1Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Türkiye
2Department of Cardiology, Gazi University Faculty of Medicine, Ankara, Türkiye
Correspondcence: Nihan Burhandağ Solhan Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Emniyet District, Mevlana Boulevard No: 29, Yenimahalle, Ankara 06560, Türkiye. Tel: +90-312-202-52-19 Fax: +90-312-212-46-47 E-mail: nihan.burhandag@gmail.com
• Received: May 11, 2025 • Revised: September 11, 2025 • Accepted: October 14, 2025
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To compare the efficacy, safety, and patient compliance of tele-cardiac rehabilitation (T-CR) versus center-based cardiac rehabilitation (C-CR) in patients with coronary artery disease (CAD). A secondary aim was to assess the effects of both interventions on quality of life (QoL) and kinesiophobia.
Methods
This nonrandomized, patient-preference controlled trial included 40 CAD patients (83% post-myocardial infarction) at a university hospital. Participants selected either C-CR or T-CR. The four-week intervention included supervised in-hospital exercise (C-CR) or telemonitored exercise with heart rate feedback (T-CR). The primary outcome was peak oxygen uptake (VO2 peak). Secondary outcomes included VO2 at ventilatory anaerobic threshold (VO2 at VAT), time to VAT, oxygen pulse, QoL, Fear of Activity in Patients with Coronary Artery Disease (Fact-CAD) scores, and exercise adherence.
Results
Baseline VO2 peak was higher in the T-CR group (23.2±3.5 vs. 19.4±4.2, p=0.004). Rehabilitation improved VO2 peak (p<0.001), VO2 at VAT (p=0.004), and time to VAT (p<0.001) in both groups. Fact-CAD scores decreased (p=0.004), and QoL improved (p<0.001). However, C-CR led to greater kinesiophobia reduction (p=0.038) and slightly higher QoL improvements (p=0.05). T-CR participants completed more exercise sessions (14.9±2.9 vs. 12.0±0, p<0.001), with no serious adverse events reported.
Conclusion
T-CR is a safe and effective alternative to C-CR, providing similar physiological benefits. However, C-CR may be superior in reducing kinesiophobia. Future studies should assess long-term adherence and psychological outcomes in diverse populations.
Coronary artery disease (CAD) is the third leading cause of death worldwide, accounting for more than 17 million deaths annually [1]. Cardiac rehabilitation (CR) is a multidisciplinary intervention designed to accelerate physical and psychosocial recovery from heart disease while reducing the risk of future cardiac events. Exercise-based CR holds a class IA recommendation in international guidelines [2,3]. Despite its proven benefits, participation and adherence rates remain low [4].
In recent decades, telerehabilitation has emerged as an innovative extension of telemedicine, addressing barriers to hospital-based CR. For cardiac patients who face challenges in accessing center-based programs, home-based exercise methods have gained prominence [5]. Tele-cardiac rehabilitation (T-CR) provides an alternative to conventional center-based cardiac rehabilitation (C-CR) by offering home or outdoor exercise training, physical activity counseling, and social support [6]. With advancements in technology, T-CR programs now include physical activity monitoring through wearable devices, remote heart rate (HR) monitoring, and interactive education using telecommunication tools [7-9]. Evidence from randomized controlled studies demonstrates that T-CR is safe and yields comparable outcomes to C-CR in terms of exercise capacity, physical activity levels, and quality of life (QoL) in patients with coronary heart disease [10]. However, most of these studies originate from high-income countries, leaving a significant gap in data from low- and middle-income countries, including Türkiye [6]. While there are a few studies in Türkiye examining home-based exercises for various conditions [11-13], research on the application of T-CR remains scarce [14]. Additionally, participation rates in conventional CR in Türkiye are strikingly low—below 20%—compared to European countries, emphasizing the urgent need for alternative approaches such as T-CR [2,15].
Kinesiophobia represents a major barrier to CR participation and is associated with reduced physical performance and QoL [16,17]. While conventional CR programs have been shown to alleviate kinesiophobia, evidence on the impact of T-CR in this context remains limited [18]. In patients with CAD after percutaneous coronary intervention (PCI), T-CR reduced kinesiophobia but to a lesser extent than C-CR [19]. Conversely, the multicenter SWEDEHEART trial in post-myocardial infarction (MI) patients reported comparable improvements with T-CR and C-CR programs [20]. Beyond cardiac populations, trials in fibromyalgia [21] and chronic neck pain [22] have also demonstrated significant reductions in kinesiophobia through telerehabilitation.
