Quality-of-life and functional outcomes in virtual vs traditional cardiac rehabilitation: A retrospective cohort study

Abstract

Virtual cardiac rehabilitation (VCR) offers a potential strategy to expand access to cardiac rehabilitation and address participation barriers, including transportation, work obligations, and limited program availability. This retrospective cohort study compared quality-of-life, functional capacity, and other clinical outcomes between patients enrolled in VCR and traditional cardiac rehabilitation (TCR) at a single academic center between June 2022 and August 2024. Outcomes of interest included changes in Dartmouth COOP quality-of-life scores, metabolic equivalents (METs), Patient Health Questionnaire-9 (PHQ-9), Rate Your Plate dietary scores, body mass index (BMI), and systolic and diastolic blood pressure. A total of 171 patients (40 VCR, 131 TCR) were included. VCR participants demonstrated greater improvement in Dartmouth COOP scores (–5.13 ± 4.65vs –3.20 ± 4.34; p < 0.05), whereas TCR participants had comparable improvements in METs (1.93 ± 1.19 vs 0.92 ± 0.85; p = 0.11). No significant differences were observed in PHQ-9, Rate Your Plate scores, BMI, or blood pressure. In exploratory subgroup analyses, female participants in VCR had greater quality-of-life improvement (–6.18 ± 4.85 vs –2.86 ± 3.85; p < 0.05), while TCR participants had greater MET improvement among those with ≥5 mmHg diastolic blood pressure reduction. VCR was associated with quality-of-life improvements comparable to TCR and may offer potential benefits for women, while TCR produced larger functional capacity gains in subgroup analyses. These findings are hypothesis-generating, reflect a single-center predominantly homogenous population, and require confirmation in prospective, randomized studies.

1. Introduction

Cardiac rehabilitation (CR) improves functional capacity, quality of life (QoL), and cardiovascular outcomes in patients with coronary artery disease, heart failure, and after cardiac surgery or percutaneous coronary intervention [[1], [2], [3]]. Despite these benefits, participation rates remain low; only 28.6 % of Medicare beneficiaries complete at least one session within a year of discharge [4]. Barriers include limited program availability, transportation challenges, work and caregiving obligations, and sex disparities in referral and enrollment [[5], [6], [7]]. Furthermore, higher out-of-pocket costs for CR sessions have been associated with reduced adherence [8].

Virtual cardiac rehabilitation (VCR) has emerged as a strategy to increase access to preventive cardiac care. Early studies suggest that VCR and hybrid programs may provide outcomes comparable to traditional cardiac rehabilitation (TCR), including similar improvements in functional capacity, stress test duration, and body composition, and may reduce hospitalizations and healthcare utilization [5,[9], [10], [11], [12]]. However, most existing evidence involves hybrid rather than fully virtual programs, and limited data exist from real-world U.S. settings.

Additionally, sex-specific outcomes in VCR remain poorly characterized. Women have historically been underrepresented in TCR and face unique participation barriers [6,7,13,14]. Whether VCR may reduce these disparities and improve QoL in women is unclear.

Clarifying the effectiveness of VCR in real-world preventive cardiology practice is essential to inform equitable delivery of secondary prevention. This study compared QoL, functional capacity, and other clinical outcomes between VCR and TCR participants in a single academic center. We hypothesized that VCR would be associated with QoL outcomes comparable to TCR, with potential differences in functional capacity and sex-specific responses.

2. Methods

2.1. Study design and oversight

This retrospective cohort study compared outcomes of patients who participated in TCR or VCR at North Shore University Hospital, Manhasset, NY, between June 2022 and August 2024. The study was approved by the Northwell Health Institutional Review Board (IRB #23-0831) with an exempt determination under 45 CFR 46.104(d)(4)(iii). A waiver of HIPAA authorization was granted due to the retrospective design and minimal risk to participants.

