Scoping Review of Telemedicine Application in Cardiac Rehabilitation for Coronary Heart Disease Patients

LIU Yan¹, YUAN Yanling², LING Rong¹, WANG Lanyun¹, SUN Li¹*

¹Department of Cardiovascular Medicine, 940th Hospital, PLA Joint Logistic Support Force, Lanzhou 730050, China
²School of Nursing, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, China

Corresponding author: SUN Li, E-mail: 3761104944@qq.com

Abstract

Background: Coronary heart disease (CHD) is a common cardiovascular disease that severely impacts patients' quality of life and survival rate globally. Cardiac rehabilitation (CR), a crucial component of post-CHD recovery, significantly improves patient prognosis and quality of life. In recent years, with the development of information technology, telemedicine has emerged in cardiac rehabilitation for CHD patients, showing promising prospects and providing more convenient rehabilitation support. However, differences in rehabilitation quality among centers affect the stability and accessibility of rehabilitation outcomes.

Objective: This scoping review aims to systematically summarize existing research on telemedicine application in cardiac rehabilitation for CHD patients, providing a reference for healthcare professionals conducting remote cardiac rehabilitation.

Methods: Based on Arksey and O'Malley's scoping review framework, we searched multiple databases including Cochrane Library, PubMed, Web of Science, Embase, EBSCO, China Biology Medicine disc, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, and VIP Network from their inception to August 20, 2024. We screened, summarized, and analyzed the included literature.

Results: We included 23 articles from 10 countries, comprising 21 randomized controlled trials, 1 quasi-experimental study, and 1 qualitative study. Telemedicine carriers mainly included applications and remote monitoring systems. Telemedicine could guide rehabilitation exercise frequency and intensity, monitor cardiac rhythm, provide health education, and offer social support. Most studies focused on CHD-related indicators and symptom assessment, quality of life, self-management, patient rehospitalization and mortality rates, resource costs, user experience (satisfaction and safety), anxiety and depression, and physical activity levels.

Conclusion: Telemedicine helps enhance CHD patients' participation in cardiac rehabilitation, improve exercise motivation and medication adherence, reduce sedentary behavior, and increase survival rate and quality of life. Although telemedicine is rapidly developing in China, it still faces challenges and limitations. Future improvements should involve optimizing remote cardiac rehabilitation platform functions with artificial intelligence technology, refining evaluation systems, and strengthening integration with community services to comprehensively enhance application effectiveness.

Keywords: Coronary Disease; Telemedicine; Cardiac rehabilitation; Scope review

1. Materials and Methods

1.1 Research Questions

Through preliminary literature review, we identified three key questions: (1) What are the specific forms of telemedicine application in CR for CHD patients? (2) What are the specific management contents of telemedicine in CR for CHD patients? (3) What are the effects of telemedicine application in CR for CHD patients?

1.2 Inclusion and Exclusion Criteria

Based on the PCC principle, inclusion criteria were: (1) Participants (P): CHD patients; (2) Concept (C): Various forms of CR management based on internet remote monitoring for CHD patients; (3) Context (C): Home-based CR; (4) Study designs including randomized controlled trials, quasi-experimental studies, qualitative studies, and other interventional studies; (5) Languages: Chinese or English. Exclusion criteria were: (1) Studies focusing solely on telemedicine system development or software usability testing; (2) Literature with unavailable full text.

1.3 Search Strategy

We searched Cochrane Library, PubMed, Web of Science, Embase, EBSCO, China Biology Medicine disc, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, and VIP Network. The search scope included titles, keywords, and other common fields for studies on telemedicine application in CR for CHD patients from database inception to August 20, 2024. The PubMed search strategy was as follows: (("Coronary Disease"[MeSH] OR "Coronary Diseases"[Ti/Ab] OR "Coronary Heart Disease"[Ti/Ab] OR "Coronary Heart Diseases"[Ti/Ab]) AND ("Virtual Medicine"[MeSH] OR "Mobile Health"[Ti/Ab] OR "mHealth"[Ti/Ab] OR "Telehealth"[Ti/Ab] OR "eHealth"[Ti/Ab] OR "Telemedicine"[Ti/Ab]) AND ("Cardiac Rehabilitations"[MeSH] OR "Cardiovascular Rehabilitation"[Ti/Ab] OR "Cardiovascular Rehabilitations"[Ti/Ab])). The Chinese search terms in CNKI included "冠心病," "冠状动脉粥样硬化性心脏病," "冠状动脉疾病," "远程监测," "远程," "移动," "可穿戴," "电子健康," "网站," "智能," "APP," and "康复."

