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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The picture of cardiac rehabilitation &#40;CR&#41; in Portugal has been periodically framed by the Portuguese Society of Cardiology &#40;SPC&#41; through a survey carried out by the SPC&#39;s Working Group on Exercise Physiology and Cardiac Rehabilitation&#46; Surveys are fundamental to measure the status of CR and are especially useful to define strategies that can fill the gaps in CR at the national level&#46; It has long been known that CR is effective but underutilized due to already identified barriers&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The next step&#44; besides implementing a national CR registry&#44; which will be most helpful&#44; is to define a plan for action&#44; involving advocacy and other strategies to improve CR implementation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest CR national survey&#44; for 2019&#44; published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> states that CR programs have a central role in cardiovascular &#40;CV&#41; medicine&#44; but I would rather say&#44; instead&#44; that they should have such a role&#44; because in practice they in fact do not&#46; This remains a chronic issue in many countries&#44; and in particular in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Looking at the present results of the 2019 survey<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and comparing them to those of the previous survey &#40;2013&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> there was an increase of 5&#37; in the number of CR centers &#40;n&#61;25&#41; and of 13&#37; in the number of patients &#40;n&#61;2182&#41; included in phase II programs&#46; This increase has been progressive over time&#44; since 1998&#44; but always small&#46; In fact&#44; the issue is not only to have more centers&#44; but also to improve their capacity in terms of numbers of rehabilitated patients&#44; which depends on the availability of material and human resources&#44; as well on appropriate and systematic referral&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As in most countries&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> ischemic heart disease&#44; with 67&#37;&#44; represents the largest slice of rehabilitated patients&#44; with 50&#37; of the total for ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The small increase in ACS patients referred to CR of 1&#46;3&#37; in absolute terms &#40;9&#46;3&#37; vs&#46; 8&#37; in 2013&#41; is clearly inadequate&#46; The reported increase in the referral rate for phase II programs&#44; planned or scheduled at discharge&#44; revealed by the Portuguese Registry of ACS &#40;ProACS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> was certainly insufficient to significantly increase CR uptake among ACS patients&#46; Planning and scheduling are different processes&#46; Planning without effectively performing registration in a phase II program&#44; without obtaining the patient&#39;s commitment&#44; is obviously not enough&#46; Increasing phase I CR programs with a structured discharge plan including a signed consent registration for phase II and pre-discharge schedule could improve the situation&#46; At the national level&#44; more initiatives for implementation of CR after ACS are needed&#46; Advocacy measures and strategies on the part of medical societies&#44; medical and patient organizations and universities need urgently to be adopted&#46; It is not acceptable that there is solid scientific evidence for the benefits of CR&#44; especially on total and CV mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> but that clinical practice does not follow this evidence&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding heart failure&#44; the number of rehabilitated patients reached 14&#46;5&#37;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> with a slight absolute increase of 1&#46;8&#37; &#40;relative to the previous 12&#46;7&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> which is not surprising&#46; For many reasons&#44; heart failure patients are less often referred for CR than ACS patients&#46; Barriers including age&#44; depression&#44; low level of education and lack of resources are responsible for this underuse of CR in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In addition&#44; patients with implantable cardioverter-defibrillators or cardiac resynchronization therapy devices need to be referred for CR more frequently&#59; the referral rate for these patients is only 4&#46;2&#37; in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">What is really unacceptable is that only 10&#46;2&#37; of patients undergoing coronary artery bypass graft surgery and fewer than 6&#37; of those undergoing surgical or percutaneous valvular intervention are included in CR programs&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> when these patients could benefit significantly&#44; especially in functional terms&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Cardiac surgeons need to be involved in the CR process&#44; but this can be difficult since they spend most of their time inside the operating room&#44; without time or availability for medical issues like CR&#46; Motivation and demonstration of the benefits of CR in surgical patients need to be promoted among surgical teams&#44; including nurses&#44; an important professional group in rehabilitation teams&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The good news is the 33&#37; increase in the number of phase I CR programs&#46; These are particularly important&#44; particularly in increasing referral for and uptake of phase II CR&#46; Apparently easier at first sight&#44; phase I programs are in fact challenging&#44; since most centers do not have the means to create a dedicated team&#44; and must use multitasking healthcare professionals&#44; mainly nurses&#44; sometimes physiotherapists and