Given these gaps, the primary aim of this study is to evaluate the efficacy, safety, and patient compliance of T-CR for patients with CAD, with a focus on its applicability in clinical practice. A secondary aim is to compare the effects of T-CR and C-CR on QoL and CAD-related kinesiophobia.
METHODS
Participants
This study was conducted between September 2022 and December 2023 at the Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine Hospital. Patients with CAD who applied to the outpatient clinic or were referred for rehabilitation were assessed for eligibility. Written and verbally informed consent was obtained from all participants who met the inclusion and exclusion criteria. The inclusion criteria were: (1) age≥18 years; (2) clinically stable, documented diagnosis of CAD such as angina pectoris, MI, PCI, or coronary artery bypass grafting (CABG); (3) no acute cardiac events in the past six weeks; (4) low to intermediate risk of cardiac events according to the American Heart Association classification; and (5) access to a smartphone and home internet connection. Patients were excluded if they had severe ventricular arrhythmia, residual coronary ischemia requiring revascularization, pacemakers or implantable cardioverter-defibrillators, class IV heart failure according to the New York Heart Association, untreated cancer, or orthopedic, neurological, or psychiatric conditions that could interfere with exercise.
The study was approved by the Gazi University Clinical Research Ethics Committee (decision number: 2021-11) and was conducted in accordance with the Declaration of Helsinki. Clinical Trials registration number is NCT06614634.
Allocation and blinding
Since blinding patients is not feasible in CR studies, traditional randomization may not always reflect real-world clinical practice. Research on rehabilitation approaches that consider patient preferences has shown that less than half of CAD patients are willing to participate in randomized trials [23,24]. To improve generalizability and minimize follow-up data loss, we employed a patient preference trial method, allowing participants to choose between C-CR and T-CR after being fully informed about both options [25,26]. The assessor (L.K.) was blinded to group allocation.
Interventions
A comprehensive clinical evaluation was conducted for all participants, including demographic data collection, medical history review, medication assessment, electrocardiogram and echocardiogram analysis, cardiovascular risk factor evaluation, and a detailed physical examination. A symptom-limited maximal cardiopulmonary exercise test (CPX) was performed with the modified Bruce protocol using a Quark CPX device (COSMED S.R.L.). Metabolic data were collected via breath-by-breath sampling. Maximal effort was confirmed by the presence of at least one of the following criteria: a sustained respiratory exchange ratio of 1.1 or above, a HR exceeding 90% of the age-predicted maximum, or a perceived exertion score greater than 17 on the modified Borg Scale [27]. Additional components of the initial interview included physical activity and dietary counseling for cardiovascular risk reduction, smoking cessation guidance, and referrals for psychosocial support [3]. Participants were subsequently assigned to one of the two exercise programs for a four-week period.
C-CR group
Patients in the C-CR group participated in supervised aerobic and resistance training sessions at the CR unit three times per week for four weeks. Each session was conducted under the supervision of a physiotherapist, nurse, or research physician.
Aerobic training consisted of 30-minute treadmill walking sessions after warm-up, guided by HR monitoring, targeting 60%–80% of the peak oxygen uptake (VO2 peak). Strengthening exercises were performed using medium-resistance elastic bands, focusing on the shoulder girdle, elbow flexors and extensors, hip girdle, and knee flexors and extensors. Sessions included warm-up and cool-down phases, with an initial regimen of 10 repetitions per exercise. The resistance and number of repetitions were progressively increased according to individual tolerance and progress.
T-CR group
Participants engaged in 30-minute walking sessions at home or outdoors, at least three times per week for four weeks. The target HR was set at 60%–80% of VO2 peak, as determined by CPX. HR monitoring was performed using a Polar H9 (Polar Electro Oy) chest strap device, with data tracked via the Polar Flow web application. To ensure familiarity with the technology, the first exercise session took place in the CR unit, where participants were trained on using the HR monitor and transferring data to the web platform (Fig. 1).
