Knowledge, attitudes, and practices of cardiopulmonary rehabilitation among physiotherapists in Lebanon

Background
Insufficient physical activity is one of the leading mortality risks worldwide for cardiovascular and pulmonary diseases. Physiotherapists (PT) are core healthcare professionals who play a major role in the prevention of disease complications and in inspiring a healthy lifestyle. To identify challenges in the promotion of cardiopulmonary rehabilitation (CR) in Lebanon, a survey was conducted among PT and physiotherapy students. The aim was to assess the knowledge, attitudes, and practices of CR in Lebanon.

Results
The response rate was 46.1% (N = 322). Results show that 24.5% of respondents have good to excellent knowledge about CR. More than 60% of the respondents indicate possible barriers to starting a CR program, and one of two respondents identify the absence of skills as a main barrier. Findings highlight the importance of the role of PT as a mediator to increase a healthy lifestyle among patients and to promote the prevention of cardiovascular diseases and pulmonary diseases in the country.

Conclusions and recommendations
Our results support the evidence and clinical guidelines that PT play a major role by increasing the participation of patients in CR. A cost-effective CR program needs to be covered by the private and public system in Lebanon.

Development of the International Cardiac Rehabilitation Registry Including Variable Selection and Definition Process

Introduction: The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) is developing a registry (ICRR) specifically for low-resource settings, where the burden of cardiovascular diseases is greatest and the need for program development highest. Herein we describe the development process, including the variable selection process.

Method: Following a literature search on registry best practices, a stepwise model for ICRR development was identified. Then, based on recommendations by Core Outcome Set-STAndards for Development (COS-STAD), we underwent a process to identify variables. All available CR registries were contacted to request their data dictionaries, reviewed CR quality indicators and guideline recommendations, and searched for common data elements and core outcome sets; 35 unique variables (including patient-reported outcomes) were selected for potential inclusion. Twenty-one purposively-identified stakeholders and experts agreed to serve on a Delphi panel. Panelists rated the variables in an online survey, and suggested potential additional variables; A webcall was held to reach consensus on which to include/exclude. Next, panelists provided input to finalize each variable definition, and rated which associated indicators should be used for benchmarking in registry dashboards and a patient lay summary; a second consensus call was held. A 1-month public comment period ensued.

Results: First, registry objectives and governance were approved by ICCPR, including data quality and access policies. The protocol was developed, for public posting. For variable selection, the overall mean rating was 6.1 ± 0.3/7; 12 were excluded, some of which were moved to a program survey, and others were revised. Two variables were added in an annual follow-up, resulting in 13 program and 16 patient-reported variables. Legal advice was sought to finalize ICRR agreements. Ethics approvals were obtained. Usability testing is now being initiated.

Conclusion: It is hoped this will serve to harmonize CR assessment internationally and enable quality improvement in CR delivery in low-resource settings.

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal

Background
Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal.
Objective
The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes.
Method
A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using “The Health System Assessment Approach”. Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews.
Result
Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols.
Conclusion
Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building.

Impact of COVID-19 on Cardiovascular Disease Presentation, Emergency Department Triage and Inpatient Cardiology Services in a Low- to Middle-Income Country – Perspective from a Tertiary Care Hospital of Pakistan

Aims: To identify the changes in cardiovascular disease presentation, emergency room triage and inpatient diagnostic and therapeutic pathways.

Methods: We conducted a retrospective cohort study at the Aga Khan University Hospital, Karachi. We collected data for patients presenting to the emergency department with cardiovascular symptoms between March–July 2019 (pre-COVID period) and March–July 2020 (COVID period). The comparison was made to quantify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, and in-hospital mortality between the two periods.