We submitted charges for VCR without continuous electrocardiogram monitoring and used a telehealth modifier. For the initial and last sessions, which are in-person, we submitted charges for CR with continuous electrocardiogram monitoring. Following Centers for Medicare and Medicaid Services (CMS) guidelines, direct supervision for VCR included a medical director who was immediately available remotely, with additional in-person physician presence in an outpatient office setting. Our CR program operates within current CMS approval pathways for VCR delivery in an outpatient ambulatory physician setting. Patients were encouraged to communicate with the CR team, including exercise physiologists and providers through direct discussion during the sessions. They were also encouraged to ask questions outside of the sessions with phone calls rather than directly through the electronic medical record.

2.2. Study population

All patients meeting standard indications for CR during the study period were eligible, including those with myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, valve repair or replacement, chronic systolic heart failure, chronic stable angina, or heart or heart–lung transplant within the preceding year. Exclusion criteria for VCR included high fall risk, hemodialysis, left ventricular assist device, dyspnea at rest, complex ventricular arrhythmias, severe symptomatic valvular disease, dementia or other cognitive impairment, severe chronic obstructive pulmonary disease, home oxygen use, or inability to speak or understand English.

If patients met qualifying CMS diagnoses for CR, clinical history was obtained, and the medical director may deem the patient more suitable for TCR based on the exclusion criteria. At the intake, if appropriate, both TCR and VCR are discussed with the patient. While our TCR waitlist can be anywhere from 4 to 16 weeks, there is generally no more than a 2-week waitlist for VCR. Patients may choose which program they would like to attend.

2.3. Interventions

Both TCR and VCR consisted of up to 36 one-hour sessions performed 2–3 times weekly. All patients underwent an initial in-person visit, which included assessment by a cardiologist and development of an individualized treatment plan addressing exercise, nutrition, emotional well-being, and modifiable risk factors. TCR sessions were facility-based. For VCR participants, our health system produced a video that includes a cardio-aerobic routine that includes dynamic focused movements such as marching in place, walking with forward/backward and side-steps, knee raises, and arm movements. At the phone intake and at the first session, it is collaboratively decided what modality the patient will be using for exercise during VCR. If a patient does not have an exercise machine at home (treadmill, stationary bike, elliptical), a structured floor-based aerobic exercise protocol is offered. Each VCR session is grouped homogenously, meaning patients with home exercise equipment are included together, and those without home exercise equipment are grouped together to follow the structured floor-based aerobic exercise video. The video script was developed and approved by our exercise physiologists, medical director, and nurse practitioners. The video includes warm-up, aerobic exercise, and cooldown/stretching, as well as resistance training with bodyweight (or light dumbbells as discussed with the exercise physiologist).

2.4. Outcomes and measurements

Outcomes of interest included changes in Dartmouth COOP QoL scores, metabolic equivalents (METs), Patient Health Questionnaire-9 (PHQ-9), Rate Your Plate dietary scores, body mass index (BMI), and systolic and diastolic blood pressure (sBP, dBP). Baseline demographics and medical history (hypertension, hyperlipidemia, coronary artery disease, myocardial infarction, atrial fibrillation, stroke, heart failure, chronic kidney disease, diabetes mellitus, asthma, and chronic obstructive pulmonary disease) were also recorded.

We performed an exercise assessment at the first session, which is in-person for both groups, during which patients exercise on a bike, recumbent stepper, or treadmill, starting with a warm-up for 5 min. For VCR patients, we increased the work intensity by 1 MET every 3 min until the patient reached a rating of perceived exertion of 13 in their first and last sessions and compared the estimated peak METs. For TCR patients, we compared the peak METs achieved at the third and last sessions using the same calibrated exercise equipment. The Dartmouth COOP assessment is given to patients in-person, prior to the first session. Team members are available to answer any questions they may have about its completion.

