PONE-D-22-14087The Impact of Covid-19 Pandemic on Cardiac Rehabilitation of patients following acute coronary syndrome.PLOS ONE

Dear Dr. Pereg,

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1) While the paper is within the word limit, I feel that readability would be enhanced by being more succinct and shortening the word count.

2) The authors should provide a more specific definition of the primary endpoint. The present definition ("The primary endpoint was the effect of cardiac rehabilitation suspension during COVID-19 pandemic on exercise capacity of the participants") appears too general.

3) The authors report that "tests between independent samples" were used. Independent sample tests are used to compare independent groups. Based on the study design, this approach does not seem correct for the analysis.

4) The sample size is relatively modest to offer robust evidence on the topic.

5) The authors should provide detailed information regarding all the reasons for not returning to cardiac rehabilitation.

6) The study population consisted of patients with previous acute coronary syndrome. Yet, only 79% of patients received aspirin. What were the reasons for not prescribing aspirin in the remaining 21% of cases? The same reasoning also apply to the prescription of statins.

7) The manuscript presentation, including the graphical presentation, should be substantially improved.

Reviewer #2: The manuscript by Prof. David Pereg and Colleagues analysed the impact of the COVID-19 pandemic on a cardiac rehabilitation program of coronary patients.

Briefly, the Authors found that cardiac rehabilitation (CR) suspension for 4 months during the COVID-19 pandemic caused a significant reduction in exercise capacity and increased weight and body fat percent highlighting the unmet need for specific remote measures to ensure better follow up strategies.

Currently, direct evidence on the impact of COVID-19 on CV rehabilitation programs is still limited and, for this reason the study is welcome. Although concise and clearly written, one may wonder if a more in-depth analysis on the present data could be performed to identify those patients at highest risk of losing CR benefit.

Please find my comments below.

Major Comments.

1. A total of 198/281 patients who were initially referred for CR returned for program continuation. Of the 99 patients who had achieved >10% improvement in exercise capacity, only 48 maintained this improvement. It would be interesting to acknowledge which factors were associated with lack of improvement (age, gender, BMI, baseline METs, LVEF, social factors?). A focus on this group could be helpful for the attending physician or nurse for future counselling. A logistic regression model could be a simple tool to assess this topic.

2. It is sometimes difficult to understand how the final population was derived and how many improved exercise capacity. A flowchart of the study population (even as supplementary material) could be useful.

3. In lines 157-159, Authors briefly refer to gender and age specific differences, however no quantitative data is reported. My suggestion is to either add data in the tables or remove the information altogether.

4. LDL concentrations seem to decrease through time although Authors highlight the lack of statistical significance. What test did they use? Was it a repeated measure test? By looking at the numbers the trend may seem significant.

5. A clearer presentation of the baseline vs. pre-lockdown vs. post lock-down characteristics of the study population could be useful: restructuring Table 2 to include trends of variables like body weight, BMI (and BMI >30), METs, etc. would be informative and may identify potential topics which could be amenable of future improvement.

Minor comments.

1. Introduction: The introduction paragraph has too many references (20).

2. Methods: the study design has not been reported.

3. Methods: a reference for the 10% cut-off to consider capacity improvement could be useful.

4. Tables: please add measurement units whenever missing and at least 1 decimal.

5. Table 1: how many patients were obese?

6. Table 1: do the Authors have echocardiographic information?

7. Table 1: PVD abbreviation is for PAD?

8. Figure 1: please add number of patients.

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Reviewer #1: No

Reviewer #2: Yes: Carlo Fumagalli, MD

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The Impact of Covid-19 Pandemic on Cardiac Rehabilitation of patients following acute coronary syndrome.

PONE-D-22-14087R1

Dear Dr. Pereg,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Giuseppe Limongelli

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all the comments of the Editors and Reviewers.

I have not further comments.

Reviewer #2: I thank the Authors of ‘The Impact of Covid-19 Pandemic on Cardiac Rehabilitation of patients following acute coronary syndrome’ for acknowledging all the points raised during the reviewing process.

Although the limitations due to the sample size and the difficulty in extrapolating potential factors associated with benefit (or lack thereof) of cardiac rehabilitation during the COVID-19 pandemic may limit generalizability, the results of the report are still of interest.

The Authors may want to report the lack of associated factors with maintained improvement in the Results section and Discussion/Limitations paragraph.

Minor comments.

Please amend all percentages to the first decimal point in figures and tables.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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