Multidisciplinary cardiac rehabilitation and secondary prevention programs (CR/SP) are considered essential components of myocardial infarction (MI) management.1 In fact, growing evidence demonstrates a significant reduction in all-cause mortality as well as lower recurrent cardiovascular event and hospitalization rates in patients following CR/SP programs after a cardiac event.2 Despite this, traditional CR/SP programs appear to be unsustainable and less accessible due to several barriers, especially in older patients.1,3 These involve socioeconomic factors, along with logistic, physical, or cognitive limitations.4,5 Moreover, many clinicians and patients do not consider CR/SP a high priority and patients, therefore, decline to follow the program. Thus, because of low adherence to CR/SP programs, there is a need for alternative follow-up interventions to promote and maintain a physically active lifestyle among older MI patients. The present narrative study describes the impact of a motivational and educational approach for improving lifestyle change and participation in a more feasible and patient-centered CR/SP program.
METHODS
This study used data collected by the Center for Exercise Science and Sports (University of Ferrara, Italy), employing an approach utilized for the long-term management of patients with stable cardiovascular disease, within a tailored exercise-based secondary prevention program. This approach was used in the "Physical Activity Intervention for Elderly Patients with Reduced Physical Performance after Acute Coronary Syndrome (HULK)" randomized clinical trial (http://www.clinicaltrials.gov.NCT03021044).6 A detailed representation of the model of intervention is reported in the Figure. It is based on a motivational interview between the patient, exercise specialist, and physician. The importance of maintaining a physically active lifestyle is emphasized. Metrics for improvement are related to the quality of life, focusing on independence and reduced need to be looked after by caregivers. To increase social support and to share decisions, patients are encouraged to bring their partner and/or a significant family member. Self-reported weekly leisure-time physical activity (PA) is assessed from a 7-d PA recall questionnaire.7 Individualized patient goals (ie, achievement of the recommended level of PA) are discussed and they are used as a basis for adjustment of the exercise prescription. Patients who report significant improvement are encouraged to maintain their level of commitment. Patients who fail to achieve the target goals are provided support to overcome their limiting factors. In addition, during center-based sessions, all patients performed a submaximal, moderate, and perceptually regulated 1-km treadmill walking test.8 Based on the results of the test, patients were encouraged to replicate similar walking sessions at home. In addition, a selection of calisthenics exercises based on the Otago Exercise Program is performed,9 with the recommendation to be replicated at home. Barriers to completing the home program are discussed and solutions proposed, even during the walking test, as such functioning as an informal problem-solving activity, integrated within the testing session. The program is regularly adjusted during subsequent follow-up visits.
RESULTS
Results of the trial showed a positive impact of the intervention on the maintenance of long-term adherence rates. Of 118 participants enrolled in the intervention group, 65 (55%) are still attending the exercise program after 3 yr of follow-up. Furthermore, a significant improvement has been observed in PA levels. The percentage of patients meeting the minimum recommended dose of PA (>= 7.5 METs-hr/wk) increased over time from 20-76%.
DISCUSSION
The major finding of this study is the contribution of this method to the long-term management of older MI patients (aged >=70 yr) and its efficacy in the improvement and maintenance of a physically active lifestyle. This is consistent with previous studies, which highlighted the importance of developing new strategies to improve adherence rates and the management of the disease during maintenance CR.1 Our data are relatively novel, given the focus on older MI patients and long-term adherence. These individuals are less represented in the available randomized clinical trials and in general, the referral to CR/SP of older adults in several European countries is <10%.5 We found a significant impact on PA levels, similar to those in which short-term interventions were conducted for 12 wk among patients with a lower mean age ([almost equal to]62 yr).10 Furthermore, according to our previous findings, these results reflect a meaningful improvement in physical functioning and quality of life and are associated with a significant reduction in adverse events.6 Regarding the structure and the purpose of this intervention strategy, they are consistent with other studies. According to a recent review, the communicative approach needs to be more focused on the emotional, psychological, and socioeconomic mindsets that influence decisions made by patients about their health, with the purpose to enhance their motivation and adherence.4 Moreover, at the end of the protocol, patients can voluntarily continue to attend the exercise-based program. In accordance with this evidence, continuous motivational counseling and the importance of patient perception, along with a specific strategy of exercise testing, are the core components of our approach. In addition, the 1-km treadmill walking test plays an educational role, facilitating learning through this assessment. In fact, the test is not only useful for exercise capacity assessment but patients can experience and learn the proper intensity and duration of walking, in order to replicate it at home.7
Limitations of the study include the fact that the intervention likely varies between patients, which can affect patient motivation and lifestyle habits. Second, the results were obtained from patients involved in a trial mainly focused on exercise training. It is important to note that the proposed CR/SP model does not represent a substitute for traditional CR/SP models. It should be considered an alternative for patients refusing traditional CR or in need of a different option. Alternatively, the proposed approach may be considered a first step to promote CR/SP after MI, especially in frail patients, and many patients who were not initially eligible for traditional CR may later be included in the CR/SP program. Future results will address these limitations.
In conclusion, this motivational and educational exercise-based intervention model is effective in treating older MI patients and may contribute to greater participation for such patients in CR/SP programs.
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