal/wk 1700 (900, 2685) 1464 (806,
group was not inferior to the sCRP in terms of change in 3423)
total treadmill time. Abbreviations: BMI, body mass index; HDL-C, high-density lipoprotein cholesterol; IHD,
For secondary outcomes, within-group comparisons ischemic heart disease; LDL-C, low-density lipoprotein cholesterol; LTPA, leisure time
showed reductions in TG and TC/HDL-C for the sCRP physical activity; METs, metabolic equivalents; rCRP, reduced cardiac rehabilitation
group at 4 months compared with baseline, whereas HDL-C program; sCRP, standard cardiac rehabilitation program; TC, total cholesterol.
was increased in the rCRP (Table 2). Both groups also had a
Data reported as mean ± standard deviation or n (% of group) or median and interquartile
a significant improvement of self-reported physical activity range.

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 Table 2
Treadmill Time and Ischemic Heart Disease Risk Factor Values at Baseline, 4, and 16 Monthsa
sCRP (n = 52) rCRP (n = 50)
0 mo 4 mo 16 mo 0 mo 4 mo 16 mo
Treadmill time, s 524 ± 168 630 ± 150b 604 ± 172b,c 565 ± 183 655 ± 196b 640 ± 192b
Exercise capacity, 8.9 ± 2.1 10.1 ± 1.8b 9.8 ± 2.0b 9.5 ± 2.3 10.6 ± 2.5b 10.4 ± 2.4b
METs
TC, mmol/L 4.13 ± 1.11 3.91 ± 0.84 4.30 ± 1.07c 4.12 ± 1.03 3.99 ± 0.78 4.21 ± 0.93
LDL-C, mmol/L 2.24 ± 0.88 2.13 ± 0.67 2.33 ± 0.89 2.23 ± 0.75 2.09 ± 0.67 2.27 ± 0.79
HDL-C, mmol/L 1.20 ± 0.32 1.22 ± 0.29 1.32 ± 0.33b,c 1.27 ± 0.33 1.36 ± 0.36b 1.35 ± 0.35b
TG, mmol/Ld 1.25 (0.93, 1.91) 1.10 (0.86, 1.50)b 1.38 (0.89, 1.76)c 1.25 (0.94, 1.63) 1.22 (0.81, 1.42) 1.11 (0.91, 1.47)
TC/HDL-C, mmol/L 3.56 ± 0.99 3.28 ± 0.67b 3.34 ± 0.80 3.36 ± 0.88 3.08 ± 0.84 3.21 ± 0.74
FBG, mmol/L 5.6 (5.3, 6.4) 5.7 (5.1, 6.2) 5.8 (5.4, 6.2) 5.5 (5.1, 6.3) 5.7 (5.2, 6.1) 5.8 (5.4, 6.2)
SBP, mm Hg 118 ± 16 119 ± 14 121 ± 15 120 ± 15 117 ± 14 120 ± 17
DBP, mm Hg 69 ± 10 70 ± 10 68 ± 10 71 ± 10 69 ± 9 69 ± 10
BMI, kg/m2 28.1 ± 3.7 27.9 ± 3.7 28.1 ± 4.2 27.7 ± 3.8 27.6 ± 3.7 27.8 ± 3.7
WC, cm 96.8 ± 10.8 96.6 ± 10.4 96.8 ± 12.5 97.1 ± 10.8 96.7 ± 10.6 97.3 ± 10.2
LTPA, kcal/wk 1590 (853, 2905) 2180 (1181, 3542)b 2115 (1326, 4288) 1729 (825, 3108) 2399 (1464, 3418)b 2216 (1498, 4676)
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; LTPA,
leisure time physical activity; METs, metabolic equivalents; rCRP, reduced cardiac rehabilitation program; SBP, systolic blood pressure; sCRP, standard cardiac rehabilitation program; TC, total
cholesterol; TG, triglycerides; WC, waist circumference.
a
Data reported as mean ± standard deviation apart from TG, FBG, and LTPA, which are reported as median and interquartile range.
b
Significant difference compared with baseline (month 0).
c
Significant difference compared with 4 months from baseline.
d
Data were log transformed before analyses.

In addition, some of these studies provided costly home ex-
ercise equipment, focused only on low-risk patients, were
limited to exercise-only interventions, and conducted no
follow-up after the intervention. Our study addressed these
gaps and demonstrated that a CRP with 10 center-based
exercise sessions was as effective as the standard CRP in
modifying cardiac risk factors immediately after completion
and for 1 year after in low- and moderate-risk patients.
