Strategies to Optimize Recovery in Frail Patients With Cardiovascular Disease Through Exercise-Based Cardiac Rehabilitation

Abstract

Cardiovascular disease (CVD) remains a critical global health challenge, with frailty in older adults further exacerbating the risk of adverse outcomes. Exercise-based cardiac rehabilitation (EBCR) offers a promising approach to improving cardiovascular function, reducing mortality, and enhancing quality of life in individuals with CVD. However, frail patients often encounter unique barriers, including reduced muscle strength, impaired mobility, and logistical challenges, which hinder their participation in traditional EBCR programs. Resistance training has been shown to improve muscle strength, balance, and functional independence while reducing fall risk, making it a key intervention for frail individuals. Aerobic exercise, when introduced gradually, further enhances cardiovascular endurance and overall resilience. Telehealth exercise strategies can provide an effective means of overcoming logistical barriers by fostering adherence and enabling real-time adjustments to exercise regimens, despite challenges such as digital literacy. This narrative review highlights innovative strategies integrating personalized exercise regimens and telehealth solutions to address the unique needs of frail patients. By prioritizing adaptable, accessible, and evidence-based strategies, an evolved EBCR approach holds the potential to significantly improve long-term health outcomes and quality of life for this vulnerable population.

INTRODUCTION

Despite significant advancements in cardiovascular interventions and diagnostic technologies, cardiovascular disease (CVD) remains the leading health challenge, responsible for nearly 18 million deaths annually and accounting for 32% of all global fatalities.¹ The burden of CVD is immense, encompassing coronary artery disease, heart failure, stroke, and valvular heart disease, each of which often demands urgent interventions.² However, while acute treatments effectively reduce immediate risks, the chronic nature of CVD requires sustained, proactive strategies to ensure long-term recovery and quality of life. Exercise-based cardiac rehabilitation (EBCR) has emerged as a cornerstone in this continuum of care, proven to improve cardiovascular function, elevate physical fitness, and prevent disease recurrence.³,⁴,⁵

A robust body of systematic reviews and meta-analyses consistently underscores the transformative impact of EBCR on long-term cardiovascular outcomes, with documented reductions in all-cause mortality, CVD mortality, and hospitalization rates.³,⁴,⁵ Incorporating EBCR into standard care is, therefore, essential not only for improving patient prognosis but also for fostering a return to functional independence and quality of life. However, the effectiveness of EBCR is limited by coexisting conditions such as frailty.⁶,⁷ Characterized by depleted physiological reserves, reduced muscle strength, and heightened vulnerability to adverse events, frailty—often accompanied by sarcopenia—significantly elevates risks of falls, fractures, and CVD-related mortality, adding complexity to EBCR.⁸ For frail patients with CVD, barriers, including impaired mobility, transportation hurdles, and the physical demands of regular rehabilitation sessions, limit their ability to participate in traditional EBCR programs.⁹ Addressing these barriers through adaptive approaches is imperative to extend the benefits of EBCR to this high-risk population.¹⁰

To address the unique challenges faced by frail patients, telehealth technologies offer a promising solution by reducing logistical and physical barriers to rehabilitation.⁶,¹¹ Telehealth enables patients to engage in EBCR from the comfort of their homes, with real-time monitoring of physiological parameters such as heart rate, blood pressure, electrocardiogram, and physical activity levels.¹²,¹³ Facilitated by wearable devices and video conferencing, telehealth-based exercise programs can provide a structured, safe, and effective alternative that minimizes the strain of frequent in-person visits.¹⁴ Despite these benefits, digital literacy remains a significant obstacle, particularly among older and frail populations, potentially limiting their full participation.¹⁵ Overcoming these digital literacy challenges is vital to the successful integration of EBCR through telehealth, ensuring that this approach reaches its full potential as an accessible, impactful option for comprehensive EBCR.¹⁶

This review highlights tailored exercise strategies within EBCR for frail CVD patients, with a focus on the critical role of telehealth interventions in addressing their specific needs. It also examines digital literacy challenges and current efforts to improve access to telehealth-based exercise. Additionally, the review explores future research directions, such as combining cognitive training with physical exercise and advancing personalized exercise protocols through precision exercise medicine. These innovative approaches have the potential to significantly improve long-term cardiovascular outcomes, enhance quality of life, and promote health equity for these vulnerable populations.

