Exercise training intervention after coronary angioplasty: the ETICA trial

[Cardiac rehabilitation: first experience in Algeria]

Cardiac rehabilitation should be considered part of the management of coronary artery disease patients. One is surprised, however, by the discrepancy between the proven benefits of cardiac rehabilitation and the use of cardiac rehabilitation, particularly in developing countries. This paper describes the initial experience of the first Algerian rehabilitation centre and the results achieved in the first 158 coronary patients participating in a cardiac rehabilitation programme. Overall, there was a marked improvement in functional capacity and quality of life for all patients.

Exercise training after coronary angioplasty improves cardiorespiratory function

AIM

The aim of this prospective randomized study was to evaluate the impact of long-term aerobic exercise training on respiratory function, left ventricular systolic function and remodeling in patients with coronary heart disease and ischemic heart failure after successful angioplasty.

DESIGN

Patients (n=185) have undergone Doppler echocardiography and ergospirometry. Ninety-five patients practiced 6 month-term aerobic exercise training, less by 10% to their anaerobic threshold. Ninety patients were studied as controls. They were given only drug treatment without training. Measurements were repeated after 6 and 12 months.

RESULTS

Training group patients after 6 months showed significant (p<0.05) improvement in exercise capacity, oxygen consumption and ventilating equivalents. The Doppler echocardiographic findings revealed significant (p<0.05) improvement in ejection fraction, left ventricular and atria morphometric data. Improved ergospirometric and echocardiographic data were established after 12 months, too.

CONCLUSIONS

Long-term aerobic exercise training is an effective and workable measure improving respiratory efficiency, left ventricular systolic function, attenuating negative remodeling and stopping further progression in patients with coronary heart disease and chronic heart failure after successful angioplasty.

Exercise training in the management of cardiac failure and ischaemic heart disease

Advice regarding physical activity is an important part of the management of cardiovascular disease. In addition to its role in primary prevention, it is now clear that patients with established ischemic heart disease and cardiac failure can benefit from exercise training.

Dietary measures and exercise training contribute to improvement of endothelial function and atherosclerosis even in patients given intensive pharmacologic therapy

PURPOSE

Atherosclerosis contributes to cardiovascular mortality and morbidity even with aggressive lipid management. Our objective is to determine whether a combined pharmacological and lifestyle intervention can improve atherosclerosis.

METHODS

We conducted a 2-year observational study at a specialized clinic in a tertiary care hospital. One hundred fifty-six subjects with coronary disease were enrolled in an intensive pharmacological management and lifestyle measures (including counseling and exercise training) program designed to reach specific targets. The main outcome measures were carotid intima media thickness and plaque area; brachial artery flow-mediated dilation; nitroglycerin-mediated dilation; flow-mediated dilation-nitroglycerin-mediated dilation ratio; laboratory parameters including lipids, glucose, creatinine, and homocysteine; and physical fitness.

RESULTS

At completion, there were improvements in lipids and physical fitness. There were no overall changes in flow-mediated dilation, nitroglycerin-mediated dilation, or carotid intima media thickness in the entire cohort. However, multivariate logistic regression showed that dietary and exercise variables, such as increasing fiber intake and reducing body weight and body fat percentage, were independent predictors of improvements in endothelial function and carotid plaque burden.

CONCLUSIONS

Even in the setting of intensive pharmacological therapy, lifestyle interventions, including exercise training and dietary changes, are important determinants of improved endothelial function and atherosclerosis.

Endothelial progenitor cells in cardiovascular disorders

The important role of the vascular endothelium in cardiovascular health is increasingly recognized. However, mature endothelial cells possess limited regenerative capacity. There is therefore much interest in circulating endothelial progenitor cells (EPCs) among the scientific community, especially into their purported role in maintenance of endothelial integrity and function, as well as postnatal neovascularization. It has been suggested that these cells might not only be responsible for the continuous recovery of the endothelium after injury/damage, but also might take part in angiogenesis, giving the hope of new treatment opportunities. Indeed, there is accumulating evidence showing reduced availability and impaired EPC function in the presence of both cardiovascular disease and associated comorbid risk factors. Thus, many studies into the potential for use of EPCs in the clinical setting are being undertaken. The goal of this review article is to provide an overview of data relevant to the clinical role of EPCs and perspectives for treatment of cardiovascular disorders.

Endothelial progenitor cells: a new target for the prevention of cardiovascular diseases

Endothelial progenitor cells (EPCs) are circulating precursor cells that have been implicated recently in vascular and cardiac regeneration. There is an ongoing discussion on the immunocytological definition of EPCs, based on various surface markers, and currently different cell types are included in the term 'EPC'. This review summarizes the mechanisms that influence function, survival, mobilization and differentiation of EPCs. Furthermore, there are several reports on the clinical use of EPCs for the treatment of cardiovascular diseases. We have focused specifically on the influence of physical activity on EPC function.

