Cardiac Telerehabilitation Using a Smartwatch and a Gamified Smartphone App: Single-Arm Pre-Post Feasibility Study

Home-based cardiac rehabilitation (CR) using digital health technologies (ie, cardiac telerehabilitation [CTR]) has emerged as a practical alternative to conventional center-based CR, particularly during and after the COVID-19 pandemic. However, maintaining sustained participation in CR remains challenging. Gamification holds the potential to enhance motivation and adherence in CR, but its role in CTR for patients with acute coronary syndrome (ACS) remains under-studied.

This feasibility study evaluated the feasibility, acceptability, and safety of a combination of a gamification-enabled smartphone app and a smartwatch supporting CTR after ACS. We focused specifically on participation motivation, adherence to prescribed exercise intensity, and short-term physiological outcomes.

This single-arm, pre-post intervention study was conducted at 2 Japanese institutions. Sixteen patients diagnosed with ST-elevated myocardial infarction or non-ST-elevated myocardial infarction and undergoing percutaneous coronary intervention were enrolled after discharge. Each patient received a smartphone and smartwatch connected to the Shin-po Kei app, through which participants earned points when exercising within their target anaerobic threshold heart rate (HR) range (±10 bpm). The 1-month intervention prescribed walking for 30 minutes or longer 3 to 5 days or more per week, at an intensity corresponding to a Borg scale score of 11 to 13. The primary end point was the number of app log-in days divided by the number of intervention days (app use rate). Secondary end points included the target HR exercise adherence rate (defined as the proportion of patients who exercised for 30 minutes within the target HR range on 3 or more days per week), changes in peak oxygen consumption, and changes in perceived exertion using a visual analog scale.

The mean patient age was 62 (SD 13) years, and 94% (15/16) were male. The mean intervention duration was 29 (SD 6) days, and the overall app use rate was 59.9%. The target HR exercise adherence rate was 50%. Peak oxygen consumption increased from 18.4 (SD 4.1) to 21.1 (SD 5.4) mL/kg/min, and the mean visual analog scale score for exercise-related hassle reduced from 57 (SD 33) to 32 (SD 26). No adverse events related to app use were identified, and 1 hospitalization unrelated to the intervention occurred during the study period.

This feasibility study suggests that short-term engagement with a smartwatch-linked gamified smartphone app is achievable in CTR after ACS. However, adherence to predefined gamified exercise standards was lower than app use rates, suggesting that refinement of reward rules and target HR thresholds may be necessary.