A COMPREHENSIVE FRAMEWORK FOR FRAIL PATIENTS WITH CVD TO OPTIMIZE EBCR

Given the multifaceted needs in delivering EBCR for frail patients with CVD, a comprehensive framework is illustrated in this review (Fig. 1). This framework addresses key barriers—including frailty, limited access to center-based programs, digital literacy, and the need to incorporate innovative exercise modalities such as high-intensity interval training (HIIT) and cognitive training to enhance the accessibility, inclusivity, and effectiveness of EBCR for high-risk populations. This flowchart serves as a guiding structure for the subsequent discussion, offering a systematic approach to implementing a comprehensive EBCR model.

Fig. 1. Comprehensive flowchart for EBCR: integrating frailty management, telehealth exercise, digital literacy, and innovative exercise approaches.

EBCR, exercise-based cardiac rehabilitation.

FRAILTY IN CVD: CHALLENGES IN CLINICAL APPLICATION TO EXERCISE FOR FRAIL PATIENTS WITH CVD

Frailty is prevalent clinical syndrome in older patients with CVD, characterized by decreased physiological reserves (i.e., reduced physiologic capacity) and increased vulnerability to stressors such as illness or surgery.⁸,⁹ Frailty is more prevalent among older adults with established CVD, compared to the general population, affecting up to 30% of individuals with coronary artery disease, 80% of those with heart failure, and 74% of those with aortic stenosis.⁸ Frailty is often defined by Fried Frailty Phenotype which includes 3 or more of clinical characteristics such as sarcopenia (loss of muscle mass and strength), fatigue, reduced energy expenditure, and diminished functional capacity (reduced gait speed),¹⁷,¹⁸ all of which can directly impact a patient’s ability to participate in EBCR.

The clinical significance of frailty was emphasized in a recent study from the National Health and Aging Trends Study which examined the broader cardiovascular risks associated with frailty. In this large prospective cohort study assessing 4,656 participants, 16% were classified as frail, and 47% as pre-frail, with a higher prevalence of chronic conditions such as hypertension, diabetes, lung disease, and dementia compared to non-frail individuals.¹⁹ Frailty was strongly associated with a higher incidence of major adverse cardiovascular events, including death, acute myocardial infarction, stroke, and peripheral vascular disease over 6 years. Notably, frail individuals had a 2.7-fold higher risk of all-cause mortality and significantly elevated cardiovascular event risk, underscoring the importance of early frailty identification, even in patients without preexisting CVD, to mitigate its detrimental effects on cardiovascular health later. This finding is supported by another large study of over 3 million US Veterans, showing that frailty was a strong, independent predictor of cardiovascular mortality. Specifically, veterans classified as pre-frail had a 1.8 times higher risk of cardiovascular death (hazard ratio [HR], 1.8, 95% confidence interval [CI], 1.7–1.9), while those with mild frailty had a 3.2-fold increased risk (HR, 3.2, 95% CI, 3.1–3.3).²⁰ For individuals with moderate frailty, the HR increased to 5.2 (95% CI, 5.1–5.4), and in cases of severe frailty, the risk was 8.6 times higher (HR, 8.6, 95% CI, 8.3–8.9). These associations remained significant even after adjusting for variables such as age, race, smoking status, hyperlipidemia, and statin use, highlighting the crucial role of frailty as a cardiovascular risk factor independent of other conditions.

Given the profound impact of frailty on cardiovascular risk, its presence in patients undergoing EBCR presents additional, unique challenges. However, conventional EBCR may not address the distinct needs of frail patients. Consequently, frail patients struggle to meet the prescribed exercise volume and intensity, resulting in lower adherence rates and less pronounced improvements in cardiovascular and physical health. Studies have shown that frail patients experience greater difficulty completing the prescribed volume and intensity of exercise, leading to lower adherence rates and suboptimal improvements in cardiovascular outcomes.²¹,²² As a result, frail individuals may not fully benefit from EBCR, underscoring the need for tailored exercise interventions that incorporate both resistance and aerobic training to enhance physical function, reduce fall risk, and improve cardiovascular mortality in this vulnerable group.²³ In the following sections, strategies for adapting EBCR to better serve frail individuals will be discussed, aiming to mitigate the compounded risks and ultimately improve long-term cardiovascular outcomes.