Recent Progress in the Treatment of Pulmonary Arterial Hypertension: Expectation for Rho-Kinase Inhibitors

Pulmonary arterial hypertension (PAH) is a disease with poor prognosis characterized by progressive elevation of pulmonary arterial pressure and vascular resistance due to pulmonary artery hyperconstriction and remodeling. However, the precise mechanism of PAH still remains to be elucidated. Although anticoagulant agents, vasodilators (e.g., prostaglandins, sildenafil, and bosentan), and lung transplantation are currently used for the treatment of PAH, more effective treatment needs to be developed. Rho-kinase causes vascular smooth muscle hyperconstriction and vascular remodeling through inhibition of myosin phosphatase and activation of its downstream effectors. In a series of experimental and clinical studies, we have demonstrated that Rho-kinase-mediated pathway plays an important role in various cellular functions, not only in vascular smooth muscle hyperconstriction but also in actin cytoskeleton organization, cell adhesion and motility, cytokinesis, and gene expression, all of which may be involved in the pathogenesis of arteriosclerosis. We also have recently demonstrated that Rho-kinase is activated in animal models of PAH with different etiologies (monocrotaline and chronic hypoxia) associated with enhanced pulmonary vasoconstricting and proliferating responses, impaired endothelial vasodilator functions, and pulmonary remodeling. Indeed, we were able to demonstrate that intravenous fasudil, a selective Rho-kinase inhibitor, exerts acute pulmonary vasodilator effects in patients with severe PAH who were refractory to conventional therapies. Taken together, our findings indicate that Rho-kinase is a novel and important therapeutic target of PAH in humans and that Rho-kinase inhibitors are a promising new class of drugs for the fatal disorder.

Clinical evidence for a health benefit from cardiac rehabilitation: an update

The recent decision by the Centers for Medicare and Medicaid Services to expand the indications for cardiac rehabilitation (CR) provides an opportunity to review the clinical evidence of the efficacy of exercise in the CR setting for patients who have experienced an acute myocardial infarction, coronary artery bypass graft surgery, stable angina, percutaneous coronary intervention, chronic heart failure, cardiac transplant, or cardiac valve repair/replacement. Evidence shows that physician-directed, exercise-based CR positively affects the basic pathophysiology of coronary artery disease, the extent of disability and level of quality of life, and the ability to potentially impact events of both morbidity and mortality. The role of CR, including regular exercise, lifestyle modification, and appropriate medical therapy, is effective in younger and older men and women with cardiac diagnoses. The efficacy of this important therapeutic modality warrants its more widespread application.

Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation

The Canadian Cardiovascular Society formed an Access to Care Working Group ('Working Group') in the spring of 2004. The mandate of the group was to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The present commentary presents the rationale for benchmarks for cardiac rehabilitation (CR) services. The Working Group's search for evidence included: a full literature review of the efficacy of CR, and the factors affecting access and referral to CR; a review of existing guidelines for access to CR; and a national survey of 14 CR programs across Canada undertaken in May 2005 to solicit information on referral to, and wait times for, CR. The Working Group also reviewed the results of The Ontario Cardiac Rehabilitation Pilot Project (2002) undertaken by the Cardiac Care Network of Ontario, which reported the average and median wait times for CR. Some international agencies have formulated their own guidelines relating to the optimal wait time for the onset of CR. However, due to the limited amount of supporting literature, these guidelines have generally been formed as consensus statements. The Canadian national survey showed that few programs had guidelines for individual programs. The Cardiac Care Network of Ontario pilot project reported that the average and median times from a cardiac event to the intake into CR were 99 and 70 days, respectively. The national survey of sampled CR programs also revealed quite remarkable differences across programs in terms of the length of time between first contact to first attendance and to commencement of exercise. Programs that required a stress test before program initiation had the longest wait for exercise initiation. Some patients need to be seen within a very short time frame to prevent a marked deterioration in their medical or psychological state. In some cases, early intervention and advocacy may reduce the risk of loss of employment. Or, there may be profound disturbances in the patient's family as a result of the cardiac event. For other patient groups, preferable wait times vary from one to 30 days, and acceptable wait times vary from seven to 60 days. All cardiovascular disease patients require core aspects of CR services. Patients who would derive benefit from formal CR programs should be provided the opportunity, given the proven efficacy and cost effectiveness of CR.