1.4 Literature Screening and Data Extraction

After importing references into EndNote to remove duplicates, two trained researchers independently screened titles and abstracts, then reviewed full texts of potentially eligible studies. Discrepancies were resolved through discussion or consultation with a third reviewer. Data extraction included author, publication year, country, study type, participants, telemedicine application forms, management contents in CR for CHD patients, and outcome indicators.

2. Results

2.1 Literature Screening Results

The initial search yielded 857 articles. After removing duplicates, 663 articles remained. Following title and abstract screening, 578 articles were excluded, leaving 85 articles for full-text review. After excluding 62 articles (16 with unavailable full text and 46 with irrelevant content), 23 articles were finally included [FIGURE:1]. The initial retrieval included 284 articles from Web of Science, 64 from PubMed, 2 from Cochrane Library, 3 from Embase, 114 from EBSCO, 165 from China Biology Medicine disc, 74 from China National Knowledge Infrastructure, 116 from Wanfang Data Knowledge Service Platform, and 35 from VIP Network.

2.2 Basic Information of Included Literature

Among the 23 included articles, 3 were in Chinese and 20 in English, representing 10 countries: China (7 articles), United States (2), Spain (2), Czech Republic (3), Netherlands (2), United Kingdom (1), Greece (1), Israel (1), Belgium (2), and New Zealand (2). In terms of study design, 21 were randomized controlled trials, 1 was a quasi-experimental study, and 1 was a qualitative study [TABLE:1].

2.3 Application Forms of Telemedicine in CR for CHD Patients

2.3.1 Applications

Six studies [10-11,17-18,21,30] involved using smartphone applications (APPs) for CR in CHD patients, including both standalone APP use and APP combined with other methods, with the latter being more common. LAO et al. [30] developed an APP incorporating education, health data input with push notifications, health status tracking, and interactive communication, providing educational support, health data feedback, and motivational text messaging services for CR patients. YOU et al. [10] utilized a Smart heart rate and muscle oxygen monitoring network composed of heart rate belts, muscle oxygen monitoring wearable devices, and a mobile APP. Data collected by the heart rate belt and muscle oxygen monitoring devices were transmitted via Bluetooth to the mobile APP, which displayed target heart rate and monitored real-time heart rate and muscle oxygen saturation (SmO2) during exercise, enabling assessment of patients' exercise capacity and assisting healthcare providers in adjusting exercise intensity appropriately. Additionally, five studies [16,22,25,27-28] combined APPs with wearable devices such as motion sensors, accelerometers, and pedometers to monitor patients' vital signs and physical activity in real time, assessing exercise effectiveness and safety.

2.3.2 Remote Monitoring Systems

Eight studies [12-14,19-20,24,26,31] indicated that remote ECG monitoring systems enable real-time monitoring of CHD patients' CR without time or geographical constraints, allowing healthcare providers to deliver effective intervention and guidance, promptly identify risks during exercise, adjust rehabilitation protocols, and reduce adverse cardiovascular events. JIANG et al. [12] employed the TE-8000Y3 wireless network physiological parameter monitor, which used portable monitoring terminals for continuous real-time monitoring of patients and transmitted collected data through mobile communication networks to a server that subsequently sent abnormal data to healthcare providers' mobile phones for patient guidance. DALLI et al. [14] developed the Cardioplan cardiac telerehabilitation system, which included health management software to record patients' general conditions, vital signs, and medication adherence, provide dietary recommendations, and offer exercise modules with warm-up and stretching exercise videos, virtual classes, and detailed exercise tracking and recording capabilities.

2.3.3 Professional Websites

Two studies [15,23] managed CHD remote CR through professional websites. BATALIK et al. [15] developed a professional web platform integrating a Polar M430 heart rate monitor and H10 chest sensor compatible with the web platform for real-time heart rate monitoring, electronic health record establishment, and data security. This platform enabled rehabilitation specialists to review historical data records through training diaries, compare training values, and accurately formulate rehabilitation plans, while restricting access to only rehabilitation specialists and patients to effectively protect privacy. DUAN et al. [23] utilized a professional website to monitor lifestyle and physical activity in CHD patients during CR, providing tailored intervention plans to help patients maintain healthy behaviors throughout rehabilitation.