SPECIFIC EXERCISE RECOMMENDATIONS FOR MANAGING FRAILTY IN PATIENTS WITH CVD

Given these unique challenges, a conventional EBCR approach may be inadequate for frail individuals. Frail patients often require modified exercise protocols that not only improve cardiovascular fitness but also address specific functional deficits associated with frailty.²²,²⁴ Aerobic exercise has long been the foundation of EBCR, primarily aimed at enhancing cardiovascular fitness. In fact, 73% of EBCR trials focused on aerobic exercise, with only 27% incorporating resistance training in a recent meta-analysis.⁴ However, for frail patients who frequently experience sarcopenia, muscle weakness, and reduced physical resilience, aerobic exercise alone may be insufficient.²⁵ While aerobic exercise improves cardiovascular endurance, it does not address critical aspects such as sarcopenia, balance, and functional independence—key factors for frailty management.⁷ Emerging evidence highlights the importance of resistance training as a crucial intervention to meet the unique needs of frail individuals with sarcopenia.²⁶,²⁷

Importantly, exercise interventions for frail patients with CVD, particularly those incorporating resistance training, have shown significant benefits across diverse settings, including in-hospital,²⁸,²⁹ outpatient,³⁰ home-based,³¹ and telehealth platforms³² (Table 1). Tailored in-hospital resistance and functional exercises have proven effective in enhancing balance, mobility, muscle strength, and independence, ultimately leading to shorter hospital stays.³³,³⁴ Structured resistance and balance training programs have also yielded improvements in functional capacity, with marked increases in the 6-Minute Walk Distance, Timed Up-and-Go scores, and relative workload capacity.³⁵,³⁶,³⁷,³⁸

Table 1. Exercise interventions for frailty reduction in patients with CVD.

Author (Year)	Study sample	Intervention	Outcome measures	Main findings
Opasich et al. (2010)33	RCT; 224 older adults post-cardiac surgery	Tailored in-hospital physiotherapy with mobility and functional exercises	Nursing needs, mobility, balance, and muscle strength	Significant improvement in mobility, balance, muscle strength, increased independence, shorter length of hospital stay
Busch et al. (2012)34	RCT; 173 patients post-CABG	Daily resistance and balance training within cardiac rehabilitation	CPET, 6MWT, TUG, isometric strength	Significant improvement in 6MWD, TUG, and relative workload soon after CABG
Waite et al. (2017)31	Prospective pilot; 22 pre-CABG patients	Home-based preoperative program with balance and strength exercises	6MWT, SPPB, frailty score	Significant improvement in clinical frailty score, 6MWT, SPPB, hospital length of stay
Eichler et al. (2017)35	RCT; 136 patients post-TAVI	Multicomponent cardiac rehabilitation including aerobic, resistance, and flexibility training	6MWT, frailty index, maximum workload, Short form-12	Significant improvement in 6MWD, maximum workload, and quality of life
Reeves et al. (2017)36	RCT, n=27 (older adults with acute decompensated heart failure)	Tailored, progressive multidomain physical rehabilitation intervention including strength, balance, mobility, and endurance exercises	SPPB score; Secondary: 6-mon all-cause rehospitalization rate	Significant improvement in SPPB score at 3 mon. Reduction in 6-mon rehospitalization rate. SPPB improvement strongly correlated with reduced rehospitalizations
Lutz et al. (2020)37	Retrospective; 243 frail older adults	Phase II cardiac rehabilitation with aerobic and strength exercises	Gait speed, TUG, hand grip strength, 6MWT	Frail patients showed greater improvement in TUG than the other groups
Ushijima et al. (2021)30	Observational; 89 elderly CVD patients (65+ yr)	3-mon outpatient cardiac rehab with aerobic, resistance, and flexibility training	Frailty status, CPET	Significant improvement in gait speed, grip strength, and lower extremity strength
Tamulevičiūtė-Prascienė et al. (2021)29	RCT; 252 patients post-valve surgery	Resistance and balance training integrated into cardiac rehab	6MWT, SPPB, leg strength (one repetition maximum)	Significant improvement in 6MWD, SPPB, frailty and sustained over 3 mon follow-up
Kitzman et al. (2021) 38	RCT, n=349 (older adults hospitalized for acute decompensated heart failure)	36-session transitional, tailored, progressive rehabilitation intervention targeting 4 domains: strength, balance, mobility, and endurance	SPPB, 6-mon all-cause rehospitalization rate	Significant improvement in SPPB score at 3 mon in intervention group. No significant difference in 6-mon rehospitalization rate between groups
Pandey et al. (2023)28	RCT, n=337 (older adults with acute decompensated heart failure, stratified by frailty status)	3-mon early, transitional, tailored, multidomain physical rehabilitation intervention	SPPB, 6-mon all-cause hospitalization or mortality	Frail patients showed a 2.6-fold greater improvement in SPPB score compared to prefrail
Su et al. (2024)32	Pilot RCT, n=43 (older adults with CHD)	12-wk CTR with individualized assessments, e-coaching, and home-based CTR	Daily steps, HPLP scores, CTR usage statistics	Significant improvements in daily steps and health-promoting lifestyle profile scores. 40% used the website for data uploads, 90% used a pedometer for telemonitoring. Barriers: physical discomfort, technology use difficulties

