1. Nabutovsky, Irene PhD
  2. Breitner, Daniel BMSc
  3. Heller, Alexis BA
  4. Klempfner, Yarin
  5. Klempfner, Robert MD

Article Content

The global crisis of COVID-19 has highlighted how the health care system needs to adapt. Telemedicine services have proven to be essential during this time.1 Previous studies have shown that telemedicine reduces hospitalizations, enhances care, and increases treatment compliance.2


During the pandemic, Israel had a partial lockdown (January 15, 2020, to May 10, 2020). Extreme restrictions were implemented, which are shown to have an adverse effect on physical and mental health in patients with chronic diseases.3,4 Remote cardiac rehabilitation programs (RCRP), however, continued. Previous studies have shown that RCRP are effective, safe, and equivalent to institutional rehabilitation.5 So far, few have analyzed the susceptibility of patients to telemedicine programs during COVID-19.


The objectives of this study were to characterize the first of its kind program in Israel at the level of the patients and care team during the crisis compared with normal. We explored the following: (1) how restrictions on movement and fear of infection will affect patient activity; (2) how the crisis will affect the performance of the RCRP care team; and (3) the concerns and satisfaction levels of patients during the crisis.



After lockdown, we analyzed data on RCRP patients and the care team. Data refer to two time periods: period-1 (P1)-9 wk before the lockdown; period-2 (P2)-7 wk during the lockdown. The following were assessed for both periods: aerobic exercise (min) and time in target heart rate (min) as well as the steps/d and mobile application use/wk. We also examined patterns of the care team: the number of contacts with the patient/wk and the ratio between automatic and manual follow-up tasks.


Patients were sent an anonymous survey at the end of isolation to assess their training; compare workouts during the two periods; assess the level of satisfaction/concerns with the program; and assess how much the program helps maintain a healthy lifestyle.


A description of the program was previously published.6 The program involves structured remote exercise. Remote cardiac rehabilitation programs set the following goals for patients: (1) 3-5 aerobic workouts/wk (150 min); (2) >=120 min at a target heart rate; and (3) >=8000 steps/d. Patients were asked to frequently use the mobile app. The program duration was 3-12 mo. During the lockdown, the RCRP protocol remained unchanged; however, there was a reduction of care team workers, decreasing the weekly working hours (from 60 to 40).


Descriptive statistics for the study population are presented as counts/percentages for discrete variables and mean +/- SD for continuous data. Selected variables were represented as their weekly averages and trends were analyzed. The studied duration was split into two groups, P1 (wk 1-9) and P2 (wk 10-16). We compared variables between the two periods, using the Student t test and Wilcoxon rank sum test, for normally and nonnormally distributed data, respectively. All analyses were performed using R 3.6.2 (The R Foundation). Statistical significance was set at P < .05 (two-sided).



The analysis included 38 patients who participated during P1 and P2. Patients were mostly male (92%), <65 yr (58 +/- 11 yr), with a recent diagnosis of cardiovascular disease following myocardial infarction or coronary interventions (57%), without significant left ventricular dysfunction or residual clinical ischemia. During P2, there was an increase in patient activity: total aerobic minutes and minutes in the target heart rate (Figure). Other variables remained unchanged from P1 to P2. The survey conducted revealed that 83% of patients believed that they were exercising as much or more. More than 86% of patients reported feeling safe and satisfied with RCRP. Only 6% of patients were afraid of contracting COVID-19. More were concerned that the lockdown would prevent them from reaching program goals (35%). Others (46%) had no significant concerns. Overall, 84% of participants answered that RCRP helped them maintain a healthy lifestyle. In addition, care team working hours were reduced by a third in P2. The total number of opened tasks/wk remained unchanged during the lockdown; however, the number of manually opened tasks decreased by 39%.

Figure. The clinical... - Click to enlarge in new windowFigure. The clinical program management center and patient performance during P1 and P2. This figure is available in color online (


This study evaluated the feasibility of a cardiac rehabilitation program at home during COVID-19 lockdown. Our results showed that RCRP patients exercised with no significant changes. We hypothesize that factors such as having more free time due to the lockdown, receiving daily video material, and automatic exercise reminders helped maintain patient activity.


It has been proven that isolation endangers mental health and causes sensations similar to post-trauma.7 Previous studies have shown that prolonged (>10 d) quarantine was associated with a significant deterioration in mental health.8 Unlike previous studies,9 our survey showed that RCRP patients in lockdown did not experience anxiety or fear. Similar to a recent study,7 we hypothesize that regular communication, access to remote psychological support, and daily educational materials prevented feelings of loneliness/isolation.


The RCRP algorithm for automatically opening tasks and ensuring adherence to protocol existed before the pandemic and has already proven to be reliable. This allowed the reduced staff to successfully maintain a normal workload during the lockdown. These findings are consistent with recent studies on the effectiveness of similar algorithms for remote monitoring and treating patients.10 Unlike previous studies that highlighted telemedicine limitations,11 our study shows how a well-functioning telemedicine system can effectively cope with current global challenges.


Our study has several limitations. First, the number of participants is relatively small due to the RCRP program being fairly new and the requirement of patients to train for at least 2 mo before the lockdown. Second, the Israeli Ministry of Health has approved the RCRP for only low-risk patients, who are often younger and more technologically oriented than high-risk patients.


In conclusion, during the lockdown due to COVID-19, RCRP were proven to be effective in maintaining the mental and physical health of patients, even with a substantial reduction in staff. This shows how telemedicine has the potential to prevent the detrimental effects of a national crisis on chronic patient care.


Irene Nabutovsky, PhD


Cardiac Prevention and Rehabilitation Institute,


Leviev Heart Center, Sheba Medical Center, Tel HaShomer,


Ramat Gan, Israel


Daniel Breitner, BMSc


Alexis Heller, BA


Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel


Yarin Klempfner


Cardiac Prevention and Rehabilitation Institute,


Leviev Heart Center, Sheba Medical Center,


Tel HaShomer, Ramat Gan, Israel


Robert Klempfner, MD


Cardiac Prevention and Rehabilitation Institute,


Leviev Heart Center, Sheba Medical Center,


Tel HaShomer, Ramat Gan, Israel


Sackler Faculty of Medicine,


Tel Aviv University, Tel Aviv, Israel




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