Reabilitação cardíaca com ênfase no exercício: uma revisão sistemática

O objetivo desta revisão sistemática foi determinar o efeito da reabilitação cardíaca com ênfase no exercício (RCEE) sobre a mortalidade, fatores de risco modificáveis e qualidade de vida relacionada à saúde em pacientes com doença arterial coronariana. Foram analisados apenas ensaios clínicos controlados e randomizados (ECCR) com follow-up igual ou superior a seis meses, publicados entre 1990 e 2004. Utilizaram-se os critérios propostos pelo Clinical Practice Guideline: cardiac rehabilitation para julgar os estudos selecionados. Fizeram parte desta revisão 21 ECCR envolvendo 2.220 pacientes entre 49 e 63 anos (86% homens). A maioria dos ECCR apresentaram resultados favoráveis à RCEE para mortalidade total e cardíaca quando comparada com os cuidados usuais (controle). Esse fato também foi observado para os eventos de reinfarto e revascularização do miocárdio. Os resultados da RCEE sobre os fatores de risco modificáveis e a qualidade de vida não foram conclusivos quando comparados com a intervenção controle, apesar de alguns estudos apresentarem diferenças estatísticas a favor da RCEE. Esta revisão confirma os benefícios da RCEE na abordagem terapêutica de coronariopatas, reduzindo suas taxas de mortalidade cardíaca e por todas as causas, além de contribuir para a diminuição da ocorrência de outros eventos coronarianos, tais como a revascularização miocárdica e a taxa de reinfarto. Em relação aos fatores de risco modificáveis e à qualidade de vida, houve uma tendência favorável à utilização da RCEE. Em adendo, parece que o exercício físico regular per se constitui o principal responsável pelos resultados favoráveis da intervenção em relação aos desfechos estudados.

[Benefits and risks of exercise training in coronary artery disease patients]

Cardiac rehabilitation programs improve vital and functional prognosis in patients suffering from stable angina or after myocardial infarction. The studies focusing on the balance risks/benefits of cardiac rehabilitation are relatively old; therefore, the patients included in these studies are different from today's patients mainly because of different management of the acute phases and of modifications of the medical treatment in stable angina (ABCDE protocols). The authors present the preliminary results of a French multicentric register focusing on complications during cardiac rehabilitation conducted on behalf of the French Society of Cardiology. Complications are rare: one resuscitated cardiac arrest/1.3 millions exercise training hours and no death was reported. It must be highlighted that, in some patients, the antianginal medical treatment must be reinforced in order to allow exercise training without myocardial ischaemia.

Evidence for prescribing exercise as therapy in chronic disease

Considerable knowledge has accumulated in recent decades concerning the significance of physical activity in the treatment of a number of diseases, including diseases that do not primarily manifest as disorders of the locomotive apparatus. In this review we present the evidence for prescribing exercise therapy in the treatment of metabolic syndrome-related disorders (insulin resistance, type 2 diabetes, dyslipidemia, hypertension, obesity), heart and pulmonary diseases (chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication), muscle, bone and joint diseases (osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, chronic fatigue syndrome) and cancer, depression, asthma and type 1 diabetes. For each disease, we review the effect of exercise therapy on disease pathogenesis, on symptoms specific to the diagnosis, on physical fitness or strength and on quality of life. The possible mechanisms of action are briefly examined and the principles for prescribing exercise therapy are discussed, focusing on the type and amount of exercise and possible contraindications.

Running exercise of different duration and intensity: effect on endothelial progenitor cells in healthy subjects

BACKGROUND

Increased numbers of circulating endothelial progenitor cells (EPC) are associated with improved vascular function. Exercise is a central component of the primary prevention of vascular diseases. The effect of physical activity on circulating EPC in healthy individuals is not known.

DESIGN

A prospective crossover study.

METHODS AND RESULTS

In order to study a potential link between the extent of physical exercise and progenitor cells in humans, EPC were quantified by flow cytometry and cell culture in 25 healthy volunteers undergoing three protocols of running exercise. Intensive running, defined as 30 min at 100% of the velocity of the individual anaerobic threshold (IAT; approximately 82% maximal oxygen consumption; VO2max), as well as moderate running with 30 min at 80% of the velocity of the IAT ( approximately 68% VO2max), increased circulating EPC numbers to 235+/-93% and 263+/-106% of control levels, respectively. However, moderate short-term running for 10 min did not upregulate EPC counts. The maximum increase in circulating EPC numbers was observed 10-30 min after intensive running. Exercise increased EPC migratory and colony-forming capacity.

CONCLUSIONS

Intensive and moderate exercising for 30 min, but not for 10 min, increased circulating levels of EPC, which may represent an important beneficial outcome of physical exercise. The data support the notion that increased numbers of EPC correlate with cardiovascular health and suggest EPC quantification as a novel surrogate parameter of the vascular effects of exercising.

Flow-mediated effects on abdominal aortic aneurysms

Abdominal aortic aneurysms (AAAs) are a common and lethal disease of the elderly. 'Atherosclerotic' aneurysms occur far more frequently in the caudal or infrarenal segment, a localization influenced at least in part by site-specific hemodynamic conditions. Alterations in aortic flow and wall shear stress modify AAA disease progression in small animal models and may explain increased prevalence in certain at-risk patient populations. If a specific hemodynamic risk profile can be established, anti-aneurysmal lower extremity exercise protocols or the development of molecular interventions that mimic the benefits induced by exercise may prove effective in reducing progression of small AAAs or limiting continued remodeling or expansion following endovascular exclusion.

Aerobic Exercise and Lipids and Lipoproteins in Patients With Cardiovascular Disease

PURPOSE

Use the meta-analytic approach to examine the effects of aerobic exercise on lipids and lipoproteins in adults with cardiovascular disease (CVD).

