Remotely monitored telerehabilitation for cardiac patients: A review of the current situation

Table 1 Description of telerehabilitation studies

Ref.	Design	TR group patients	TR intervention			Outcomes
			Remote monitoring	Exercise prescription	Feedback	I-primary II-secondary
Avila et al[15], 2018	RCT, 12-wk III-phase CR active CBCR	n = 30 age 59 I-II CVR	Post-exercise, chest strap HR monitor, internet connection	Target HR zone 70%-80% HRR, 150 min/wk	Phone call or email 1/wk	I-exercise capacity II-daily PA, strength CVR factors
Bravo-Escobar et al[16], 2017	RCT, 8-wk II-phase CR active CBCR	n = 14 age 56 II - CVR	Post-exercise, ECG, biometric vest, smartphone internet	Target HR zone 70%-80% HRR, 60 min > 2/wk	Supervised CR in center 1/wk	I-exercise capacity II-CVR factors, HRQL, adherence
Fang et al[17], 2018	RCT, 6-wk II-phase CR usual care CG	n = 40 age 60 I - CVR	Real-time belt strap sensor, smartphone internet connection	Physical activity booklet, walking 3/wk	Phone call 1/wk	Exercise capacity, anxiety, depression CVR factors
Frederix et al[18], 2015	RCT, 24-wk II-III phase CR usual care CG	n = 70 age 61	Post-exercise accelerometer, webservice, internet	Target HR zone 1VT, 45-60 min 2/wk	Email or SMS 1/wk	I-exercise capacity II-daily PA, HRQL, CVR factors
Hwang et al[24], 2017	RCT, 12-wk HF-CR active CBCR	n = 24 age 68	Real-time video platform via internet, educational lectures	Target RPE zone 9-13 RPE, 60 min 2/wk	15 min real-time video feedback	I-walking distance II-balance, strength, HRQL
Kraal et al[19], 2014	RCT, 12-wk II-phase CR active CBCR	n = 25 age 59 I-II CVR	Post-exercise, chest strap HR monitor, internet platform	Target HR zone 70%-85% HRmax 45%-60% min > 2/wk	Weekly coaching via telephone	I-exercise capacity II-HRQL, training adherence
Lee et al[20], 2013	RCT, 12-wk II-phase CR usual care CG	n = 26 age 54 I-II CVR	Wearable ECG equipment via mobile phone	Target HR zone 40%-80% HRR, 50 min, 4-5/wk	Phone call 1/wk	I-exercise capacity II-HRQL
Maddison et al[21], 2019	RCT, 12-wk II-phase CR active CBCR	n = 82 age 61	Chest-worn wearable ECG sensor, internet smartphone app, accelerometry	Target HR and RPE zone 40%-65% HRR, 11-13 RPE 30-60 min, 3/wk	Real-time audio service via earphones	I-exercise capacity II-daily PA, HRQL, CVR factors, costs
Peng et al[25], 2018	RCT, 8-wk HF-CR usual care CG	n = 49 age 66	Real-time, HR monitor smartphone, internet platform	Target HR zone 40%-70% HRR 20 min, 3/wk	Text, audio service via webcam	I-HRQL II-walking distance, anxiety, depression
Piotrowicz et al[26], 2014	RCT, 8-wk HF-CR usual care CG	n = 77 age 54	Real-time, ECG, BP and BW monitor, mobile phone	Target HR zone 40%-70% HRR 45-60 min 5/wk	Real-time telephone call	I-exercise capacity II-walking distance HRQL, adherence
Skobel et al[22], 2017	RCT, 24-wk III-phase CR usual care CG	n = 55 age 60	Real-time, ECG sensor vest, smartphone, internet platform	Target RPE zone 11-13 RPE, 10-60 min 3/wk	Real-time via smartphone	I-exercise capacity II-HRQL, CVR factors, anxiety
Varnfield et al[23], 2014	RCT, 24-wk II-phase CR active CBCR	n = 53 age 56	Post-exercise, step-counter, BP and BW monitor, web portal, internet	Target RPE zone 11-13 RPE, > 30 min most d/wk	Text message telephone consultation first 6 wk	I-uptake, adherence II-HRQL, CVR factors, functional capacity

BP: Blood pressure; BW: Body weight; CBCR: Center-based cardiac rehabilitation; CG: Control group; CR: Cardiac rehabilitation; CVR: Cardiovascular risk; ECG: Electrocardiogram; HF: Heart failure; HR: Heart rate; HRQL: Health-related quality of life; HRR: Heart rate reserve; n: Number of participants; PA: Physical activity; RCT: Randomized controlled trial; RPE: Ratings of perceived exertion; SMS: Short message service; TR: Telerehabilitation.

Table 2 Study quality using Tool for the assEssment of Study qualiTy and reporting in EXercise scale

Ref.	Study quality, Max 5	Study reporting, Max 10	Total score, Max 15
Avila et al[15], 2018	4	9	13
Bravo-Escobar et al[16], 2017	4	7	11
Fang et al[17], 2018	2	3	5
Frederix et al[18], 2015	5	8	13
Hwang et al[24], 2017	5	10	15
Kraal et al[19], 2014	4	8	12
Lee et al[20], 2013	2	3	5
Maddison et al[21], 2019	4	6	10
Peng et al[25], 2018	4	7	11
Piotrowicz et al[26], 2014	4	6	10
Skobel et al[22], 2017	5	5	10
Varnfield et al[23], 2014	4	9	13

Max: Maximum.

Table 3 Studies outcomes

Ref.	Follow-up, in week	Completion rate, %		Adverse events, n	Exercise capacity between group differencesa
		TR	CG
Avila et al[15], 2018	12	94	1001	No adverse events	TR = CBCR
Bravo-Escobar et al[16], 2017	8	93	1001	3 angina type pain during TR, no ECG changes; no serious CV events	TR = CBCR
Fang et al[17], 2018	6	83	85	Not reported	TR > UC
Frederix et al[18], 2015	24	89	91	Not reported	TR > UC
Hwang et al[24], 2017	12	100	901	Minor adverse events: 3 angina, 2 palpitation, 3 diaphoresis; no serious CV events	TR = CBCR
Kraal et al[19], 2014	12	86	961	No adverse events	TR = CBCR
Lee et al[20], 2013	12	87	97	Not reported	TR > UC
Maddison et al[21], 2019	12	88	921	Mild: 12 non-serious; moderate: 6 medically important event, hospitalization; no serious CV complications	TR = CBCR
Peng et al[25], 2018	8	86	84	No adverse events	TR > UC
Piotrowicz et al[26], 2014	8	97	94	Minor: 4 skin reactions due to the ECG electrodes; no serious CV events	TR > UC
Skobel et al[22], 2017	24	35	67	No CV events associated to CR adverse events: 9; 2 chest infection, 3 angina, 2 chest pain before training, 1 atrial fibrillation, 1 palpitation	TR > UC
Varnfield et al[23], 2014	6	91	681	10 deterioration in health and/or medical care needs unrelated to CR; no serious CV events	TR = CBCR

^aP < 0.05.

¹Center-based cardiac rehabilitation. CBCR: Center-based cardiac rehabilitation; CG: Control group; CR: Cardiac rehabilitation; CV: Cardiovascular; ECG: Electrocardiogram; TR: Telerehabilitation; UC: Usual care.