As for sustainability of results, we are aware of 1 study
that found that participants in a 6-month home-based
exercise program achieved a greater exercise capacity
Figure 3. Total treadmill time in seconds for the sCRP and rCRP groups
at baseline, 4, and 16 months. Closed circles denote the sCRP and
open circles denote the rCRP. aSignificant differences from baseline.
b
Significant difference between 4 and 16 months in the sCRP group.
Significance indicators above the plot refer to the rCRP data and below
the plot to the sCRP data. rCRP indicates reduced cardiac rehabilitation
program; sCRP, standard cardiac rehabilitation program.
and participated in more physical activity than those in a
6-month center-based program at 1-year follow-up.28 Al-
though in our study treadmill time and physical activity lev-
els were comparable between the 2 groups, patients in the
sCRP experienced a decline in total treadmill time after 1
year that was not observed in the rCRP patients.
Program adherence measured as attendance to scheduled
center-based CR was higher for the rCRP group (84% vs
71.5%, P < .01). This could be explained by the rCRP be-
ing less time-consuming, requiring less transportation and
hospital time. This is consistent with the literature as many
CRP participants perceive the effort to attend center-based
sessions as a barrier for participation and adherence.29 The
decreased center-based number of CR sessions, however,
did not translate into reduced self-reported physical activ-
ity at program completion and at 1-year follow-up. This
positive change was not significantly different between the
groups. These findings are consistent with Carlson et al,30
who reported no difference in physical activity between
a home and center-based group at program completion
(3.8 ± 1.3 vs 4.3 ± 1.2 exercise sessions per week, respec-
tively; P > .05).
Although observational studies introduce inherent bias,
some have reported a positive association between CRP
“dose” and survival in secondary prevention patients.31-33
Our findings do not contradict these reports. The reduction
in center-based time was not a reduction of CRP “dose,” as
rCRP participants were encouraged to exercise and self-man-
age modifiable risk factors outside the hospital setting, while
still being supervised by the CRP staff. Indeed, we performed
subanalyses that showed no significant correlation between
center-based session attendance and exercise capacity change
in either group (r = 0.161, P ≥ .05) (data not shown).
The results of this study have important implications for
the delivery of CRP services. Traditional programs have
accessibility challenges: extended travel time,7 low intake ca-
pacity, and increased cost.34 Although the number patients
with cardiovascular disease who survive their coronary
events increases, CR availability has not and it continues to

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 Table 3
Mixed Model Analyses for Total Treadmill Time Change Between the sCRP and rCRP Groups at 4 and 16 Months Adjusted
for Baseline Treadmill Timea,b
Intent-to-Treat Analysis
Beta Coefficient (95% CI of Group Estimate)
Group estimate 9.4128 (−25.5914 to 44.4171)
Abbreviations: rCRP, reduced cardiac rehabilitation program; sCRP, standard cardiac rehabilitation program.
a
rCRP is the reference group for the categorical variables.
b
The group estimate refers to treadmill time difference for the sCRP relative to the rCRP.
be underfunded.35 Therefore, as guidelines indicate,6 alterna-
tive CRP models are needed to help overcome current uti-
lization barriers. Evaluation of such programs is the initial
step for the changes to come in the way CRP services are
delivered. Our results indicate that, for a selected proportion
of participants, the number of center-based sessions can be
drastically reduced and therefore free up crucial health care
resources for CRP participants who need more intense super-
vision (ie, elderly, high risk, low baseline fitness). This could
potentially improve patient capacity, adherence, and resource
allocation, while offering more flexibility to patients.
LIMITATIONS
Although direct assessment of maximal oxygen uptake
· 2. Pack QR, Goel K, Lahr BD, et al. Participation in cardiac rehabil-
(VO2max) is the most accurate measure of exercise capacity,
indirect estimates on the basis of treadmill time (using the
Bruce protocol) is an appropriate surrogate as it is associat-
ed with cardiovascular events and all-cause mortality21 and
·
is positively associated with VO2max.36 We also recognize that
our study population may not be entirely representative of
those patients who would benefit from a CRP. This is due
to underrepresentation of many patient groups in CRP such
as women, the elderly, ethnic minorities, and patients with
poor baseline fitness4,36; our purposeful exclusion of high-
risk patients and patients with significant comorbidities was
for safety reasons14 and a higher than anticipated refusal
rate. Of the 476 eligible patients who refused to participate,
60% had a preference for the sCRP and 40% for the rCRP,
and therefore they were unwilling to be potentially random-
ized to the group not of their choice. For the latter group,
since they did not want to attend the sCRP or participate
in the study, this group received no CRP. Implementation of
the rCRP into standard care may be a way to ensure these
patients do have CRP options that might be appealing.