METHODS

Studies were retrieved via electronic databases, review of reference lists from retrieved articles, including reviews, and hand searching. Inclusion criteria were: (1) randomized controlled trials, (2) aerobic exercise >or=4 weeks as an intervention, (3) studies published in English language only between January 1, 1955 and January 1, 2005, (4) studies published in journals or as dissertations or master's theses, (5) human subjects >or=18 years, (6) all subjects diagnosed with some type of CVD, and (7) pre and post data available for total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and/or triglycerides (TG). Random-effects models were used for data analysis.

RESULTS

Of the more than 3,000 studies reviewed, a total of 10 representing 1,260 subjects (580 exercise, 680 control) were included in our analysis. There was a statistically significant increase of 9% in HDL-C (mean +/- SEM, 3.7 +/- 1.3 mg/dL; 95% CI, 1.2 to 6.1 mg/dL) and a statistically significant decrease of 11% in TG (-19.3 +/- 5.4 mg/dL; 95% CI, -30.1 to -8.5 mg/dL), but no statistically significant decreases in TC or LDL-C (TC, -8.8 +/- 6.8 mg/dL; 95% CI, -22.3 to 4.7 mg/dL; LDL-C, -7.7 +/- 6.0 mg/dL; 95% CI, -19.5 to 4.2 mg/dL).

CONCLUSIONS

The present findings suggest that chronic aerobic exercise increases HDL-C and decreases TG in adults, especially men, with CVD.

Effects of exercise training on mortality in patients with coronary heart disease

Endothelial dysfunction not only precedes the development of significant coronary artery stenosis, it has also been identified as a general phenomenon predicting future cardiovascular events in patients who are at risk. As regular physical activity as a part of a multifactorial intervention has been shown to affect symptoms beneficially, increase myocardial perfusion and--most importantly--reduce mortality in patients with coronary heart disease or myocardial infarction, this review will elucidate potential mechanisms responsible for the improvement in survival as a result of regular physical activity. The importance of exercise training-mediated regression of coronary stenosis, collateral formation, correction of endothelial dysfunction including the adaptation at the molecular level, as well as vasculogenesis will be discussed as possible underlying key players, and their potential contribution to the training-induced survival benefit in patients with coronary heart disease will be critically evaluated.

Long-term care after percutaneous coronary intervention: focus on the role of antiplatelet therapy

Arterial wall injury caused by percutaneous coronary intervention (PCI) triggers transient platelet activation and mural thrombosis; these effects are superimposed on the preexisting platelet hyperreactivity associated with underlying atherothrombosis. Platelet activation has been implicated in the major complications of PCI: acute and subacute thrombosis and restenosis. Antithrombotic and anticoagulant therapy minimizes thrombotic complications after PCI. Aspirin plus a thienopyridine (ticlopidine or clopidogrel) is more effective than aspirin plus heparin and extended warfarin therapy in preventing periprocedural ischemic events and subsequent stent thrombosis and results in less major and minor bleeding. Dual antiplatelet therapy with aspirin and clopidogrel (the preferred thienopyridine because of its superior hematologic safety) is recommended for at least 4 weeks to prevent subacute stent thrombosis with bare-metal stents and 3 to 6 months to prevent late-stent thrombosis with drug-eluting stents. Coronary atherothrombosis is a diffuse vascular disease, and reduction of the risk of future ischemic events requires strategies that extend beyond the focal treatment of stenotic lesions. Optimal long-term care after PCI requires aggressive systemic pharmacotherapy (antiplatelet agents, statins, beta-blockers, and angiotensin-converting enzyme Inhibitors) in conjunction with therapeutic lifestyle changes (smoking cessation, weight reduction, dietary measures, and exercise). In this context, dual antiplatelet therapy (aspirin plus clopidogrel) is recommended for at least 12 months after PCI for prophylaxis of future atherothrombotic events.

Cardiopulmonary Rehabilitation and Cancer Rehabilitation. 1. Cardiac Rehabilitation Review

Cardiac rehabilitation includes not only the rehabilitation of people with ischemic heart disease but also those with congestive heart failure, heart transplantation, congenital heart disease, and other conditions. New advances in medical treatment have arisen, and there are new approaches in treatment, including alternative medicine and complementary care. New surgical approaches that help restore cardiac function have also been introduced, and rehabilitation professionals must be aware of these advances and be able to incorporate this knowledge into the practice of rehabilitation medicine.

OVERALL ARTICLE OBJECTIVES

(a) To identify major categories of cardiac disease, (b) to elucidate appropriate interventions and support for patients with coronary artery disease, (c) to describe the new interventions available for the treatment of cardiac disease, and (d) to describe the appropriate role of cardiac rehabilitation for people with various forms of cardiac disease.