CVD, cardiovascular disease; RCT, randomized controlled trial; CABG, coronary artery bypass grafting; CPET, cardiopulmonary exercise testing; 6MWT, Six-Minute Walk Test; TUG, Timed Up and Go; SPPB, Short Physical Performance Battery; TAVI, transcatheter aortic valve implantation; CHD, coronary heart disease; CTR, cardiac telerehabilitation; HPLP, health-promoting lifestyle profile.

Determining the optimal type of exercise—whether resistance, aerobic exercise, or a combination of both—that can best support frail patients with CVD in enhancing their physical resilience and cardiovascular health is a crucial consideration (Fig. 2). A recent large exercise trial provides compelling insights into the benefits of resistance training.³⁹ This randomized controlled trial investigated the comparative effects of aerobic, resistance, and combined exercise on CVD risk profiles in overweight or obese adults. The study involved 406 participants (aged 35–70) who were randomized into 4 groups: resistance training, aerobic exercise, combined aerobic plus resistance, or no exercise for one year. Although aerobic exercise offers well-established cardiovascular benefits, it did not significantly improve muscle strength or hypertrophy in this study. Resistance training, on the other hand, specifically promoted muscle hypertrophy and muscular strength. The trial further emphasized that resistance training offers unique advantages in building muscular strength and lean body mass, benefits that aerobic exercise alone cannot provide which translate into better mobility and physical performance, key for maintaining independence in older adults and frail populations. The combined exercise group offered additional benefits by improving composite CVD risk scores and muscular strength—an outcome not seen in the aerobic group alone. Notably, adherence to the exercise program was higher in the resistance and combined groups compared to the aerobic group, suggesting that these interventions are not only effective but also feasible for long-term commitment. Resistance training, therefore, should emerge as a cornerstone intervention for restoring and preserving functional independence in vulnerable populations, significantly reducing the likelihood of injury.

Fig. 2. Comparison of exercise interventions and delivery models for frail cardiovascular patients: benefits, evidence, practical applications, and limitations.

A PHASED EXERCISE APPROACH: THE ROLE OF RESISTANCE TRAINING IN EBCR FOR FRAIL PATIENTS

As outlined in the preceding sections, it is obvious that integrating both aerobic and resistance exercises is crucial for the success of EBCR in frail patients with CVD. Yet, frail patients face significant challenges that often impede their ability to engage in both aerobic and resistance exercise modalities within a single session. One potential solution is to alternate aerobic and resistance training on different days, thereby reducing the physical and mental strain on patients.⁴⁰,⁴¹ This strategy enables them to focus on one exercise type at a time, while also allowing for adequate recovery between sessions—particularly beneficial for those with diminished muscle strength and endurance. Despite these potential advantages, separating exercise modalities across alternate days may not be feasible in real-world clinical settings as participation rates in EBCR programs remain disappointingly low. In most countries including the United States, Europe and Korea, less than 50% of eligible patients participate in these programs.⁴²,⁴³ These low adherence rates are driven by various factors, including logistical barriers such as transportation, time constraints, and inadequate patient education and support systems.⁴⁴