cardiologists&#44; who are already involved in many other activities inside the hospital&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In contrast to the trend in phase II&#44; the number of patients included in phase III CR programs fell by 37&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Structured phase III programs are less standardized and frequently more difficult to define&#46; At the same time&#44; patients find it easier to participate in phase II programs&#44; since they are closely attached in time to the CV event and are limited in duration&#46; Many patients do not maintain long-term CR&#44; even though the benefits of CR are known to be rapidly lost&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> It would be helpful if CR centers with phase II programs could also provide phase III programs or transfer the patient directly to a connected phase III program&#44; as already happens in some Portuguese centers&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Another encouraging sign is that 91&#37; of the centers had a drop-out rate compatible with the quality indicators proposed by the European Association of Preventive Cardiology and other medical societies&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> However&#44; drop-out rates of 26-68&#37; in 9&#37; of the centers<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> are completely unacceptable&#44; necessitating investigation of the reasons for these figures&#46; A drop-out rate of &#60;25&#37; is an accepted quality indicator&#44; and so higher rates suggest that the programs need to be modified&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is still the case that in several centers&#44; phase II CR programs remain essentially exercise-based&#46; It is necessary to reinforce the importance of the other components besides exercise&#44; including risk factor control&#44; nutritional and psychological assessment and intervention&#44; and structured education&#44; all of which are part of secondary prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> It is not a good result when only 32&#37; of programs offer a nutritional component and 68&#37; offer psychosocial assessment to all CR patients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">As a final comment&#44; CR in Portugal is slowly improving&#44; but the same barriers remain as in previous surveys&#46; This could give rise to the development of new proposals for strategies to enable CR to be more effectively implemented&#46; Additionally&#44; new models of CR such as telerehabilitation and hybrid models&#44; and more flexible programs&#44; are needed to adapt to contemporary circumstances&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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How healthy is cardiac rehabilitation in Portugal?
Quão saudável é a reabilitação cardíaca em Portugal?
Ana Abreu
Serviço de Cardiologia, Hospital de Santa Maria, Lisboa, Portugal
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    "titulo" => "How healthy is cardiac rehabilitation in Portugal&#63;"
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        "titulo" => "Qu&#227;o saud&#225;vel &#233; a reabilita&#231;&#227;o card&#237;aca em Portugal&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The picture of cardiac rehabilitation &#40;CR&#41; in Portugal has been periodically framed by the Portuguese Society of Cardiology &#40;SPC&#41; through a survey carried out by the SPC&#39;s Working Group on Exercise Physiology and Cardiac Rehabilitation&#46; Surveys are fundamental to measure the status of CR and are especially useful to define strategies that can fill the gaps in CR at the national level&#46; It has long been known that CR is effective but underutilized due to already identified barriers&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The next step&#44; besides implementing a national CR registry&#44; which will be most helpful&#44; is to define a plan for action&#44; involving advocacy and other strategies to improve CR implementation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest CR national survey&#44; for 2019&#44; published in the current issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> states that CR programs have a central role in cardiovascular &#40;CV&#41; medicine&#44; but I would rather say&#44; instead&#44; that they should have such a role&#44; because in practice they in fact do not&#46; This remains a chronic issue in many countries&#44; and in particular in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Looking at the present results of the 2019 survey<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and comparing them to those of the previous survey &#40;2013&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> there was an increase of 5&#37; in the number of CR centers &#40;n&#61;25&#41; and of 13&#37; in the number of patients &#40;n&#61;2182&#41; included in phase II programs&#46; This increase has been progressive over time&#44; since 1998&#44; but always small&#46; In fact&#44; the issue is not only to have more centers&#44; but also to improve their capacity in terms of numbers of rehabilitated patients&#44; which depends on the availability of material and human resources&#44; as well on appropriate and systematic referral&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As in most countries&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> ischemic heart disease&#44; with 67&#37;&#44; represents the largest slice of rehabilitated patients&#44; with 50&#37; of the total for ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The small increase in ACS patients referred to CR of 1&#46;3&#37; in absolute terms &#40;9&#46;3&#37; vs&#46; 8&#37; in 2013&#41; is clearly inadequate&#46; The reported increase in the referral rate for phase II programs&#44; planned or scheduled at discharge&#44; revealed by the Portuguese Registry of ACS &#40;ProACS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> was