Participants are monitored continuously during 2–6 TCR sessions on telemetry. Heart rate is taken prior to each TCR session using a pulse oximeter. Patients were not on continuous telemetry during the VCR sessions. Patients are provided with a pulse oximeter at the first session and are instructed on its use. Prior to each VCR session, the patient verbally informs the exercise physiologist of their heart rate. After warm-up and after each 10–15 min of exercise and at the end of the session, each person verbally informs the exercise physiologist of their rating of perceived exertion and heart rate. This data is entered into the electronic medical record after being collected during each session and reviewed as participants continue CR.

2.5. Statistical analysis

Continuous variables were reported as mean ± standard deviation and compared using independent t-tests. Categorical variables were compared using chi-square or Fisher’s exact tests. A p-value <0.05 was considered statistically significant. Subgroup analyses evaluated changes in outcomes stratified by sex and by blood pressure response (≥10 mmHg sBP reduction or ≥5 mmHg dBP reduction). Outcomes were adjusted for sex, age, and BMI. For outcomes stratified by sex, outcomes were adjusted for age and BMI. Subgroup analyses were exploratory and not prespecified. All analyses were conducted using standard statistical software.

3. Results

A total of 171 patients met eligibility criteria, including 40 VCR and 131 TCR participants. The mean age was 66.7 ± 12.3 years in VCR and 68.1 ± 11.4 years in TCR (p = 0.51), and females comprised 27.5 % of VCR and 33.6 % of TCR participants (p = 0.47). The mean BMI was 29.3 ± 5.45 kg/m² in VCR and 30.1 ± 6.68 kg/m² in TCR (p = 0.48). Hypertension (75.0 % vs 63.9 %, p < 0.05) and hyperlipidemia (77.3 % vs 64.7 %, p < 0.05) were more frequent in VCR at baseline, whereas coronary artery disease was more common in TCR (56.8 % vs 76.7 %, p = 0.05). Other comorbidities were similar between groups (Table 1). VCR participants attended a similar number of sessions compared to TCR participants (32.5 ± 7.23 vs 29.8 ± 7.83; p = 0.05). There were, on average, 2.91 participants per VCR session and 4.06 participants per TCR session.

Table 1.

Baseline characteristics of study participants.

Variable	VCR (n = 40)	TCR (n = 131)	p-value
Age, years (mean ± SD)	66.7 ± 12.3	68.1 ± 11.4	0.51
Female, n (%)	11 (27.5)	44 (33.6)	0.47
Body mass index, kg/m² (mean ± SD)	29.3 ± 5.45	30.1 ± 6.68	0.48
Race, n (%):
White	23 (57.5)	73 (55.7)	0.84
Black	4 (10.0)	19 (14.5)	0.49
Asian	7 (17.5)	21 (16.0)	0.82
Multiracial	2 (5.0)	13 (9.9)	0.38
Other	3 (7.5)	1 (0.8)	0.01
Unknown	1 (2.5)	4 (3.1)	0.84
Hypertension, n (%)	33 (75.0)	85 (63.9)	0.03
Hyperlipidemia, n (%)	34 (77.3)	86 (64.7)	0.02
Coronary artery disease, n (%)	25 (56.8)	102 (76.7)	0.05
Myocardial infarction, n (%)	3 (6.8)	15 (11.3)	0.48
Atrial fibrillation, n (%)	7 (15.9)	21 (15.8)	0.83
Stroke, n (%)	1 (2.3)	7 (5.3)	0.46
Heart failure, n (%)	6 (13.6)	29 (21.8)	0.33
Chronic kidney disease, n (%)	2 (4.5)	12 (9.0)	0.40
Diabetes mellitus, n (%)	13 (29.5)	45 (33.8)	0.83
Asthma, n (%)	4 (9.1)	14 (10.5)	0.90
Chronic obstructive pulmonary disease, n (%)	1 (2.3)	10 (7.5)	0.25

Values are shown as mean ± SD or as n (%). Significant p-values (<0.05) are bolded. Abbreviations: Standard deviation (SD), traditional cardiac rehabilitation (TCR), and virtual cardiac rehabilitation (VCR).