While participating both aerobic and resistance exercise modalities may theoretically improve multiple clinical outcomes, the practical reality of low adherence necessitates alternative approaches. Given the limitations frail patients face and low adherence, a phased exercise approach to rehabilitation can be implemented. A phased approach could be effective for frail patients in EBCR, where resistance training is prioritized initially to build muscular strength and functional capacity, followed by a gradual introduction of aerobic exercise in later phases.⁴⁵ This hypothetical strategy may address specific needs of frail patients, who suffer from sarcopenia and reduced muscle strength, making it difficult to tolerate the demands of aerobic exercise early in rehabilitation. Supporting this, a meta-analysis of 25 studies involving 2,267 participants demonstrated that resistance training alone significantly improves handgrip strength (effect size [ES]=0.51, p=0.001), lower-limb strength (ES=0.93, p<0.001), agility (ES=0.78, p=0.003), gait speed (ES=0.75, p<0.001), postural stability (ES=0.68, p=0.007), functional performance (ES=0.76, p<0.001), fat mass (ES=0.41, p=0.001), and muscle mass (ES=0.29, p=0.002).⁴⁵ Resistance training during early stages of rehabilitation is particularly effective for improving gait speed and functional strength. Based on these findings, resistance training should be considered a highly effective preventive strategy for delaying and mitigating the negative effects of frailty across both early and late stages of rehabilitation.⁴⁶

Specifically, focusing on resistance training for several weeks or months in the initial phase would help improve muscle mass, neuromuscular function, and overall physical resilience. As the patient's strength and balance improve, this could lead to better mobility and reduced risk of falls, which are critical for maintaining independence in frail individuals. Once a solid foundation of muscular health is established, aerobic exercise can be introduced progressively in the subsequent phase. This phased approach may allow patients to safely and gradually increase cardiovascular endurance without overloading their weakened musculoskeletal system.⁴⁷ Furthermore, early success with resistance training can boost confidence and improve adherence, setting the stage for the introduction of more demanding aerobic exercises later. This phased exercise strategies could potentially offer a more sustainable and less overwhelming intervention, ensuring that frail patients can eventually benefit from the full spectrum of EBCR while reducing the risk of dropout and non-adherence. This hypothetical phased approach, if validated in a large randomized controlled trial, could offer a sustainable recovery, ensuring that frail patients benefit from the full spectrum of EBCR.

A PARADIGM SHIFT IN EBCR: TAILORED APPROACHES FOR FRAIL POPULATIONS

As exercise science continues to advance, the landscape of EBCR is shifting towards more innovative, personalized and evidence-based approaches. While conventional aerobic and resistance exercise remains foundational, novel modalities such as HIIT is gaining attention for its time-efficient—improving both cardiovascular fitness and muscle strength in shorter, possibly more manageable efforts.⁴⁸ When combined with resistance training, HIIT may provide a comprehensive exercise strategy that targets both cardiovascular and muscular needs of frail patients, allowing for more efficient recovery in a shorter timeframe. A recent study investigated the effects of 2 different resistance training modalities—cluster training (CT: short inter-repetition rest periods) and traditional training (TT)—on the force-velocity relationship, physical function, and frailty in pre-frail and frail older adults.⁴⁹ Forty-three participants (average age 81.4±5.1 years) were assigned to one of 3 groups: cluster (CT; 10-second intra-set rest), traditional (TT; no intra-set rest), or a control group. Results indicated that both CT and TT groups achieved significant improvements in physical function (i.e. Short Physical Performance Battery) and reductions in frailty. These findings suggest that both training methods can be effective for improving physical function and mitigating frailty in older adults, with TT potentially offering additional benefits for enhancing both force and velocity capabilities. However, these interventions are still in the early stages of clinical testing in frail CVD populations. Future research should focus on validating the safety, feasibility, and long-term outcomes of HIIT in combination with resistance training for frail CVD patients. Key questions include whether HIIT can be adapted for varying levels of frailty, how it compares to traditional rehabilitation in terms of adherence and outcomes, and whether it can mitigate the risks of sarcopenia and falls that are particularly prevalent in this population.

Another area for future investigation is the integration of cognitive training with physical exercise, particularly for frail patients with CVD. Cognitive decline frequently coexists with physical frailty, and emerging research suggests that combining cognitive tasks with exercise may offer synergistic benefits.⁵⁰,⁵¹ This dual approach may not only enhance cognitive function but also promotes physical function, potentially addressing 2 critical aspects of frailty. Future studies are warranted to explore the mechanisms behind this interaction, determine the most effective cognitive and physical training combinations, and assess long-term outcomes in delaying or mitigating the onset of cognitive dysfunction, further emphasizing the need for rigorous clinical trials to evaluate its full impact.