2.3.4 Other Forms

Two studies [29,32] used short message services and virtual world technology for CR program development and management in CHD patients. PFAEFFLI et al. [29] used short message services and a support website to deliver customized health plan messages to patients daily, providing CR guidance that effectively motivated patients to improve self-efficacy, thereby reducing blood pressure and rehospitalization rates. Another study [32] implemented CR for CHD patients using a virtual reality technology platform, holding weekly meetings focused on cardiovascular health-related topics with professional nutritionists and exercise physiologists providing in-depth guidance on diet and exercise through live "expert consultation" group chats. Additionally, patients participated in various virtual activities covering healthy food selection and portion control, CHD risk factor analysis, medication management, behavioral strategies, and exercise planning. However, communication via text messages may have limitations such as lack of feedback and information overload, making it difficult to achieve expected intervention effects.

2.4 Management Content of Telemedicine in CR for CHD Patients

2.4.1 Rehabilitation Exercise Frequency and Intensity Guidance

CR is considered crucial for CHD management as it improves cardiac function and health-related physical fitness, with exercise being an essential component and Class I Level A recommendation in international guidelines [19,24]. Many researchers have investigated different CR exercise modalities, evolving from continuous single-intensity training to interval aerobic training, and now to personalized exercise prescription-centered management models. Despite this evolution, rehabilitation still involves multiple risk factors requiring effective monitoring. Twenty studies [10-12,14-15,17-29,31-32] demonstrated that remote medical technology can guide exercise intensity, modality, frequency, and duration in CR. YOU et al. [10] used APPs and wearable devices to monitor real-time dynamic changes in heart rate and muscle oxygen curves during exercise, assessing patients' exercise capacity and setting reasonable target heart rate ranges based on these data. By using the walking speed corresponding to the target heart rate, they formulated and adjusted patients' exercise intensity to ensure safety and effectiveness while setting exercise compliance standards in the APP. SONG et al. [19] confirmed that remote monitoring can effectively improve exercise tolerance in CHD patients, with rehabilitation effects comparable to or even better than traditional center-based rehabilitation methods.

2.4.2 Cardiac Rhythm Monitoring

Eighteen studies [10-12,14-22,24-28,31] mentioned that telemedicine can overcome time and geographical limitations for real-time cardiac rhythm monitoring, providing timely warnings for cardiovascular events such as arrhythmias and myocardial ischemia. JIANG et al. [12] confirmed that remote ECG monitoring throughout the entire rehabilitation training process can promptly detect arrhythmias including premature ventricular and supraventricular contractions, supraventricular/ventricular tachycardia, atrial fibrillation and flutter, atrial tachycardia, sinus tachycardia, and ventricular fibrillation, effectively improving arrhythmia detection rates. ANTONIOU et al. [22] enabled patients to exercise within specified heart rate zones by remotely viewing real-time heart rate and current exercise status, ensuring exercise safety and effectiveness.

2.4.3 Health Education

Unhealthy behaviors contribute to adverse events in CHD patients, with diet, physical activity, and smoking cessation being major factors for improving health behaviors. Therefore, delivering disease-related knowledge and management content regarding diet, exercise, medication, weight, and lifestyle through applications, websites, WeChat, and text messages in text, graphic, and video formats is key to health education. LI et al. [11] conducted weekly telephone follow-ups and home visits to record and promptly answer patients' questions while providing emotional support. Brewer et al. [32] used virtual reality technology with interactive 3D spaces to create immersive experiences and discussion opportunities among participants, promoting healthy lifestyle changes and improving patients' self-management efficacy.

2.4.4 Social Support

Social support is considered an important factor in determining psychological stress and health. As CHD patients' cognitive levels improve, close relationships and smooth communication with surrounding groups can stimulate their internal motivation, ultimately improving CR adherence. All 23 included studies provided social support for CHD patients, including support from healthcare providers, relatives, and families. DUAN et al. [23] identified two distinct stages in the health behavior change process, with the first motivational stage primarily relying on social support through weekly nurse contact via phone calls and text messages, reminder messages, and phone credit rewards to improve CR participation.