VCR participants demonstrated greater improvement in Dartmouth COOP QoL scores compared with TCR (–5.13 ± 4.65 vs –3.20 ± 4.34; p < 0.05), whereas no statistically significant difference in MET improvement was observed between TCR and VCR (1.93 ± 1.19 vs 0.92 ± 0.85; p = 0.11) (Fig. 1). No significant differences were observed in PHQ-9 scores, Rate Your Plate dietary scores, BMI, or changes in systolic or diastolic blood pressure.

Fig. 1.

Title: Changes in Key Outcomes (Mean ± SD). Caption: The change in key outcomes before and after cardiac rehabilitation for both virtual and traditional programs are shown. Abbreviations: Body mass index (BMI), Metabolic equivalents (METs), Patient Health Questionnaire-9 (PHQ-9), Quality of Life (QoL), Standard deviation (SD), Systolic and diastolic blood pressure (sBP, dBP), Traditional cardiac rehabilitation (TCR), and Virtual cardiac rehabilitation (VCR).

In exploratory subgroup analyses, sex-specific differences were observed. Among females, VCR was associated with greater improvement in Dartmouth COOP scores (–6.18 ± 4.85 vs –2.86 ± 3.85; p < 0.05). Among males, changes in Dartmouth COOP (–4.72 ± 4.60 vs –3.52 ± 4.56; p = 0.29) and PHQ-9 (–2.21 ± 3.75 vs –1.00 ± 2.82; p = 0.09) did not differ significantly between groups (Fig. 2).

Fig. 2.

Title: Sex-Specific Subgroup Analysis (Mean ± SD). Caption: The mean change in key metrics before and after rehabilitation is shown stratified by sex. Abbreviations: Metabolic equivalents (METs), Patient Health Questionnaire-9 (PHQ-9), Standard deviation (SD), Traditional cardiac rehabilitation (TCR), and Virtual cardiac rehabilitation (VCR).

Additional exploratory analyses stratified by blood pressure response demonstrated that among patients with ≥10 mmHg sBP reduction, VCR participants had greater PHQ-9 improvement (–2.67 ± 3.94 vs –0.68 ± 1.68; p < 0.05) and greater COOP reduction (–6.44 ± 5.15 vs –2.51 ± 4.46; p < 0.05). Among those with ≥5 mmHg dBP reduction, TCR participants had greater improvement in METs (1.94 ± 1.18 vs 0.58 ± 0.57; p < 0.05) (Fig. 3).

Central illustration.

Fig. 3.

Title: Blood Pressure Subgroup Analysis (Mean ±SD). Caption: The mean change in key metrics before and after rehabilitation in patients with improvements in their blood pressure is shown. Abbreviations: Metabolic equivalents (METs), Patient Health Questionnaire-9 (PHQ-9), Standard deviation (SD), Traditional cardiac rehabilitation (TCR), and Virtual cardiac rehabilitation (VCR).

4. Discussion

This single-center retrospective cohort study evaluated outcomes of VCR compared with TCR. VCR was associated with greater improvement in Dartmouth COOP QoL scores, particularly among female participants, and was associated with comparable gains in functional capacity measured by METs. No significant differences were observed in depression symptoms, dietary habits, or blood pressure changes overall; however, VCR participants with significant sBP reductions demonstrated greater PHQ-9 and COOP improvements, although there was large statistical variation for these outcomes. In exploratory subgroup analyses stratified by sex and blood pressure response, TCR was associated with greater improvement in METs compared with VCR. These subgroup findings were exploratory and should be interpreted as hypothesis-generating.

