Modified Application of Cardiac Rehabilitation (CR) for Older Adults (MACRO)

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Cardiovascular disease (CVD) is endemic in the rapidly expanding population of older adults. Moreover, older adults with CVD are at particular risk for recurrent cardiovascular events as well as interrelated geriatric vulnerabilities to functional decline, weakening, frailty, and disability. Cardiac rehabilitation (CR) is a multidimensional program that enhances medical and functional recovery of CVD patients. Older CVD patients benefit from CR, but only few participate, and even among this small subset, age-related problems commonly impede full participation and engagement. A key part of the problem is that standard of care CR (SOC-CR) lacks fundamental constructs to address complexities of old age (e.g., multimorbidity, polypharmacy, frailty, physical and cognitive decline, falls, depression, and low self-efficacy). To address this significant gap in age- sensitized care, we developed Modified Application of Cardiac Rehabilitation for Older Adults (MACRO). MACRO is an innovative strategy that transforms CR from a program that is based oriented to CVD into a program relatively more centered on the patients who have CVD, i.e., MACRO enhances CR and increases its efficacy by better linking CR to the needs of older complex patients with CVD. In a randomized controlled trial we will show that MACRO achieves greater participation among older candidates for CR, with superior functional gains, wellness and qualitative benefits. MACRO is devised to integrate into existing SOC-CR programs with additional infrastructure and processes to meet needs of older CR patients. The value of MACRO extends to site-based, home-based, and other versions of SOC-CR that have become accepted across the spectrum of contemporary CR; while each mode of CR has proponents and stakeholders, all nonetheless share the similar omission of specific methods to address the distinctive needs of older adults. Key MACRO precepts are: (1) Improved transitions (i.e., from hospital to CR and from CR to sustained behaviors); (2) Shared decision making informed by personalized goal setting in combination with comprehensive assessments of risk (CVD, functional, and psychosocial) to guide management; (3) Patient- centered engagement and counseling techniques to motivate patients, facilitate full participation, and achieve behavior change despite depression, low self-efficacy, and/or cognitive impairment; (4) Expert-led de- prescribing to minimize polypharmacy’s contribution to fatigue, falls, cognitive impairment, or excessive risks; (5) Personalized nutrition to mitigate sarcopenia and frailty while optimizing CV health; (6) Home assessments to best enable physical activity and wellness in a patient’s home environment. We propose to study MACRO vs. SOC-CR as a randomized controlled multisite trial. Endpoints include short (3 month) and long-term (12 month) differences in: (1) functional/qualitative metrics; (2) participation, adherence and patient-reported satisfaction; and (3) falls, medication burden, readmissions and hospitalization. We will also clarify which patient subgroups benefit the most from MACRO.