Results: Of 2976 patients presenting with cardiac complaints to the emergency department (ED), 2041(69%) patients presented during the pre-COVID period, and 935 (31%) patients presented during the COVID period. There was significant reduction in acute coronary syndrome (ACS) (8% [95% CI 4–11], p < 0.001) and heart failure (↓6% [95% CI 3–8], p < 0.001). A striking surge was noted in Type II Myocardial injury (↑18% [95% CI 20–15], p < 0.001) during the pandemic. There was reduction in cardiovascular admissions (coronary care unit p < 0.01, coronary step-down unit p = 0.03), cardiovascular imaging (p < 0.001), and procedures (percutaneous coronary intervention p = 0.04 and coronary angiography p = 0.02). No significant difference was noted in mortality (4.7% vs. 3.7%). The percentage of patients presenting from rural areas declined significantly during the COVID period (18% vs. 14%, p = 0.01). In the subgroup analysis of sex, we noticed a falling trend of intervention performed in females during the COVID period (8.2% male vs. 3.3 % female). Conclusions: This study shows a significant decline in patients presenting with Type I myocardial infarction (MI) and a decrease in cardiovascular imaging and procedures during the COVID period. There was a significant increase noted in Type II MI.

A practical approach to perioperative risk optimisation for non-cardiac surgery

The combination of careful perioperative considerations, less invasive surgeries and the liberal use of neuro-axial techniques has decreased perioperative major adverse cardiac events (MACE) and overall mortality in vascular surgical patients.

Despite this, the recently published ASOS-2 study still demonstrated a 1% mortality even with intensive postoperative monitoring for a range of patients and procedures in lower-middle income countries (LMICs).1 As surgeons, our outcome measures are sometimes different to other perioperative physicians (primarily anaesthesiologists and cardiologists). Our outcomes are not limited to the myocardial function or the safe awakening after anaesthesia, but also incorporates medium term outcomes such as postoperative infections, wound healing, returns to the operating theatre and restoration of pre-morbid functional capacity.

Rheumatic Heart Disease is Missing from the Global Health Agenda

Rheumatic heart disease (RHD) is a complication of untreated throat infection by Group A beta-hemolytic streptococcus with a high prevalence among socioeconomically disadvantaged populations. Despite its high incidence and prevalence, RHD prevention is not a priority in major global health discussions. The reasons for the apparent neglect are multifactorial, including underestimated morbidity and mortality burden, underappreciated economic burden, lack of public awareness, and lack of sustainable investment. In this review, we recommend multisectoral collaboration to tackle the burden of RHD by engaging the public, health experts, and policymakers; augmenting funding for clinical care; improving distribution channels for prophylaxis, and increasing research and innovation as critical interventions to save millions of people from preventable morbidity and mortality.

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis

Background
Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time.

Methods
All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records.

Results
Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery.

Conclusion
This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country.

Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020.

Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively.

Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy.

Highlights:
Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.
Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.
Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan

Background
Rheumatic heart disease (RHD) remains a leading cause of morbidity and mortality in Sub-Saharan Africa despite widely available preventive therapies such as prophylactic benzathine penicillin G (BPG). In this study, we sought to characterize facilitators and barriers to optimal RHD treatment with BPG in Sudan.

Methods
We conducted a mixed-methods study, collecting survey data from 397 patients who were enrolled in a national RHD registry between July and November 2017. The cross-sectional surveys included information on demographics, healthcare access, and patient perspectives on treatment barriers and facilitators. Factors associated with increased likelihood of RHD treatment adherence to prophylactic BPG were assessed by using adjusted logistic regression. These data were enhanced by focus group discussions with 20 participants, to further explore health system factors impacting RHD care.

Results
Our quantitative analysis revealed that only 32% of the study cohort reported optimal prophylaxis adherence. Younger age, reduced primary RHD healthcare facility wait time, perception of adequate health facility staffing, increased treatment costs, and high patient knowledge about RHD were significantly associated with increased odds of treatment adherence. Qualitative data revealed significant barriers to RHD treatment arising from health services factors at the health system level, including lack of access due to inadequate healthcare staffing, lack of faith in local healthcare systems, poor ancillary services, and patient lack of understanding of disease. Facilitators of RHD treatment included strong interpersonal support.

Conclusions
Multiple patient and system-level barriers to RHD prophylaxis adherence were identified in Khartoum, Sudan. These included patient self-efficacy and participant perception of healthcare facility quality. Strengthening local health system infrastructure, while enhancing RHD patient education, may help to improve treatment adherence in this vulnerable population.

The role of cardiac rehabilitation in improving cardiovascular outcomes

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.