Our findings are consistent with prior studies reporting that virtual or hybrid CR programs can yield QoL and functional outcomes comparable to in-person programs [5,[9], [10], [11], [12],15]. Home-based and hybrid programs have been associated with reduced hospitalizations, comparable myocardial infarction rates, and improvements in stress test duration and body composition [5,[9], [10], [11], [12]]. The greater QoL improvements among women in our VCR cohort aligns with prior evidence that women experience more logistical barriers to TCR participation, including transportation, work, and caregiving responsibilities [6,7,13,14]. The greater QoL improvement observed among women in VCR may reflect increased autonomy and convenience, consistent with behavioral adherence models in preventive cardiology. Additionally, women-tailored CR programs report higher satisfaction and greater engagement among female participants, suggesting that flexible, home-based models may be particularly acceptable to this population [16]. Peer interaction in TCR has been shown to improve mental health [17], however, greater QoL improvement was observed in the VCR group in this cohort. In contrast, the increased gains in METs with TCR in our subgroup analyses are consistent with prior evidence supporting supervised, facility-based programs, which allow for structured progression of exercise intensity and closer physiologic monitoring [10,11].

These results suggest complementary roles for both rehabilitation modalities. VCR may be particularly valuable for patients with logistical barriers or those prioritizing QoL improvement, whereas TCR may remain preferable for optimizing functional capacity. Future studies should aim to identify patient populations most likely to benefit from each approach and explore strategies to enhance functional gains in virtual programs.

Several limitations should be acknowledged. The retrospective design introduces potential selection bias and residual confounding, as program assignment was not randomized and may reflect unmeasured factors. QoL and depressive symptom measures were self-reported, introducing potential response bias. Furthermore, repeated QoL and other measurements throughout the duration of the rehabilitation sessions could have allowed for more detailed statistical analyses. We also did not measure if the participants attended the full 1-hour session and what specific activities were conducted. Furthermore, our timing of when peak METs were assessed was different between the groups (with VCR comparing the first and last sessions and TCR comparing the third and last sessions), all of which may contribute to the functional differences seen. Future prospective studies could better assess differences in functional capacity between TCR and VCR by standardizing exercise prescriptions across modalities in both groups. The study was conducted at a single center with a relatively small VCR cohort and a largely homogenous patient population, which may limit generalizability. Future multicenter studies in more racially and ethnically diverse populations are needed to confirm these findings. Long-term clinical outcomes, including hospitalizations and cardiovascular events, were not assessed.

5. Conclusions

VCR was associated with QoL improvements comparable to TCR and may offer particular benefit for women, whereas no significant differences in functional capacity were observed overall. These findings are hypothesis-generating, reflect a single-center predominantly homogenous population, and require confirmation in prospective, randomized studies designed to evaluate both clinical outcomes and implementation considerations.

Clinical perspectives

What Is New?

• •In this retrospective real-world cohort, VCR was associated with QoL improvements comparable to TCR.
• •Female participants in VCR showed greater QoL improvement. In exploratory subgroup analyses, TCR was associated with larger gains in functional capacity (METs).

What Are the Clinical Implications?

• •VCR may represent a reasonable alternative for patients with logistical barriers or prioritizing QoL improvement, but these findings require confirmation in larger, multi-center prospective studies.
• •Careful patient selection and structured exercise protocols may help optimize functional capacity in fully virtual programs.

Author declaration template

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We further confirm that any aspect of the work covered in this manuscript that has involved either experimental animals or human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.

We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author.

Sincerely,

Sri Nuvvula MD, Rahul Rege MD, Sarah Siemers NP, Jennifer Drummond MD, Benjamin J. Hirsh MD & Neil D. Shah MD

Disclosures

All authors declare no conflicts of interest. All authors have no sources of support to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Sri Nuvvula: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Rahul Rege: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Sarah Siemers: Writing – review & editing, Visualization, Validation, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation. Jennifer Drummond: Writing – review & editing, Visualization, Validation, Resources, Methodology, Investigation, Formal analysis, Conceptualization. Benjamin J. Hirsh: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Neil D. Shah: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

none