2.5 Evaluation Indicators

Twenty studies [10-12,14-15,17-29,31-32] included evaluations of telemedicine effects in CHD patient CR, covering multiple key indicators and symptoms including cardiac function assessment, arrhythmia and myocardial ischemia detection rates, weight changes, blood pressure, diabetes and hyperlipidemia control, and improvement of typical symptoms such as chest tightness and shortness of breath. SONG et al. [19] included exercise tolerance and exercise habit improvement as evaluation indicators, finding that after 6 months of intervention and follow-up, the intervention group showed significantly improved exercise tolerance, with 93.8% of patients in the remote monitoring group developing exercise habits, higher than the conventional follow-up group.

Fourteen studies [11-12,14,16-18,20-23,25,28,31-32] focused on the impact of telemedicine on quality of life in CHD patient CR. LI et al. [11] used the Chinese Cardiovascular Patient Quality of Life Assessment Questionnaire (CQQC) to evaluate quality of life, demonstrating that remote monitoring not only enables timely assessment of patients' condition changes but also significantly improves quality of life.

Five studies [16,20,22,24,31] incorporated resource costs as evaluation indicators. Brouwers et al. [16] comprehensively explored the cost-effectiveness of remote CR versus center-based CR in CHD patients, dividing 300 patients into two groups (153 in remote intervention, 147 in center control). Through basic case analysis comparing quality of life and average cardiac care and social costs during rehabilitation, the study demonstrated that remote CR was more cost-effective than center-based CR.

Fifteen studies [11,13-15,17,20-21,24-28,30-32] evaluated satisfaction and safety of telemedicine in CHD patient CR. Ten studies [11,14,15,17,20,24-28] showed high satisfaction with remote monitoring CR protocols and remote rehabilitation as an alternative to center-based rehabilitation, while five studies [13,21,30-32] evaluated application usability. One study [11] used the Family Burden Scale (FBS) to compare remote rehabilitation and center-based rehabilitation groups, finding lower FBS scores and higher patient satisfaction in the remote rehabilitation group.

Twenty-one studies [10-11,13-19,21-32] included self-management as an evaluation indicator, assessing it through follow-up questionnaires, the General Self-Management Behavior Scale (GS-MS), International Physical Activity Questionnaire (IPAQ), Mediterranean Diet Prevention Questionnaire (PREDIMED), and other tools [14,15,19,24]. Ten studies [10-12,20-23,29-31] evaluated physical activity levels or Borg scale scores, finding significant improvements in exercise capacity and oxygen consumption in CHD patients, along with reduced body weight and visceral fat. Seven studies [20-23,29-31] used the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression levels, showing that remote medical groups could achieve positive improvements through rehabilitation provider education and management even with psychological stress, demonstrating that telemedicine positively impacts behavior change in CHD patients.

3. Discussion

3.1 Diverse Carriers in Telemedicine Application for CHD Patient CR

The rapid development of internet technology and its integration with the healthcare industry has facilitated the emergence of telemedicine, which is gradually being promoted in chronic disease management. Telemedicine provides support for CHD patient CR and improves patient compliance. Early approaches used email, text messages, and WeChat for disease management reminders [29]. With continuous advancement in digital health technology, telemedicine methods such as APPs, remote monitoring systems, and virtual reality technology demonstrate advantages in predicting health risks and developing personalized CR plans. However, research exploring diverse carriers in CHD patient CR shows variations due to patient population characteristics, study design differences, and technological development levels across countries and regions. Four studies [13-14,21,27] noted that women showed lower participation and adherence in CR programs. Ten studies [17-18,21-23,26-28,30-31] emphasized that enrolled patients could use smartphones and the internet, but elderly patients may face challenges with smartphone and internet platform operation proficiency, affecting the widespread promotion and practical application of telemedicine carriers in elderly populations [13,19]. All 23 studies [10-32] were conducted in economically developed regions, with no mention of promotion and popularization in remote or resource-scarce areas. CR started relatively late in China, and combined with unbalanced regional economic and technological development, remote CR programs remain in the optimization stage. Therefore, understanding and addressing differences arising from patient characteristics and cultural backgrounds, and providing convenient consultation and monitoring services for patients in medically underserved areas, are crucial for optimizing the accessibility and effectiveness of telemedicine services. Additionally, differences in sample size, follow-up duration, and evaluation indicators may be primary reasons for variations in study results [18,24,31]. Therefore, conducting multi-center, large-sample clinical studies is imperative for more comprehensive evaluation of telemedicine carrier application effects.