Following the initial aerobic exercise session, participants were introduced to resistance exercises targeting the proximal muscle groups of the upper and lower extremities, using elastic bands similar to those in the C-CR group. Written and visual exercise guidelines were provided, instructing participants to perform these exercises at home at least three times per week. The program started with 10 repetitions per set, with a gradual increase based on perceived effort and tolerance.
To enhance adherence, participants received structured weekly follow-up phone calls and a mid-program reinforcement session at the hospital at the end of the second week. During phone calls, patients were questioned about symptoms, provided with motivational feedback based on exercise data recorded on the Polar H9 monitor, and encouraged to maintain adherence. Barriers to achieving exercise goals were discussed, and individualized solutions were suggested. A structured flowchart summarizing the interview process is presented in Fig. 2.
Outcome measures
The primary outcome was the change in VO2 peak between baseline (T0) and the end of rehabilitation (T1). Secondary outcomes related to functional capacity included oxygen consumption at the ventilatory anaerobic threshold (VO2 at VAT), time to VAT as an indicator of workload at VAT during the exercise test, and O2 pulse (VO2/HR) at peak exercise (peak O2 pulse) [28]. Kinesiophobia and QoL were also assessed using the Fear of Activity in Patients with Coronary Artery Disease (Fact-CAD) Scale and the World Health Organization Quality of Life-Brief Version (WHOQOL-BREF). The Fact-CAD Scale is a 21-item questionnaire designed to assess kinesiophobia and behavioral adaptations in patients with CAD. The total score ranges from 0 to 84, with higher scores indicating greater kinesiophobia following a cardiac event [29]. The WHOQOL-BREF is a 26-item scale designed to assess QoL. Twenty-four items under four key domains measure physical health, psychological health, social relationships, and environmental health. The remaining two items, scored individually, assess overall QoL and general health. Each item is rated on a 5-point Likert scale, and raw domain scores are obtained by summing the respective item scores. These raw scores are then converted using the formula: 100×(raw score-minimum possible score for the domain)/(score range of the domain). Each domain has a final score between 0 and 100 and higher scores indicate better QoL [30].
Statistical analysis
Based on the approximately 2.8±6.0 mL/kg/min within-group change (Cohen’s d≈0.47) reported by Kraal et al. [31], a total of 34 participants would be required to achieve 80% power at an alpha level of 0.05. To allow for balanced allocation to two groups and potential dropouts, we recruited 40 participants (20 per group). The normality of data distribution was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests, supplemented by visual inspection of histograms. Categorical variables at T0 were compared using Fisher’s exact test. Baseline comparisons of continuous variables between the C-CR and T-CR groups were conducted using Student’s t-test for normally distributed data and the Mann–Whitney U-test for non-normally distributed data. Changes from T0 to T1 were analyzed using linear mixed-effects models (LMM), including group, time, and group-by-time interaction as fixed effects and subject as a random effect. The models also accounted for potential baseline differences between groups. p<0.05 was considered statistically significant. All analyses were performed according to the intention-to-treat principle. Missing data was planned to be handled using LMM.
RESULTS
The patient inclusion process is illustrated in Fig. 3. A total of 40 participants were enrolled in the study, with 20 in the C-CR group and 20 in the T-CR group. At baseline (T0), VO2 peak, VO2 at VAT, time to VAT, and O2 pulse were significantly higher in the T-CR group compared to the C-CR group. However, there were no significant differences between the two groups in demographic or clinical characteristics, including physical activity habits, Fact-CAD scores, and WHOQOL-BREF scores (Tables 1, 2).