Finally, all participants attended the same exercise sessions,
introducing a potential for between-group contamination.
However, this is also a strength, as it allowed for rCRP
utilization of existing hospital resources and an equivalent
comprehensive treatment of patients.
CONCLUSIONS
The rCRP intervention was a comprehensive program that
achieved beneficial changes in exercise capacity and risk
factors that were noninferior to the sCRP, while using one-
third of center-based CR sessions. The rCRP was well ac-
cepted by patients as reflected by its higher attendance rate
and similar number of dropouts compared with the sCRP;
therefore, it is feasible to implement in parallel to the tra-
ditional CRP. In light of these findings, the rCRP has the
potential to reduce access barriers while offering an alterna-
tive to selected patients that would prefer this type of pro-
gram delivery due to time, distance, and travel constraints.
It also has the potential for better utilization of resources,
increasing hospital intake capacity especially for high-risk
patients who need supervision the most.
6 Journal of Cardiopulmonary Rehabilitation and Prevention 2017;00:1-7
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Per-Protocol Analysis
P Value Beta Coefficient (95% CI of Group Estimate) P Value
.595 13.3302 (−21.8132 to 48.4737) .454
ACKNOWLEDGMENT
We would like to acknowledge the Healthy Heart Program
staff at St Paul’s Hospital, Vancouver, for supporting this
research project and facilitating the study. Dr Lear holds
the Pfizer/Heart and Stroke Foundation Chair in Cardiovas-
cular Prevention Research at St Paul’s Hospital. This study
was registered (protocol ID #37553) at clinicaltrials.org.
REFERENCES
1. Heran BS, Chen JMH, Ebrahim S, et al. Exercise-based cardiac
rehabilitation for coronary heart disease. Cochrane Database Syst
Rev. 2011;7:CD001800.
itation and survival after coronary artery bypass graft surgery: a
community-based study. Circulation. 2013;128:590-597.
3. Braverman DL. Cardiac rehabilitation: a contemporary review. Am
J Phys Med Rehabil. 2011;90:599-611.
4. Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and
delivery of cardiac rehabilitation/secondary prevention programs
at clinical centers and beyond: a presidential advisory from the
American Heart Association. Circulation. 2011;124:2951-2960.
5. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilita-
tion for patients with coronary heart disease: systematic review and
meta-analysis of randomized controlled trials. Am J Med. 2004;
116:682-692.
6. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and
secondary prevention of coronary heart disease: an American
Heart Association Scientific Statement from the Council on Clini-
cal Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation
and Prevention), and the Council on Nutrition, Physical Activity,
and Metabolism (Subcommittee on Physical Activity), in Collab-
oration With the American Association of Cardiovascular and
Pulmonary Rehabilitation. Circulation. 2005;111:369-376.
7. Daly J, Sindone AP, Thompson DR, Hancock K, Chang E, Davidson P.
Barriers to participation in and adherence to cardiac rehabilitation pro-
grams: a critical literature review. Prog Cardiovasc Nurs. 2002;17:8-17.
8. Jhawar M, Chan A, Christianson L, et al. Utilization of phase II
cardiac rehabilitation in Veterans Administration patients. Mo
Med. 2013;110:71-73.
9. Dunlay SM, Witt BJ, Allison TG, et al. Barriers to participation in
cardiac rehabilitation. Am Heart J. 2009;158:852-859.
10. Arthur HM, Smith KM, Kodis J, McKelvie R. A controlled trial of
hospital versus home-based exercise in cardiac patients. Med Sci
Sports Exerc. 2002;34:1544-1550.
11. Marchionni N, Fattirolli F, Fumagalli S, et al. Improved exercise
tolerance and quality of life with cardiac rehabilitation of older
patients after myocardial infarction: results of a randomized, con-
trolled trial. Circulation. 2003;107:2201-2206.
12. Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home-based
versus centre-based cardiac rehabilitation. Cochrane Database of
Syst Rev. 2010;1:CD007130.
13. Lesaffre E. Superiority, equivalence, and non-inferiority trials. Bull
NYU Hosp Jt Dis. 2008;66:150-154.
14. American Association of Cardiovascular and Pulmonary Rehabil-
itation. Guidelines for Cardiac Rehabilitation and Secondary Pre-
vention Programs. 4th ed. Champaign, IL: Human Kinetics; 2004.