Physical activity for people with cardiovascular disease: recommendations of the National Heart Foundation of Australia

To provide physical activity recommendations for people with cardiovascular disease, an Expert Working Group of the National Heart Foundation of Australia in late 2004 reviewed the evidence since the US Surgeon General's Report: physical activity and health in 1996. The Expert Working Group recommends that: people with established clinically stable cardiovascular disease should aim, over time, to achieve 30 minutes or more of moderate intensity physical activity on most, if not all, days of the week; less intense and even shorter bouts of activity with more rest periods may suffice for those with advanced cardiovascular disease; and regular low-to-moderate level resistance activity, initially under the supervision of an exercise professional, is encouraged. Benefits from regular moderate physical activity for people with cardiovascular disease include augmented physiological functioning, lessening of cardiovascular symptoms, enhanced quality of life, improved coronary risk profile, superior muscle fitness and, for survivors of acute myocardial infarction, lower mortality. The greatest potential for benefit is in those people who were least active before beginning regular physical activity, and this benefit may be achieved even at relatively low levels of physical activity. Medical practitioners should routinely provide brief, appropriate advice on physical activity to people with well-compensated, clinically stable cardiovascular disease.

Early Exercise Training After Mitral Valve Repair

BACKGROUND

Surgical mitral valve (MV) repair is now the best technique to correct mitral regurgitation (MR). However, clinical studies have shown that without exercise training (ET), there is no significant postoperative exercise tolerance improvement. Moreover, healing duration of the MV wound is not well known; thus, the feasibility of an early ET program (ETP) may be discussed.

OBJECTIVES

To evaluate safety and feasibility of an early ETP after MV repair.

METHODS AND RESULTS

All patients hospitalized in 13 postoperative centers after MV repair from September 2002 to June 2003 were included in this prospective study. They underwent an ETP during 3 weeks on average. Transthoracic echocardiography and a cardiopulmonary exercise test were performed before and after the ETP.

PATIENTS

Two hundred fifty-one consecutive patients (male gender, 70%; mean age, 59 +/- 14 years [+/- SD]) were included 16 +/- 10 days after MV repair. There was no MR occurrence or worsening after the ETP. Left ventricular ejection fraction slightly increased (53 +/- 10% vs 55 +/- 9%, p = 0.004). Peak oxygen consumption and anaerobic threshold increased from 16.3 +/- 4.5 to 20.0 +/- 6.0 mL/kg/min (22% increase) and from 12.2 +/- 3.8 to 14.2 +/- 4.3 mL/kg/min (16% increase) respectively, (p < 0.0001).

CONCLUSION

ET after MV repair does not deteriorate the outcome of recent surgery and seems efficient.

Effects of short-term moderate exercise training on sexual function in male patients with chronic stable heart failure

BACKGROUND

Patients with chronic heart failure (CHF) have sexual dysfunction that impairs quality of life. Recent trials have demonstrated that exercise training (ET) improves quality of life (QOL) of CHF patients, but it is not established whether this benefit may be associated with an improvement in sexual dysfunction.

OBJECTIVE

To determine whether ET can improve sexual dysfunction in patients with CHF.

METHODS

We prospectively studied 59 male patients (57+/-9 years) with stable CHF in sinus rhythm and without prostatic disease. Patients were randomized into two groups. A group (T, n = 30) underwent supervised cycle ergometer ET at 60% of peak VO2, three times a week, 60 min each session, for 8 weeks. A group (NT, n = 29) was not exercised. Medications were not changed during the study. On study entry and at 8 weeks all patients underwent a symptom-limited cardiopulmonary exercise testing, brachial artery endothelium-dependent (ED) and endothelium-independent (EI) vasomotor responses, QOL and sexual activity profile assessment (SAP) by questionnaire.

RESULTS

At 8 weeks, no changes were observed in control patients. In trained patients, however, peak VO2 improved by 18% (P < 0.005) and was correlated with QOL (r = 0.80; P < 0.001). Flow-mediated dilation improved in trained patients (from 2.29+/-1.13% to 5.04+/-1.7%, P = 0.0001), while EI dilation (after 0.3 mg sublingual NTG) did not. In group T, all three domains (i.e. Domain 1=relationship with the partner; Domain 2 = quality of penile erection; Domain 3 = personal wellness) were significantly improved from baseline (total score patients: from 3.49+/-3.4 to 6.17+/-3.2, P < 0.001; partners: from 2.47+/-2.7 to 4.87+/-2.5, P < 0.001). Pre-post training change in SAP total score was correlated with changes in coronary risk profile (r = -0.49; P = 0.01), peak VO2 (r = 0.67; P < 0.001) and QOL (r = 0.73; P = 0.01). Multivariate analysis selected the improvement in ED-vasomotor response as the strongest independent predictor of SAP improvement (r = 0.63, P < 0.001).

CONCLUSIONS

In stable CHF, cycle ergometer ET significantly improves brachial artery endothelial dysfunction, suggesting a systemic effect of leg exercise. This benefit was correlated with improvements in sexual activity.

Acute coronary syndromes: cardiac rehabilitation programmes and quality of life

AIMS

This paper reports a study examining the quality of life of clients following hospital admission with acute coronary syndrome in Hong Kong and their use of cardiac rehabilitation.