At the end of fourth week, participants in the T-CR group completed a significantly higher number of exercise sessions than those in the C-CR group (14.9±2.9 sessions vs. 12.0±0 sessions; p<0.001). Since baseline differences were observed between groups in VO2 peak, VO2 at VAT, time to VAT, and O2 pulse, analyses for these outcomes were adjusted for their respective baseline values. In addition, the number of completed sessions was included as a covariate to account for variability in exercise participation. Results of LMM analyses summarized in Table 3. Time had a significant effect on VO2 peak (from 21.3±4.3 to 22.1±4.5 mL/kg/min; p<0.001), VO2 at VAT (from 16.8±3.7 to 17.7±3.9 mL/kg/min; p=0.004), and time to VAT (from 562±159 to 651±96 seconds; p<0.001). However, the change in O2 pulse was not significant (from 12.1±3.1 to 12.3±3 mL/kg/beat; p=0.274). The Fact-CAD score significantly decreased from 27.1±14.3 to 23.2±13.8 (p=0.004). In the WHOQOL-BREF assessment, overall QoL and health improved from 53.4±17.9 to 61.3±16.7 (p<0.001), and the physical health score increased from 66.8±16.2 to 71.3±14.7 (p=0.023), while other domains did not show significant changes over time. Group-by-time interaction analysis (Figs. 4, 5) indicated that, compared to the T-CR group, the C-CR group exhibited a significantly greater reduction in the Fact-CAD score (p=0.038), a more pronounced increase in time to VAT (p=0.012), and a slight but statistically significant improvement in overall QoL as measured by the WHOQOL-BREF (p=0.05). However, changes in other outcome measures did not differ significantly between the two groups. Notably, including session count as a covariate did not have a significant effect on the changes in any of the outcomes. Details of LMM results, including fixed effects of group, time, group-by-time and the covariates, are reported in the Supplementary Table S1 and S2.
During the study period, 10 participants developed mild upper respiratory tract infection symptoms, with 8 of these cases occurring in the T-CR group (p=0.065). Additionally, one participant in the T-CR group reported mild knee pain, while one participant in the C-CR group experienced mild low back pain (p>0.999). No serious cardiac events were recorded in either group.
DISCUSSION
This study demonstrates that T-CR is as effective and safe as C-CR over a four-week period in CAD patients. Both groups exhibited significant improvements in VO2 peak, VO2 at VAT, and time to VAT, with no significant differences in most outcome measures between the interventions. Additionally, no serious adverse events were recorded, further supporting the safety of T-CR. However, the C-CR group demonstrated a slightly higher improvement in overall QoL and greater reduction in Fact-CAD scores, suggesting that in-person rehabilitation may have a stronger impact on alleviating kinesiophobia related to CAD. This finding highlights a potential psychological advantage of supervised center-based programs in reducing exercise-related anxiety, despite T-CR achieving comparable physiological benefits.
Most studies comparing C-CR and T-CR have employed randomized controlled trial designs. However, in clinical practice, where both options are available, patient preferences may be associated with demographics and rehabilitation outcomes [32]. To date, no studies have investigated the role of aerobic capacity in patients’ preference for T-CR or C-CR. Although a certain causal relationship cannot be established, our findings suggest that patients with lower aerobic capacity tend to prefer C-CR. This may explain the baseline differences between groups in our study, which was designed to better reflect real-world clinical practice through a patient-preference trial approach.
In previous studies, various methods have been implemented in T-CR or home-based rehabilitation programs to improve adherence [33]. In our study, two key factors—HR monitoring and weekly reinforcement feedback—were incorporated into the T-CR program, resulting in patients in the T-CR group completing more exercise sessions than those in the C-CR group. Supporting our findings, Arthur et al. [34] reported that the use of an exercise diary and biweekly phone calls led to a higher exercise frequency in home-based CR compared to center-based programs in post-CABG patients. This tendency can be explained from various perspectives. Patients who are aware that their exercise sessions are being monitored are more likely to adopt positive behavioral changes, a phenomenon known as the Hawthorne effect, in which individuals tend to exert greater effort when they know they are being observed [35]. Additionally, feedback mechanisms play a supportive role in enhancing rehabilitation outcomes by acting as an extrinsic motivator, consistent with Bandura's social learning theory [36,37]. Therefore, this approach may enhance self-efficacy by encouraging patients to take an active role in managing their health and may facilitate valuable behavioral changes that contribute to the long-term maintenance of exercise adherence [38,39].
Previous research has demonstrated that T-CR and C-CR are equally effective in enhancing functional aerobic capacity and QoL [40]. However, most of these studies have involved longer intervention and follow-up periods, typically ranging from six weeks to six months. In contrast, our study evaluated the effects of these rehabilitation approaches over a shorter, four-week period and still observed significant improvements in functional capacity, as well as overall and physical health-related QoL. While the change in VO2 peak was modest, the substantial increase in exercise duration until the VAT was particularly noteworthy. Previous studies suggest that VAT-related changes have been proposed as an indicator of functional capacity improvement [41,42]. Furthermore, aerobic exercises can delay VAT by enhancing muscle endurance, even in the absence of a significant increase in VO2 peak [42]. Notably, our findings also highlight that while T-CR and C-CR provided comparable physiological benefits on VAT, the prognostic value of these changes should be further investigated in future research.