Precision exercise medicine has garnered increasing scientific attention for its potential to revolutionize exercise science by offering more personalized and targeted interventions.⁵² This emerging field focuses on tailoring exercise programs to an individual’s genetic, molecular, and physiological characteristics, ensuring that the prescribed regimen is both effective and safe.⁵³ By customizing exercise protocols to each patient’s unique profile, particularly across varying levels of frailty, precision exercise medicine can minimize risks while maximizing therapeutic benefits. However, no studies to date have specifically targeted frail patients with CVD using exercise training grounded in precision medicine approaches. Future research should aim to investigate this new EBCR protocols, investigating how precision exercise prescriptions can improve clinical outcomes and address the specific needs of frail patients.

PATIENT MONITORING AND ADDRESSING CHALLENGES IN FRAIL POPULATIONS

Given the unique needs of frail CVD patients, leveraging telehealth in EBCR presents an opportunity to bridge access gaps and offer more adaptable care. Telehealth-delivered EBCR provides a promising alternative for patients who may struggle with the logistical and physical demands of center-based programs. Several systematic reviews and meta-analyses aimed to evaluate the effectiveness of telehealth-delivered cardiac rehabilitation compared to center-based rehabilitation in patients with CVD, analyzing outcomes such as exercise capacity, weight, blood pressure, lipid profile, mortality, and quality of life.⁴⁴,⁵⁴,⁵⁵ The findings indicated no significant differences between telehealth and center-based EBCR in terms of these clinical outcomes, suggesting that telehealth is a viable alternative for delivering EBCR, especially for low to moderate risk CVD patients who face barriers to accessing traditional center-based programs.

Telehealth can play a crucial role in this context by offering remote monitoring and virtual consultations, allowing patients to participate in exercise programs from home while receiving continuous feedback and guidance. This is possible due to wearable devices, such as smartwatches, fitness trackers, and heart rate monitors, especially useful for monitoring cardiovascular responses to exercise, such as heart rate, blood pressure, and electrocardiogram monitoring.⁵⁶ These devices help ensure that patients can participate in regular exercise at a safe intensity level, allowing healthcare providers to adjust exercise prescriptions as needed,¹⁴ to avoid overexertion and mitigate the risk of adverse cardiovascular events. This approach not only improves adherence but also reduces the logistical challenges of attending in-person exercise sessions regularly, which are often difficult for frail individuals.⁵⁷,⁵⁸

Notably, video conferencing tools may play a crucial role in telehealth-based cardiac rehabilitation by enabling real-time interactions that support exercise demonstrations, posture correction, consultations, and progress assessments.⁵⁹ This interactive communication allows healthcare providers to closely monitor patient adherence to prescribed exercise regimens and to intervene promptly if health concerns arise.⁶⁰ In cases of medical emergencies, having family members or caregivers present can provide immediate support, further reducing risks, though such events are rare during supervised sessions.⁶¹,⁶² This approach is particularly valuable for patients who face barriers to in-person exercise due to geographic, logistical, or health-related constraints by ensuring consistent, high-quality care without the need for frequent travel to rehabilitation centers. Building on the advantages of remote exercise interventions for older adults, a recent study compared 2 technology-driven exercise methods: video conference (VC) and video-based home exercise (VBHE).⁵⁹ In this study, 30 older adults aged 65 to 75 participated in a 6-week calisthenic exercise program. The VC group engaged in exercises via real-time video conferencing with a physical therapist, while the VBHE group performed identical exercises by following pre-recorded videos. Both groups showed significant improvements in physical performance measures, including chair sit-stand, 6-minute walk, and grip strength tests; however, no changes were observed in skeletal muscle mass and body fat percentage. Notably, the VC method was found to be more effective than VBHE for enhancing physical performance, likely due to the interactive nature of live guidance. This suggests that real-time interaction may enhance engagement and adherence, underscoring the potential of telehealth interventions to provide structured support and improve physical outcomes for older adults. Through telehealth, patients can receive essential guidance and oversight, enabling them to engage actively in their recovery within the comfort and safety of their homes.

