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Study design and procedure
For the study 1, a home-based exercise program was developed through a systematic process outlined by An et al. [19]. The process included a systematic literature review to understand hospital- and home-based CR; a survey of 189 patients with CVD to assess their physical activity (PA) participation levels, attitudes, barriers, and facilitators of exercise PA, and the formation of an expert committee composed of three cardiologists and two exercise specialists to establish goals, implementation strategies, and precautions for home-based CR.
Based on an expert committee meeting, preliminary exercise programs were developed with the goal of helping patients with CVD to follow exercise guidelines for both aerobic and resistance exercises. Because physical fitness and exercise experience varied among patients, walking was recommended as the main type of aerobic exercise, and an aerobic exercise video was produced for patients when outdoor walking was not feasible. Considering that participation in resistance exercise at a fitness center may not be feasible for many patients with CVD, a calisthenic exercise program was developed. The program consisted of eight resistance exercises that utilized the participant’s own body weight. The number of repetitions, sets, and rest intervals was determined based on the initial fitness levels and joint conditions of the participants (Supplementary Table 1, Supplementary Material 1 and 2).
The study 2 was then conducted to assess the feasibility of following the exercise video and to measure heart rate responses and the rate of perceived exertion (RPE) during exercise (Study 1). During this stage of development of the exercise program, the participants exercised on two separate days and their experiences while performing the aerobic and resistance exercises were surveyed (Supplementary Table 2). Subsequently, an expert panel consisting of three cardiologists, two exercise specialists, two clinical psychologists, and two clinical nutritionists reviewed and revised the home-based CR program based on heart rate data, RPE response, and survey data. A feasibility study was then conducted to examine the implementation of a home-based exercise program in conjunction with dietary and psychological counseling over a 6-week period in a tertiary hospital setting (Study 2).
Data from the Study 1 and feasibility studies (Study 2) are reported and discussed. It is worth noting that the implementation of home-based CR includes psychological and nutritional counseling in addition to home-based exercise rehabilitation. This study was approved by the Institutional Review Board of Yonsei University College of Medicine (approval Nos: 4-2021-0576 and 4-2021-0935).
Participants
From September 2021 to July 2022, we recruited participants from Yonsei Severance Hospital in Seoul, Republic of Korea. Patients with heart failure with reduced ejection fraction (HFrEF) or MI were included in the study. The study details were explained to 127 patients who met the inclusion criteria during their visit to the Cardiology Clinic at Severance Hospital. Nine participants (MI 2, MI with HFrEF 3, and HFrEF 4) were enrolled in Study 1, and 16 participants (MI 3, MI with HFrEF 6, and HFrEF 7) were enrolled in Study 2 (Fig. 1, Table 1). All participants who agreed to participate in the study provided written informed consent.
Study design and outcome measure
Study 1 involved a 2-day exercise session, in which participants completed separate sessions of aerobic and resistance exercises each day. All exercise programs were conducted under the supervision of exercise specialists at the Yonsei University Fitness Center. On day 1, the participants engaged in three different types of aerobic exercises, each lasting approximately 15 min with three different levels of intensity (low, moderate, and high). Participants’ heart rates and RPE were monitored during the exercises. On day 2, the participants completed two sets of eight different calisthenic exercises, and their heart rates and RPE were monitored. If the exercise became too challenging or difficult to follow, participants were instructed to take a rest. Additionally, the participants were asked to complete surveys to assess their level of satisfaction with each exercise type (Supplementary Table 2).
In Study 2, upon enrollment, the participants’ levels of PA and physical functions were assessed. Two exercise education sessions were conducted in the 2nd and 4th week, along with four phone counseling sessions in the 1st, 3rd, 5th, and 6th week. The aim of the home-based CR exercise program was to increase the participants’ moderate-intensity exercise to 150 min or more per week, with resistance exercise utilizing their body weight at least twice a week. The intensity of aerobic exercise was set at 40–80% of heart rate reserve or 11–16 on the RPE scale. The participants received education from exercise specialists to perform the prescribed calisthenic exercises correctly, were encouraged to comply with the exercise program, and were monitored weekly. They were provided with an exercise diary and videos containing stretching, calisthenics, and aerobic exercises (walking and videos), which could be performed daily at home.
To assess the feasibility of the home-based exercise program, the participants’ compliance with the exercise sessions was monitored by conducting two face-to-face sessions and four telephone counseling sessions. The participants were also asked to write in an exercise diary to record their participation in the prescribed exercises. These measures were adopted to ensure that the participants were able to follow the prescribed exercise program (acceptability and fidelity) and to identify any issues that may have risen during the intervention. Additionally, the participants were asked to complete surveys to assess their level of satisfaction with each component of a home-based CR program (Supplementary Table 3).
PA levels were evaluated at baseline and at the end of the 6th week. The proportion of participants who met the PA guidelines for both aerobic and resistance exercises was also compared at baseline and at the 6th week of the intervention. PA was assessed using the Global Physical Activity Questionnaire (GPAQ). Three tests were performed to measure physical function: hand grip strength, sit-to-stand, and 6-minute walk tests. Handgrip strength was measured of both hands using a Takei A5401 hand grip dynamometer (Takei Scientific Instruments, Niigata, Japan). For the sit-to-stand test, the participants were asked to complete as many full stands as possible within 30 s. For the 6-minute walk test, participants were asked to walk for a total of 6 min and cover as much distance as possible.
Statistical analysis
Descriptive statistics were used to analyse the results of our studies. Continuous variables are expressed as means and standard deviations and where data was not normally distributed, median, and interquartile ranges were reported. Categorical variables are presented as percentages. and chi-squared tests were used to detect differences between the groups. The statistical software SPSS version 25.0 (IBM Corp, Armonk, NY, USA).
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