Prepared by Jessica R. Golbus, MD, MS – Division of Cardiovascular Medicine, University of Michigan
- Cardiac rehabilitation (CR) has strong evidence of benefit for secondary disease prevention across many cardiovascular conditions. However, CR is underutilized and has the potential to better support patients in improving and sustaining behaviors known to promote optimal cardiovascular health.
- Digital technology has the potential to address many of the challenges of traditional center-based CR and augment care. Due to a lack of standardization, digital technology is defined in this science advisory to refer to the care delivered through the internet, wearable devices, and mobile applications, as well as emerging computational methods (eg, artificial intelligence and big data).
- This AHA science advisory was assembled to help guide the development and implementation of digital CR interventions that can be translated effectively into clinical care, improve health outcomes, and promote health equity.
- Digital technologies have the capability to add value to health systems by (1) reaching patients previously underrepresented in center-based CR; (2) keeping patients connected to one another and within the health system; (3) changing the cost structure of CR by reducing scarce capital; and (4) allowing for more flexible scheduling for both patients and staff.
- To aid in the delivery of CR, digital technologies are being used (1) as an adjunct to synchronous/in-person CR; 2) for synchronous/real-time audio-visual CR (ie, virtual CR); and (3) for asynchronous CR (ie, remote CR). Generally, the field has moved towards a patient-tailored hybrid model of delivery that offers patients a combination of synchronous/in-person CR and synchronous/real-time CR.
- The current evidence supporting the use of digital technologies in CR points to major gaps that need to be addressed before it can be widely embraced as a safe and effective tool for use in routine practice.
- These evidence gaps include studies conducted in community-based practice settings with extended follow-up and standardization of comparator groups. It is important for future studies to prioritize greater patient diversity, consider frailty and multimorbidity (above and beyond just aging), include additional clinical populations, and provide more complete solutions to comorbidity management.
- It is also important that future digital CR solutions aspire to deliver and possibly refine the core components of CR more comprehensively. The emergence of smart wearable devices presents an opportunity for robust monitoring of digital biomarkers or desirable/tangible goals in order to tailor exercise prescriptions, support extended patient engagement, and overall provide a more complete solution for CR delivery.
- While use of digital technologies in CR has the potential to improve health equity, rapidly advancing technology may also exacerbate the exclusion of sociodemographic subgroups or persons with disabilities, introduce digital biases, and paradoxically widen the digital divide. Issues related to connectivity, affordability, and accessibility may disenfranchise unique populations and is important to consider up front when developing and implementing digital interventions.
- To promote equity, the development, validation, and implementation of digital technologies in CR centers on two specific goals: (1) to avoid perpetuating or worsening current health disparities; and (2) to identify opportunities to overcome barriers that have limited access to or the efficacy of CR in underrepresented populations. Examples of unique considerations when using digital technologies include selecting wearable devices with large display screens or ensuring large font in mobile applications for older adults who may have poor eyesight or dexterity.
Golbus JR, Lopez-Jimenez F, Barac A, Cornwell WK, Dunn P, Forman DE, Martin SS, Schorr EN, Supervia M; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Quality of Care and Outcomes Research; and Council on Cardiovascular and Stroke Nursing. Digital technologies in cardiac rehabilitation: a science advisory from the American Heart Association [published online ahead of print June 5, 2023]. Circulation. doi: 10.1161/CIR.0000000000001150