CHALLENGES OF DIGITAL LITERACY IN TELEHEALTH EXERCISE FOR PATIENTS WITH CVD

Despite the clear benefits, telehealth exercise faces distinct challenges, particularly in managing frail patients with CVD.⁶³ A primary obstacle is obtaining reliable health data from patients. Although wearable devices facilitate continuous monitoring, capturing the full scope of a patient’s health status is especially challenging in frail individuals with complex health needs.⁶⁴ Particularly, ensuring that older patients feel comfortable and confident using these technologies poses another significant challenge.⁶⁵ These patients often present a combination of physical, cognitive, and technological barriers, limiting their engagement with digital health tools.¹⁶ Frailty involves reduced muscle strength and mobility, making it difficult to operate wearable devices or mobile applications that require fine motor skills.⁶⁵ Additionally, cognitive decline, common in older adults, impairs their ability to understand and navigate complex digital interfaces and telehealth platforms.⁶⁶ Older adults lack familiarity with smartphones, apps, and wearable health monitors, leading to improper use or misunderstanding of key health metrics such as heart rate, blood pressure, or physical activity levels. This digital gap can result in inaccurate data reporting or misinterpretation of health information, compromising the effectiveness of telehealth monitoring.⁶⁷ Patients with lower digital literacy may struggle to adhere to prescribed exercise programs or report essential health changes in real time, limiting the potential benefits of telehealth exercise interventions.

ADDRESSING DIGITAL LITERACY IN TELEHEALTH FOR FRAIL PATIENTS

To ensure that telehealth interventions reach their full potential for frail CVD patients, additional digital support and education are necessary. Addressing this issue requires ensuring that devices are user-friendly and that sufficient training and support are provided.⁶⁸ This might include simplified interfaces, step-by-step guidance, and regular technical assistance. In a hospital or rehabilitation center, patient navigators can play a critical role in educating patients about telehealth services and their use.⁶⁹,⁷⁰,⁷¹ At home, implementing telehealth interventions for frail patients often requires the involvement of caregivers or family members to assist with operating digital tools and interpreting health data.⁷² Their support ensures that patients can fully engage with remote monitoring systems and follow exercise programs effectively, enhancing the overall success of telehealth-based rehabilitation.⁷³ As frailty increases the risk of falls, fractures, and other adverse events, close monitoring of how patients respond to exercise is essential.²³ Periodic in-person check-ins could complement remote monitoring to ensure that digital literacy challenges do not undermine the overall care plan.⁷⁴,⁷⁵ Ultimately, hybrid models that combine in-person visits with telehealth check-ins may provide a balanced approach for patients who need more hands-on guidance but also benefit from the flexibility of remote care (Fig. 2).⁷⁶,⁷⁷ By integrating technology with enhanced digital support, telehealth exercise can eliminate geographical and physical barriers, ensuring broader access to effective EBCR.

CONCLUSION

Despite the advances in EBCR, substantial gaps remain in the literature. One of the most critical needs is for large-scale, longitudinal studies that demonstrate the long-term impact of telehealth-based exercise programs on robust clinical outcomes including mortality, hospital admission rates and recurrence of cardiovascular events in frail patients with CVD. While recent findings are promising, we need robust data to definitively demonstrate the sustained benefits of EBCR over time. Furthermore, there is a clear need for research that delves deeper into personalized exercise protocols for subpopulations with complex needs, such as those with advanced frailty, multiple comorbidities, or cognitive impairments. The traditional one-size-fits-all model of EBCR is inadequate for these patients. Future research should focus on designing safe, personalized interventions that optimize efficacy while ensuring patient safety. Although wearable technology and telehealth are opening a new era of accessibility, there remains a critical gap in understanding how to best integrate these tools into clinical practice. More research is needed to identify the most effective methods for incorporating wearable technology and telehealth into existing healthcare systems while ensuring that these innovations are accessible to all, regardless of socioeconomic status. If not carefully managed, the digital device could exacerbate health disparities rather than bridge them. Finally, the combination of exercise, nutrition, and mental health is an underexplored yet critical area for future research. The development of comprehensive, interdisciplinary interventions that combine physical rehabilitation with nutritional counseling and mental health support could unlock new pathways for improving outcomes, particularly in frail, older adults with CVD. This comprehensive approach can transform EBCR by addressing the multifaceted needs of this vulnerable population.