BACKGROUND

Coronary heart disease is a major source of mortality and morbidity in Hong Kong. Western studies have suggested that participation in cardiac rehabilitation improves the quality of life of clients with coronary heart disease yet the use of cardiac rehabilitation has been reported to be low. Better understanding is needed of the psychosocial status of these clients in Hong Kong and their use of cardiac rehabilitation services.

METHODS

A prospective, pretest-post-test study was carried out, with data collected over a period of 6 months with convenience sample of 182 participants. Baseline data were obtained within one week after hospital admission for individuals experiencing ACS. The second phase of data collection commenced at 6 months after hospital discharge. Total period of data collection took over 12 months between 2002 and 2003. The Chinese version of the SF-36 was used to assess quality of life, and demographic data and the extent to which clients participated in the cardiac rehabilitation programme were assessed.

RESULTS

Only 25% of the participants attended at least one session of the cardiac rehabilitation programme. Significant improvement occurred in all clients' perceived quality of life 6 months following initial hospital admission. No significant group differences in perceived quality of life were found according to whether or not clients used the cardiac rehabilitation services.

CONCLUSION

Improvement in perceived health-related quality of life was evident over a 6-month period. Yet our findings suggested that participation in the cardiac rehabilitation programme did not have any apparent effects in subjects' perceived quality of life. Further studies using both generic and disease-specific health-related quality of life instruments, as well as the inclusion of control group, are recommended. Continual improvement in cardiac rehabilitation programmes, and consideration of alternative modes of delivery other than the traditional attendance at hospital outpatient services, are also recommended.

[Possible ways of managing cardiovascular prevention: polypharmacy, additional payment or application of evidence based medicine?]

The financial balance of the health care system has changed dramatically due to a longer life expectancy and improved treatment options in elderly patients. More than 80% of cardiovascular events are lifestyle related and potentially preventable. Lifestyle modification is therefore the causal approach to decrease cardiovascular events. Improvement of nutrition and activity habits and prevention of cigarette smoking should start in the kindergarten, school and later at the workplace. A co-operation between medical societies and government institutions is necessary to achieve a population wide modification of lifestyle habits to lower the incidence of cardiovascular events in the population. Individual risk stratification is the basis for pharmacological prevention of cardiovascular events. The concept of the polypill has to be tested in controlled randomised studies.

Physical Inactivity Increases Oxidative Stress, Endothelial Dysfunction, and Atherosclerosis

Objective— Sedentary lifestyle is associated with increased cardiovascular events. The underlying molecular mechanisms are incompletely understood. Reactive oxygen species (ROS) contribute to endothelial dysfunction and atherosclerosis. An important source of vascular ROS is the NADPH oxidase.

Methods and Results— C57BL6 mice were subjected to regular housing (physical inactivity) or voluntary training on running wheels (6 weeks). Inactivity increased vascular lipid peroxidation to 148±9% and upregulated superoxide release to 176±17% (L-012 chemiluminescence) and 188±29% (cytochrome C reduction assay), respectively. ROS production was predominantly increased in the endothelium and the media (dihydroethidium fluorescence). Activity of the NADPH oxidase was increased to 154±22% in the sedentary group. Rac1 GST-PAK pull-down assays showed an upregulation of rac1 activity to 161±14%. Expression levels of the subunits nox1, p47phox, and p67phox were increased. To address the significance of the antioxidative effects of running, experiments were repeated in apolipoprotein E–deficient mice treated with a high-cholesterol diet. Inactivity increased vascular superoxide production and impaired endothelium-dependent vasorelaxation. Atherosclerotic lesion formation was significantly accelerated in sedentary mice.

Conclusions— Inactivity increases vascular NADPH oxidase expression and activity and enhances vascular ROS production, which contributes to endothelial dysfunction and atherosclerosis during sedentary as opposed to physically active lifestyle.

Timeline for peak improvements during 52 weeks of outpatient cardiac rehabilitation

PURPOSE

Cardiac rehabilitation is an integral component of comprehensive care for patients with coronary heart disease. Although the typical programmatic delivery of outpatient cardiac rehabilitation services often involves 36 sessions over 12 weeks, that format is based more on historical practice than on outcome data. This study aimed to determine the point at which during 52 weeks of outpatient cardiac rehabilitation, patients achieved peak values for selected outcomes, and whether the number of supervised exercise sessions had any effect on these outcomes.

METHODS

In this study, 623 male patients with coronary heart disease admitted to an outpatient cardiac rehabilitation program were randomized to one of two 52-week program formats. One format (CR1) used one supervised exercise session per week over 52 weeks, and the second format (CR2) used weekly supervised sessions for 26 weeks followed by one supervised session per month for the remaining 26 weeks. Both formats used four unsupervised, documented exercise sessions per week. Selected clinical, physiologic, and psychological variables were measured at baseline, then at 4, 12, 26, 38, and 52 weeks. The program costs for both the CR1 and CR2 formats were calculated from known expenses.