Limited evidence exists regarding the impact of tele-rehabilitation on kinesiophobia in patients with CAD. Gao et al. [19] examined the effects of remote and conventional CR on fear of exercise using the Tampa Scale of Kinesiophobia in post-PCI patients and found that while both interventions reduced kinesiophobia, post-intervention kinesiophobia levels remained higher in the remote CR group compared to the conventional CR group. In our study, we used Fact-CAD, a scale specifically designed to assess kinesiophobia related to CAD. Although the difference was not statistically significant, patients who opted for C-CR tended to have higher baseline Fact-CAD scores than those in the T-CR group. Furthermore, C-CR led to a more pronounced reduction in kinesiophobia. One possible explanation is that supervised C-CR not only provides close monitoring and medical supervision, but also enhances exercise quality through accurate posture correction, progressive adjustment of exercise intensity, and immediate feedback. These factors may contribute to patients’ sense of safety and mastery, thereby facilitating reductions in kinesiophobia. In contrast, T-CR offers greater autonomy and convenience, which may foster adherence but at the potential cost of reduced supervision and quality control. This trade-off between adherence and exercise quality highlights the key message of our study and the complementary strengths of the two delivery models.
Current evidence indicates comparable safety profiles for T-CR and C-CR in cardiopulmonary rehabilitation programs [43]. In our study, the incidence of adverse events was limited to mild musculoskeletal pain and seasonal upper-respiratory infections, and no severe cardiac events occurred in either group. These results align with recent studies demonstrating the safety of T-CR interventions [44,45].
Study limitations
This study has several limitations that should be considered when interpreting the findings. First, the relatively small sample size and exclusion of patients with high cardiovascular risk may limit the generalizability of the results, and larger-scale studies with various populations are needed to confirm these findings. Second, the study duration was limited to four weeks, which may not fully capture the long-term effects of T-CR and C-CR on cardiorespiratory fitness, QoL, and kinesiophobia. Future research with extended follow-up periods is warranted to assess the sustainability of these improvements. Third, the patient-preference design, while reflective of real-world clinical practice, may have introduced selection bias, as participants who opted for C-CR had lower baseline aerobic capacity. Although baseline group differences and unequal exercise dose between groups (with more sessions completed in T-CR) were included as covariates in the LMM analysis, their potential residual confounding effects cannot be entirely ruled out. Lastly, while this study focused on physiological and psychological outcomes, factors such as socioeconomic status, digital literacy, and access to technology may also influence the effectiveness and feasibility of T-CR programs. Future studies should explore these variables to optimize tele-rehabilitation strategies for diverse patient populations.
Conclusion
This study demonstrates that T-CR is as feasible and safe as conventional C-CR in improving functional capacity and QoL in CAD patients over a four-week period. While both approaches yielded comparable physiological benefits, C-CR was more effective in reducing kinesiophobia, highlighting a potential psychological advantage. As one of the few studies conducted in a middle-to-low-income country, this research underscores the feasibility of T-CR as a scalable and accessible alternative, particularly in healthcare systems with limited rehabilitation infrastructure. From a clinical perspective our findings indicate that C-CR may be particularly suitable for patients with high levels of exercise-related fear or low initial aerobic capacity, while T-CR may represent a viable option for patients who are more confident, digitally literate, and motivated for self-directed exercise. A stepwise model, beginning with C-CR and transitioning to T-CR, could combine the psychological benefits of supervision with the long-term advantages of autonomy and accessibility. Future studies should explore the long-term sustainability of T-CR outcomes and strategies to optimize its implementation, ensuring broader accessibility and adherence in diverse patient populations.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
This study was supported by the Gazi University Scientific Research Projects Coordination Unit (Approval No: TTU-2022-7615) for provision of study materials.