certainly insufficient to significantly increase CR uptake among ACS patients&#46; Planning and scheduling are different processes&#46; Planning without effectively performing registration in a phase II program&#44; without obtaining the patient&#39;s commitment&#44; is obviously not enough&#46; Increasing phase I CR programs with a structured discharge plan including a signed consent registration for phase II and pre-discharge schedule could improve the situation&#46; At the national level&#44; more initiatives for implementation of CR after ACS are needed&#46; Advocacy measures and strategies on the part of medical societies&#44; medical and patient organizations and universities need urgently to be adopted&#46; It is not acceptable that there is solid scientific evidence for the benefits of CR&#44; especially on total and CV mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> but that clinical practice does not follow this evidence&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding heart failure&#44; the number of rehabilitated patients reached 14&#46;5&#37;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> with a slight absolute increase of 1&#46;8&#37; &#40;relative to the previous 12&#46;7&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> which is not surprising&#46; For many reasons&#44; heart failure patients are less often referred for CR than ACS patients&#46; Barriers including age&#44; depression&#44; low level of education and lack of resources are responsible for this underuse of CR in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In addition&#44; patients with implantable cardioverter-defibrillators or cardiac resynchronization therapy devices need to be referred for CR more frequently&#59; the referral rate for these patients is only 4&#46;2&#37; in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">What is really unacceptable is that only 10&#46;2&#37; of patients undergoing coronary artery bypass graft surgery and fewer than 6&#37; of those undergoing surgical or percutaneous valvular intervention are included in CR programs&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> when these patients could benefit significantly&#44; especially in functional terms&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Cardiac surgeons need to be involved in the CR process&#44; but this can be difficult since they spend most of their time inside the operating room&#44; without time or availability for medical issues like CR&#46; Motivation and demonstration of the benefits of CR in surgical patients need to be promoted among surgical teams&#44; including nurses&#44; an important professional group in rehabilitation teams&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The good news is the 33&#37; increase in the number of phase I CR programs&#46; These are particularly important&#44; particularly in increasing referral for and uptake of phase II CR&#46; Apparently easier at first sight&#44; phase I programs are in fact challenging&#44; since most centers do not have the means to create a dedicated team&#44; and must use multitasking healthcare professionals&#44; mainly nurses&#44; sometimes physiotherapists and cardiologists&#44; who are already involved in many other activities inside the hospital&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In contrast to the trend in phase II&#44; the number of patients included in phase III CR programs fell by 37&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Structured phase III programs are less standardized and frequently more difficult to define&#46; At the same time&#44; patients find it easier to participate in phase II programs&#44; since they are closely attached in time to the CV event and are limited in duration&#46; Many patients do not maintain long-term CR&#44; even though the benefits of CR are known to be rapidly lost&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> It would be helpful if CR centers with phase II programs could also provide phase III programs or transfer the patient directly to a connected phase III program&#44; as already happens in some Portuguese centers&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Another encouraging sign is that 91&#37; of the centers had a drop-out rate compatible with the quality indicators proposed by the European Association of Preventive Cardiology and other medical societies&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> However&#44; drop-out rates of 26-68&#37; in 9&#37; of the centers<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> are completely unacceptable&#44; necessitating investigation of the reasons for these figures&#46; A drop-out rate of &#60;25&#37; is an accepted quality indicator&#44; and so higher rates suggest that the programs need to be modified&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is still the case that in several centers&#44; phase II CR programs remain essentially exercise-based&#46; It is necessary to reinforce the importance of the other components besides exercise&#44; including risk factor control&#44; nutritional and psychological assessment and intervention&#44; and structured education&#44; all of which are part of secondary prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> It is not a good result when only 32&#37; of programs offer a nutritional component and 68&#37; offer psychosocial assessment to all CR patients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">As a final comment&#44; CR in Portugal is slowly improving&#44; but the same barriers remain as in previous surveys&#46; This could give rise to the development of new proposals for strategies to enable CR to be more effectively implemented&#46; Additionally&#44; new models of CR such as telerehabilitation and hybrid models&#44; and more flexible programs&#44; are needed to adapt to contemporary circumstances&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
en pt

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