RESULTS

Because there were no significant intercohort differences between CR1 and CR2 and no significant interaction (time x group), data from the two cohorts were pooled for statistical analysis. Peak oxygen intake (VO(2peak)) significantly increased by 4.4 mL/kg per minute at 38 weeks, and the greatest percentage of patients (30.1%) also achieved their highest VO(2peak) at this time. The largest gain in Medical Outcomes Survey Short Form 36 role physical scores was from baseline to 38 weeks (52.4 versus 85.2), and the highest percentage of patients (72%) with role physical scores in the excellent category occurred at 38 weeks. Clinical depression at baseline (Beck Depression Inventory score > 10) had no significant effect on the dropout rate or the gain in VO(2peak) with exercise training. Program costs for these alternative formats of service were similar to the cost for a standard program format of 36 sessions.

CONCLUSIONS

Patients achieved their highest functional capacity after 38 weeks of outpatient cardiac rehabilitation using a program format of only 29 to 38 supervised exercise sessions. The results of this study show that an outpatient cardiac rehabilitation program combining supervised with unsupervised exercise sessions and continuing for 38 weeks results in the greatest improvement in these selected outcomes.

A "poly-portfolio" for secondary prevention: a strategy to reduce subsequent events by up to 97% over five years

A "polypill" for the primary prevention of cardiovascular disease has been proposed. We estimated the projected benefit of a secondary prevention "poly-portfolio" strategy, including pharmacologic and lifestyle approaches for those with coronary heart disease (CHD) or stroke. Based on recent clinical trial results and clinical guidelines, combinations of a high-dose statin, low to standard doses of antihypertensive therapy, aspirin, omega-3 fish oil, cardiac rehabilitation, and diet were evaluated. Patients with CHD, post-myocardial infarction (MI), or stroke were projected to experience 84%, 91%, and 77% reductions, respectively, in CHD events from a pharmacologic approach. Numbers of those needed to treat (NNT) for 5 years were 9 to 11 to prevent 1 CHD event, and 21 to prevent 1 stroke. Post-MI patients were projected to experience a 93% reduction in the risk of CHD death (NNT 16) from a pharmacologic approach and a 97% reduction in the risk of CHD death (NNT 15) with the addition of lifestyle changes. A secondary prevention polyportfolio holds great promise for reducing the burden of cardiovascular disease in the highest risk patients.

Cardiac rehabilitation reduces the rate of major adverse cardiac events after percutaneous coronary intervention

BACKGROUND

Despite multiple publications on effects of rehabilitation in cardiac patients, rehabilitation is not fully known to be of value in post-percutaneous coronary intervention (PCI) patients.

AIMS

To investigate the influence of cardiac rehabilitation on the incidence of major adverse cardiac events (MACEs) in post-PCI patients.

METHODS

Retrospectively and nonrandomized 140 post-PCI patients (107 males, mean age 62 (7) years) participated in a 3-month rehabilitation program, starting 2 weeks post-PCI, while 83 post-PCI patients (54 males, mean age 68 (8) years) did not and were all followed up for 15 months. Data on cardiac medication prescription and incidence of MACE (including angina pectoris with or without reintervention, restenosis, myocardial infarction, revascularisation with re-PCI or CABG, and death) were collected. The relationship with cardiovascular risk factors including sex, smoking behaviour, obesity, diabetes mellitus, hypertension, familiar predisposition, and hypercholesterolemia was analysed.

RESULTS

The incidence of total MACE in the rehabilitation group is significantly lower than in the control group (24% vs. 42%, respectively; P<0.005). The incidence of documented restenosis, angina pectoris with resulting reintervention, all revascularisations, and death is significantly lower in the rehabilitation group, compared with the control group.

CONCLUSION

The incidence of MACE and restenosis is significantly lower when PCI patients are included in a cardiac rehabilitation program.

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials

PURPOSE

To review the effectiveness of exercise-based cardiac rehabilitation in patients with coronary heart disease.

METHODS

A systematic review and meta-analysis of randomized controlled trials was undertaken. Databases such as MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2003. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise training alone or in combination with psychological or educational interventions.

RESULTS

We included 48 trials with a total of 8940 patients. Compared with usual care, cardiac rehabilitation was associated with reduced all-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96); greater reductions in total cholesterol level (weighted mean difference, -0.37 mmol/L [-14.3 mg/dL]; 95% CI: -0.63 to -0.11 mmol/L [-24.3 to -4.2 mg/dL]), triglyceride level (weighted mean difference, -0.23 mmol/L [-20.4 mg/dL]; 95% CI: -0.39 to -0.07 mmol/L [-34.5 to -6.2 mg/dL]), and systolic blood pressure (weighted mean difference, -3.2 mm Hg; 95% CI: -5.4 to -0.9 mm Hg); and lower rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83). There were no significant differences in the rates of nonfatal myocardial infarction and revascularization, and changes in high- and low-density lipoprotein cholesterol levels and diastolic pressure. Health-related quality of life improved to similar levels with cardiac rehabilitation and usual care. The effect of cardiac rehabilitation on total mortality was independent of coronary heart disease diagnosis, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date.