15. Balady GJ, Berra KA, Golding LA, eds. ACSM’s Guidelines for Ex-
ercise Testing and Prescription. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2000.
www.jcrpjournal.com
16. Bruce RA. Exercise testing of patients with coronary heart disease.
Principles and normal standards for evaluation. Ann Clin Res.
1971;3(6):323-332.
17. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE.
Exercise capacity and mortality among men referred for exercise
testing. N Engl J Med. 2002;346:793-801.
18. Goraya TY, Jacobsen SJ, Pellikka PA, et al. Prognostic value of
treadmill exercise testing in elderly persons. Ann Intern Med.
2000;132:862-870.
19. Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to pre-
dict cardiovascular and all-cause death in asymptomatic women:
a 20-year follow-up of the lipid research clinics prevalence study.
JAMA. 2003;290:1600-1607.
20. Myers J, Kaykha A, George S, et al. Fitness versus physical activ-
ity patterns in predicting mortality in men. Am J Med. 2004;117:
912-918.
21. Lewington S, Whitlock G, Clarke R, et al. Blood cholesterol and
vascular mortality by age, sex, and blood pressure: a meta-analysis
of individual data from 61 prospective studies with 55 000 vascular
deaths. Lancet. 2007;370:1829-1839.
22. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Preven-
tion Program Research Group. Reduction in the incidence of type
2 diabetes with lifestyle intervention or metformin. N Engl J Med.
2002;346:393-403.
23. Stamler J, Dyer AR, Shekelle RB, Neaton J, Stamler R. Rela-
tionship of baseline major risk factors to coronary and all-cause
mortality, and to longevity: findings from long-term follow-up of
Chicago cohorts. Cardiology. 1993;82:191-222.
24. Pischon T, Boeing H, Hoffmann K, et al. General and abdominal
adiposity and risk of death in Europe. N Engl J Med. 2008;359:
2105-2120.
25. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the
concentration of low-density lipoprotein cholesterol in plasma,
without use of the preparative ultracentrifuge. Clin Chem. 1972;
18:499-502.
www.jcrpjournal.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
26. Richardson MT, Leon AS, Jacobs DR Jr, Ainsworth BE, Serfass R.
Comprehensive evaluation of the Minnesota Leisure Time Physical
Activity Questionnaire. J Clin Epidemiol. 1994;47:271-281.
27. Faris PD, Ghali WA, Brant R, Norris CM, Galbraith PD, Knudtson
ML. Multiple imputation versus data enhancement for dealing
with missing data in observational health care outcome analyses.
J Clin Epidemiol. 2002;55:184-191.
28. Smith KM, Arthur HM, McKelvie RS, Kodis J. Differences in sus-
tainability of exercise and health-related quality of life outcomes
following home or hospital-based cardiac rehabilitation. Eur J
Cardiovasc Prev Rehabil. 2004;11:313-319.
29. Wingham J, Dalal HM. Listening to patients: choice in cardiac re-
habilitation. Eur J Cardiovasc Nurs. 2006;5:289-294.
30. Carlson JJ, Johnson JA, Franklin BA, VanderLaan RN. Program
participation, exercise adherence, cardiovascular outcomes, and
program cost of traditional versus modified cardiac rehabilitation.
Am J Cardiol. 2000:86(1):17-23.
31. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac
rehabilitation and survival in older coronary patients. J Am Coll
Cardiol. 2009;54:25-33.
32. Doll JA, Hellkamp A, Thomas L, et al. Effectiveness of cardiac
rehabilitation among older patients after acute myocardial infarc-
tion. Am Heart J. 2015;170:855-864.
33. Martin BJ, Arena R, Haykowsky M, et al. Cardiovascular fitness
and mortality after contemporary cardiac rehabilitation. Mayo
Clin Proc. 2013;88:455-463.
34. Evenson KR, Fleury J. Barriers to outpatient cardiac rehabilita-
tion participation and adherence. J Cardiopulm Rehabil. 2000;20:
241-246.
35. Hughes S. Cardiac rehabilitation: What works, what doesn’t, and
why. Medscape Cardiology News. http://www.heartconnect.com/
news-articles/358-cardiac-rehabilitation-what-works-what-doesn-
t-and-why/portal. Accessed December 8, 2014.
36. Myers J, Bellin D. Ramp exercise protocols for clinical and cardio-
pulmonary exercise testing. Sports Med. 2000;30:23-29.
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