Key features in telehealth-delivered cardiac rehabilitation required to optimise cardiovascular health in coronary heart disease: A systematic review and realist synthesis

Telehealth-delivered cardiac rehabilitation (CR) programmes can potentially increase participation rates while delivering equivalent outcomes to facility-based programmes. However, key components of these interventions that reduce cardiovascular risk factors are not yet distinguished. This study aims to identify features of telehealth-delivered CR that improve secondary prevention outcomes, exercise capacity, participation, and participant satisfaction; and develop recommendations for future telehealth-delivered CR. The protocol for our review was registered with the Prospective Register of Systematic Reviews (#CRD42021236471). We systematically searched four databases (PubMed, Scopus, EMBASE and Cochrane Database) for randomised controlled trials comparing telehealth-delivered CR programmes to facility-based interventions or usual care. Two independent reviewers screened the abstracts and then full-texts. Using a qualitative review methodology (realist synthesis), included articles were evaluated to determine contextual factors and potential mechanisms that impacted cardiovascular risk factors, exercise capacity, participation in the intervention, and increased satisfaction. We included 37 reports describing 26 randomised controlled trials published from 2010 to 2022. Studies were primarily conducted in Europe and Australia/Asia. Identified contextual factors and mechanisms were synthesised into four theories required to enhance participant outcomes and participation. These theories are: 1) Early and regular engagement; 2) Personalised interventions and shared goals; 3) Usable, accessible, and supported interventions; and 4) Exercise that is measured and monitored. Providing a personalised approach with frequent opportunities for bi-directional interaction were critical features for success across telehealth-delivered CR trials. Real-world effectiveness studies are now needed to complement our findings.