AUTHOR CONTRIBUTION
Conceptualization: Demirsoy N, Karataş L, Utkan Karasu A. Methodology: Demirsoy N, Karataş L, Utkan Karasu A, Nihan Burhandağ Solhan, Topal S, Onurlu İ. Formal analysis: Karataş L, Burhandağ Solhan N. Funding acquisition: Burhandağ Solhan N, Demirsoy N. Project administration: Demirsoy N. Visualization: Burhandağ Solhan N. Writing – original draft: Burhandağ Solhan N. Writing – review and editing: Demirsoy N, Karataş L, Utkan Karasu A, Nihan Burhandağ Solhan, Onurlu İ. Approval of final manuscript: all authors.
Offline exercise telemonitoring and feedback system in tele-cardiac rehabilitation (T-CR). This schematic represents the offline telemonitoring system used in T-CR. Heart rate data is recorded via a chest strap, transmitted to a mobile device via Bluetooth, and later uploaded to an online platform for clinician review. Weekly feedback is provided based on the recorded data.
Fig. 2.
Semi-structured flowchart of weekly reinforcing feedback telephone calls in a tele-cardiac rehabilitation (T-CR) program. This flowchart illustrates the structured approach to weekly feedback calls in the T-CR program. The process includes symptom screening, exercise review, identification of barriers, and motivational support to enhance adherence and engagement.
Fig. 3.
Study flowchart. This flowchart summarizes the study design comparing these methods in coronary artery disease (CAD) patients. 40 of 43 patients with CAD (3 excluded due to implantable cardioverter defibrillator [ICD] implant or refusal) were allocated to center-based cardiac rehabilitation (C-CR) or tele-cardiac rehabilitation (T-CR) groups based on patient preference, with all completing each program.
Fig. 4.
Changes in functional capacity parameters following center-based cardiac rehabilitation (C-CR) and tele-cardiac rehabilitation (T-CR). (A, B) Display changes in peak oxygen uptake (VO2 peak) and VO2 at ventilatory anaerobic threshold (VAT) before (T0) and after (T1) rehabilitation for the C-CR and T-CR groups. (C) Presents the duration of exercise at VAT, showing a significant improvement in the C-CR group compared to the T-CR group (*p=0.012). (D) Illustrates peak oxygen pulse changes across both groups. Data are presented as mean±95% confidence interval (CI).
Fig. 5.
Effects of center-based cardiac rehabilitation (C-CR) and tele-cardiac rehabilitation (T-CR) on kinesiophobia and quality of life (QoL). (A) Shows changes in Fear of Activity in Patients with Coronary Artery Disease (Fear-CAD) scores before (T0) and after (T1) rehabilitation, with a significant reduction in the C-CR group compared to the T-CR group (*p=0.038). (B) Presents the overall QoL and health score, demonstrating slightly higher improvement in the C-CR group than T-CR group (**p=0.05). (C-F) Illustrate the changes in specific QoL domains, including physical health (C), psychological health (D), social relationships (E), and environmental health (F). Data are shown as mean±95% confidence interval (CI).
C-CR, center-based cardiac rehabilitation; T-CR, tele-cardiac rehabilitation; VO2 peak, peak oxygen uptake; VO2 at VAT, oxygen uptake at ventilatory anaerobic threshold; Fact-CAD, Fear of Activity in Patients with Coronary Artery Disease; WHOQOL-BREF, World Health Organization Quality of Life-Brief Version; QoL, quality of life.
a)Student’s t-test;
*p<0.05 and
**p<0.01.
Table 3.
Comparison of time-dependent changes in primary and secondary outcomes between C-CR and T-CR groups
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Comparison of Center-Based and Tele-Cardiac Rehabilitation in Coronary Artery Disease: Effects on Functional Capacity, QoL, and Kinesiophobia
Fig. 1. Offline exercise telemonitoring and feedback system in tele-cardiac rehabilitation (T-CR). This schematic represents the offline telemonitoring system used in T-CR. Heart rate data is recorded via a chest strap, transmitted to a mobile device via Bluetooth, and later uploaded to an online platform for clinician review. Weekly feedback is provided based on the recorded data.
Fig. 2. Semi-structured flowchart of weekly reinforcing feedback telephone calls in a tele-cardiac rehabilitation (T-CR) program. This flowchart illustrates the structured approach to weekly feedback calls in the T-CR program. The process includes symptom screening, exercise review, identification of barriers, and motivational support to enhance adherence and engagement.