CONCLUSION

This review confirms the benefits of exercise-based cardiac rehabilitation within the context of today's cardiovascular service provision.

Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients?

Physical exercise as an intervention in cancer patients has attracted increasing interest. This review examines the published randomised controlled trials on physical exercise, during and after cancer treatment, focusing primarily on recruitment of patients, patient compliance, content of the intervention programmes and outcome measures. We performed systematic searches of PubMed, PsychInfo, Cancerlit and the Cochrane Library using the MESH terms exercise, neoplasms, cancer, rehabilitation and intervention. We identified 12 randomised trials with sample sizes ranging from 21 to 155 patients. Only four studies reported the number of patients assessed for eligibility and the reasons for exclusion; 15% to 30% of patients assessed for eligibility were randomised into the intervention programmes. Drop-out rates in the trials ranged from 0% to 34%. Most studies included female breast cancer patients (nine studies, 62% of total number of patients). Interventions included aerobic exercise training (10 studies) and resistance exercise (two studies). The studies used a wide range of instruments to assess health-related quality of life (HRQOL) and the physical exercise capacity. The studies indicated promising effects on both physiological and psychological outcomes. Randomised clinical studies are few, small in scope, and mainly focus on breast cancer patients. Complete knowledge about the type of physical exercise most beneficial for patients at different stages of the disease progression is still lacking. Future work should identify fewer and more specific endpoints.

Physical training increases endothelial progenitor cells, inhibits neointima formation, and enhances angiogenesis

BACKGROUND

The molecular mechanisms by which physical training improves peripheral and coronary artery disease are poorly understood. Bone marrow-derived endothelial progenitor cells (EPCs) are thought to exert beneficial effects on atherosclerosis, angiogenesis, and vascular repair.

METHODS AND RESULTS

To study the effect of physical activity on the bone marrow, EPCs were quantified by fluorescence-activated cell sorter analysis in mice randomized to running wheels (5.1+/-0.8 km/d, n=12 to 16 per group) or no running wheel. Numbers of EPCs circulating in the peripheral blood of trained mice were enhanced to 267+/-19%, 289+/-22%, and 280+/-25% of control levels after 7, 14, and 28 days, respectively, accompanied by a similar increase of EPCs in the bone marrow and EPCs expanded from spleen-derived mononuclear cells. eNOS-/- mice and wild-type mice treated with N(G)-nitro-l-arginine methyl ester showed lower EPC numbers at baseline and a significantly attenuated increase of EPC in response to physical activity. Exercise NO dependently increased serum levels of vascular endothelial growth factor and reduced the rate of apoptosis in spleen-derived EPCs. Running inhibited neointima formation after carotid artery injury by 22+/-2%. Neoangiogenesis, as assessed in a subcutaneous disc model, was increased by 41+/-16% compared with controls. In patients with stable coronary artery disease (n=19), moderate exercise training for 28 days led to a significant increase in circulating EPCs and reduced EPC apoptosis.

CONCLUSIONS

Physical activity increases the production and circulating numbers of EPCs via a partially NO-dependent, antiapoptotic effect that could potentially underlie exercise-related beneficial effects on cardiovascular diseases.

Safety and implementation of exercise testing and training after coronary stenting in patients with acute myocardial infarction

The purpose of this study was to determine the incidence of subacute stent thrombosis related to exercise testing (ETT) or exercise training in cardiac rehabilitation (exercise cardiac rehabilitation (ECR)) and to clarify the appropriate timing of ETT and ECR in patients with acute myocardial infarction (AMI) treated with coronary stenting, because the safety and appropriate timing of ETT and ECR after coronary stenting for AMI have not been established. Forty-six institutes performing emergency percutaneous coronary intervention (PCI) for AMI were surveyed for the incidence of exercise-related subacute stent thrombosis and the timing of the start of ETT and ECR in patients with AMI in 1996-1998. Among the total 13,685 patients with AMI, 4,360 (31.9%) underwent coronary stenting. Of the 132 (3.0%) subacute stent thromboses that developed within 1 month after stenting, only one event was related to maximal ETT and occurred in a patient not receiving ticlopidine. No stent thrombosis occurred in association with submaximal ETT or ECR. In 7 institutes, maximal ETT was routinely performed at 14 days after stenting for AMI without any adverse events, and in 6 institutes, ECR was routinely started within 7 days without any adverse events. This survey found that only 21.0% of all AMI patients participated in ECR. In conclusion, subacute stent thrombosis related to ETT or ECR is extremely rare (0-0.02%) in patients with AMI, especially when they are receiving ticlopidine, and therefore ETT and ECR for stented patients with AMI need not be delayed (ie, approximately 7 days after stenting for submaximal ETT and ECR, and 14 days after stenting for maximal ETT). The rate of participation of post-AMI patients in ECR is low in Japan, even in major hospitals that are actively working in the field.