3.2 Safety, Universality, and Individuality in Telemedicine Management for CHD Patient CR

All included studies [10-32] demonstrated that remote CR can overcome time and space limitations, enabling patients to improve exercise and health behavior management knowledge, regulate exercise fear generalization, and promote fear extinction through health education forms such as professional websites, WeChat, and graphics, effectively meeting exercise prescription requirements [33], while also tracking medication and diet to improve CR efficacy management. Currently, elderly patients constitute the main CR population, and research reveals limitations of internet-plus CR for elderly individuals living alone or empty-nest elderly. Therefore, future development should emphasize convenience in device function and operation design to improve acceptance among elderly patients [34]. Simultaneously, healthcare providers are recommended to use targeted interviews to understand patients' needs and expectations, formulate initial CR protocols, establish multidisciplinary teams (MDT) for comprehensive patient capability assessment, and further explore and develop personalized CR protocols.

Thirteen studies [10-15,19,24,26-29,32] indicated that remote monitoring CR for low-to-medium risk CHD patients showed no serious adverse events during rehabilitation, demonstrating equivalent advantages in effectiveness and rehabilitation outcomes compared to center-based CR. Eight studies [12,14-15,17,20-22,28] emphasized system security, noting that webpages employed password protection mechanisms to ensure all accesses were password-protected, effectively safeguarding patient data confidentiality and privacy. This demonstrates the reliability of remote rehabilitation in terms of safety. However, safety studies in high-risk patients remain relatively limited, requiring future research to strengthen evaluation of rehabilitation effects and safety under remote monitoring in high-risk patients.

3.3 Definite Effects of Telemedicine in CHD Patient CR Requiring Further Indicator Refinement

Telemedicine demonstrates clear effectiveness in CHD patient CR by improving cardiac function, quality of life, and exercise tolerance while effectively reducing rehospitalization rates, mortality, and cardiovascular risk factors and complications. Additionally, multiple studies [11,13-15,17,20-21,24-28,30-32] included patient experience and satisfaction as evaluation indicators, further broadening the effectiveness scope of telemedicine in CR. Five studies [16,20,22,24,31] focused on cost-effectiveness comparisons between remote CR and center-based CR. One study [16] explored intervention costs, average healthcare costs per patient during remote CR versus center-based CR, and social costs, showing no significant differences. However, in the critical area of commuting costs, remote CR demonstrated superior cost-effectiveness compared to center-based CR, providing strong economic support for the widespread application of telemedicine in CHD patient CR.

One study [18] incorporated the Generalized Anxiety Disorder Scale (GAD-7) as an evaluation indicator to assess patients' mental health status, noting that telemedicine not only helps optimize physiological indicators in CHD patients but may also indirectly promote patients' active participation and long-term adherence to rehabilitation plans by alleviating psychological problems such as anxiety.

Although telemedicine has achieved considerable development in CHD patient CR treatment, existing research evidence still has limitations, such as insufficient long-term effect evaluation, cultural differences in evaluation tools, and long-term maintenance of self-management, which severely restrict the widespread promotion of telemedicine at the primary and community levels. Future research should focus on continuous and accurate data collection during patient rehabilitation to more objectively evaluate the effects and application potential of telemedicine in CHD patient CR.

This study conducted a comprehensive analysis of telemedicine application in CHD patient CR, systematically summarizing its carrier forms, management contents, and evaluation indicators. Results showed that telemedicine carriers are diverse, management content is comprehensive, and evaluation indicators are relatively rich. Overall, telemedicine demonstrates positive outcomes in improving exercise and medication adherence, reducing sedentary behavior, and increasing survival rate and quality of life in CHD patient CR. However, improvements are needed in knowledge-attitude-practice levels and e-health literacy among female and elderly patients, as well as in CR for high-risk CHD patients [35]. With the maturation of artificial intelligence (AI) technology [36], future integration of AI with remote monitoring systems through optimizing remote CR platform functions, refining evaluation systems, reducing rehabilitation risks, and promoting embedding into patients' lives will be essential to achieve sustainable long-term rehabilitation effects.

Author Contributions: LIU Yan was responsible for conceptualization, design, literature collection and organization, and manuscript writing; SUN Li was responsible for conceptualization, quality control and review, and overall responsibility for the article; YUAN Yanling was responsible for literature collection and organization; LING Rong was responsible for figure and table preparation; WANG Lanyun was responsible for content and format revision.

Conflict of Interest: None declared.

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(Received date: 2024-11-20; Revised date: 2025-03-20)

(Editor: ZOU Lin)