Fig. 3. Study flowchart. This flowchart summarizes the study design comparing these methods in coronary artery disease (CAD) patients. 40 of 43 patients with CAD (3 excluded due to implantable cardioverter defibrillator [ICD] implant or refusal) were allocated to center-based cardiac rehabilitation (C-CR) or tele-cardiac rehabilitation (T-CR) groups based on patient preference, with all completing each program.
Fig. 4. Changes in functional capacity parameters following center-based cardiac rehabilitation (C-CR) and tele-cardiac rehabilitation (T-CR). (A, B) Display changes in peak oxygen uptake (VO2 peak) and VO2 at ventilatory anaerobic threshold (VAT) before (T0) and after (T1) rehabilitation for the C-CR and T-CR groups. (C) Presents the duration of exercise at VAT, showing a significant improvement in the C-CR group compared to the T-CR group (*p=0.012). (D) Illustrates peak oxygen pulse changes across both groups. Data are presented as mean±95% confidence interval (CI).
Fig. 5. Effects of center-based cardiac rehabilitation (C-CR) and tele-cardiac rehabilitation (T-CR) on kinesiophobia and quality of life (QoL). (A) Shows changes in Fear of Activity in Patients with Coronary Artery Disease (Fear-CAD) scores before (T0) and after (T1) rehabilitation, with a significant reduction in the C-CR group compared to the T-CR group (*p=0.038). (B) Presents the overall QoL and health score, demonstrating slightly higher improvement in the C-CR group than T-CR group (**p=0.05). (C-F) Illustrate the changes in specific QoL domains, including physical health (C), psychological health (D), social relationships (E), and environmental health (F). Data are shown as mean±95% confidence interval (CI).
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Fig. 4.
Fig. 5.
Graphical abstract
Comparison of Center-Based and Tele-Cardiac Rehabilitation in Coronary Artery Disease: Effects on Functional Capacity, QoL, and Kinesiophobia
Characteristic
C-CR group (n=20)
T-CR group (n=20)
p-value
Sex
Female
8 (40.0)
5 (25.0)
0.501a)
Male
12 (60.0)
15 (75.0)
Age (yr)
58.2±9.9
56.3±5.7
0.474b)
Body mass index (kg/m2)
27.5±5.6
27.8±4.6
0.850b)
CAD history
STEMI
7 (35.0)
8 (40.0)
0.841a)
NSTEMI
5 (25.0)
3 (15.0)
USAP
8 (40.0)
9 (45.0)
Comorbidities
DM
8 (40.0)
4 (20.0)
0.301a)
Hypertension
15 (75.0)
12 (60.0)
0.501a)
Dyslipidemia
14 (70.0)
13 (65.0)
>0.999a)
Obesity
4 (20.0)
6 (30.0)
0.716a)
Medications
Beta-blockers
17 (85.0)
20 (100)
0.231a)
ACE inhibitors
6 (30.0)
9 (45.0)
0.514a)
ARBs
8 (40.0)
5 (25.0)
0.501a)
CCBs
3 (15.0)
2 (10.0)
>0.999a)
Statins
20 (100)
20 (100)
>0.999a)
Antiplatelet drugs
20 (100)
20 (100)
>0.999a)
Smoking status
Current smoker
7 (35.0)
8 (40.0)
>0.999a)
Never smoked
5 (25.0)
4 (20.0)
Former smoker
8 (40.0)
8 (40.0)
Regular exercise
Yes
1 (5.0)
1 (5.0)
>0.999a)
No
19 (95.0)
19 (95.0)
Regular walking
Yes
10 (50.0)
11 (55.0)
>0.999a)
No
10 (50.0)
9 (45.0)
Daily step count
4,576±2,812
5,600±3,180
0.379b)
Education level
Primary school
6 (30.0)
2 (10.0)
0.14a)
Secondary school
1 (5.0)
0 (0)
High school
5 (25.0)
8 (40.0)
Associate’s degree
2 (10.0)
1 (5.0)
Bachelor’s degree
6 (30.0)
8 (40.0)
Master’s degree
0 (0)
1 (5.0)
Parameter
C-CR group
T-CR group
p-valuea)
Metabolic parameters
VO2 peak (mL/kg/min)
19.4±4.2
23.2±3.5
0.004**
VO2 at VAT (mL/kg/min)
15.4±3.2
18.2±3.6
0.012*
Time to VAT (s)
487.3±183.6
637.7±84.9
0.003**
Peak O2 pulse (mL/kg/beat)
11.1±2.8
13.1±3.1
0.030*
Peak respiratory exchange ratio
1.1±1.0
1.1±1.0
0.329
Fact-CAD score
30.8±15.5
23.5±12.4
0.108
WHOQOL – BREF domains
Overall QoL and health
50.6±17.9
56.3±17.9
0.327
Physical health
64.6±13.4
69.1±18.6
0.390
Psychological health
70.0±19.1
71.5±16.0
0.795
Social relationships
71.7±19.6
66.3±20.3
0.396
Environmental health
70.9±16.4
68.6±13.0
0.620
Parameter
C-CR group
T-CR group
Timea)
Group×Timea)
VO2 peak (mL/kg/min)
Pre
19.4±4.2
23.2±3.5
F=13.1; p<0.001
F=0.3; p=0.563
Post
20.4±4.4
23.9±4.0
95% CI: 0.4, 1.3
VO2 at VAT (mL/kg/min)
Pre
15.4±3.2
18.2±3.6
F=9.4; p=0.004
F=0.2; p=0.658
Post
16.2±3.8
19.3±3.5
95% CI: 0.3, 1.5
Time to VAT (s)
Pre
487.3±83.6
637.7±84.9
F=29.2; p<0.001
F=6.9; p=0.012
Post
619.3±109.6
652.3±96.8
95% CI: 55, 122
Peak O2 pulse (mL/kg/beat)
Pre
11.1±2.8
13.1±3.1
F=1.2; p=0.274
F=2.7; p=0.108
Post
11.5±2.7
13.1±3.1
95% CI: -0.4, 0.1
Fact-CAD score
Pre
30.8±15.5
23.5±12.4
F=9.3; p=0.004
F=4.6; p=0.038
Post
24.0±14.0
22.3±13.4
95% CI: -6.5, -1.3
Overall QoL and health score
Pre
50.6±17.9
56.3±17.9
F=15.2; p<0.001
F=4.1; p=0.050
Post
6.52±18.6
60.0±14.9
95% CI: 3.8, 11.9
Physical health score
Pre
64.6±13.4
69.1±18.6
F=5.6; p=0.023
F=0.2; p=0.637
Post
70.0±12.7
72.7±16.7
95% CI: 0.7, 8.3
Psychological health score
Pre
70.0±19.1
71.5±16.0
F=0.1; p=0.715
F=0.1; p=0.715
Post
71.0±15.8
71.5±14.4
95% CI: -2.3, 3.4
Social relationships score
Pre
71.7±19.6
66.3±20.3
F=0.2; p=0.659
F=1.3; p=0.255
Post
67.9±17.8
67.9±18.6
95% CI: -5.8, 3.7
Environmental health score
Pre
70.9±16.4
68.6±13.0
F=0.5; p=0.502
F=0.03; p=0.854
Post
70.3±16.7
67.5±12.5
95% CI: -3.4, 1.7
Table 1. Demographic characteristics
Values are presented as number (%) or mean±standard deviation.
Table 2. Baseline comparison of primary and secondary outcomes between C-CR and T-CR groups
Values are presented as mean±standard deviation.
C-CR, center-based cardiac rehabilitation; T-CR, tele-cardiac rehabilitation; VO2 peak, peak oxygen uptake; VO2 at VAT, oxygen uptake at ventilatory anaerobic threshold; Fact-CAD, Fear of Activity in Patients with Coronary Artery Disease; WHOQOL-BREF, World Health Organization Quality of Life-Brief Version; QoL, quality of life.
Student’s t-test;
p<0.05 and
p<0.01.
Table 3. Comparison of time-dependent changes in primary and secondary outcomes between C-CR and T-CR groups
Values are presented as mean±standard deviation.
C-CR, center-based cardiac rehabilitation; T-CR, tele-cardiac rehabilitation; VO2 peak, peak oxygen uptake; VO2 at VAT, oxygen uptake at ventilatory anaerobic threshold; Fact-CAD, Fear of Activity in Patients with Coronary Artery Disease; QoL, quality of life; CI, confidence interval.
, Levent Karataş, MD1
