Long-Term Results of High-Intensity Exercise-Based Cardiac Rehabilitation in Revascularized Patients for Symptomatic Coronary Artery Disease

Exercise capacity is a strong predictor of survival rate in patients with and without coronary artery disease. Exercise-based cardiac rehabilitation (CR) with improvements in the peak oxygen uptake (VO_2peak) of 3.5 ml/kg/min or more has been shown to be beneficial in earlier observational studies. Long-term results on VO_2peak after CR are rare. The aim of this study was to assess if a 12-week outpatient CR program including high-intensity interval training would preserve or improve VO_2peak 15 months after CR entry. A total of 133 coronary patients attended the CR program (the Norwegian Ullevaal model). At baseline, at the end of the program, and after 15 months, the patients were evaluated with a cardiopulmonary exercise test, body mass index, blood pressure, self-reported exercise habits, and quality of life (the COOP-WONCA questionnaire). Long-term outcomes were available for 86 patients (65 %). The mean age was 57 ± 9 years and 87% were men. VO_2peak improved significantly from baseline (31.9 ± 7.6 ml/kg/min) to program end (35.9 ± 8.6 ml/kg/min) (p <0.001), and further progress was seen at the long-term follow-up (36.8 ± 9.2 ml/kg/min) (p <0.05). COOP-WONCA was significantly enhanced in all domains (p <0.001) with a meaningful clinical improvement in "physical fitness" from baseline to long-term follow-up. In conclusion, at follow-up, the patients still exercised (mean 2.5 ± 1 times per week) and had improved or preserved their VO_2peak and quality of life.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review previously published in 2009 and 2015.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 21 September 2016. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials, including parallel group, cross-over or quasi-randomised designs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on pre-defined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Quality of evidence was assessed using GRADE principles and a Summary of findings table was created.

MAIN RESULTS

We included six new studies (624 participants) for this update, which now includes a total of 23 trials that randomised a total of 2890 participants undergoing cardiac rehabilitation. Participants had an acute myocardial infarction, revascularisation or heart failure. A number of studies provided insufficient detail to enable assessment of potential risk of bias, in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported.No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in clinical primary outcomes up to 12 months of follow up: total mortality (relative risk (RR) = 1.19, 95% CI 0.65 to 2.16; participants = 1505; studies = 11/comparisons = 13; very low quality evidence), exercise capacity (standardised mean difference (SMD) = -0.13, 95% CI -0.28 to 0.02; participants = 2255; studies = 22/comparisons = 26; low quality evidence), or health-related quality of life up to 24 months (not estimable). Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate quality evidence). However, there was evidence of marginally higher levels of programme completion (RR 1.04, 95% CI 1.00 to 1.08; participants = 2615; studies = 22/comparisons = 26; low quality evidence) by home-based participants.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- and centre-based forms of cardiac rehabilitation seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction or revascularisation, or with heart failure. This finding supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme may reflect local availability and consider the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in the included short-term trials can be confirmed in the longer term and need to consider adequately powered non-inferiority or equivalence study designs.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with usual care on mortality, morbidity and HRQL in patients with CHD.To explore the potential study level predictors of the effectiveness of exercise-based CR in patients with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 6, 2014) from December 2009 to July 2014. We also searched MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Science Citation Index Expanded (December 2009 to July 2014).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with a no exercise control. The study population comprised men and women of all ages who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or who have angina pectoris, or coronary artery disease. We included RCTs that reported at least one of the following outcomes: mortality, MI, revascularisations, hospitalisations, health-related quality of life (HRQL), or costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion and exclusion criteria. One author extracted data from the included trials and assessed their risk of bias; a second review author checked data. We stratified meta-analysis by the duration of follow up of trials, i.e. short-term: 6 to 12 months, medium-term: 13 to 36 months, and long-term: > 3 years.

MAIN RESULTS

This review included 63 trials which randomised 14,486 people with CHD. This latest update identified 16 new trials (3872 participants). The population included predominantly post-MI and post-revascularisation patients and the mean age of patients within the trials ranged from 47.5 to 71.0 years. Women accounted for fewer than 15% of the patients recruited. Overall trial reporting was poor, although there was evidence of an improvement in quality of reporting in more recent trials.As we found no significant difference in the impact of exercise-based CR on clinical outcomes across follow-up, we focused on reporting findings pooled across all trials at their longest follow-up (median 12 months). Exercise-based CR reduced cardiovascular mortality compared with no exercise control (27 trials; risk ratio (RR) 0.74, 95% CI 0.64 to 0.86). There was no reduction in total mortality with CR (47 trials, RR 0.96, 95% CI 0.88 to 1.04). The overall risk of hospital admissions was reduced with CR (15 trials; RR 0.82, 95% CI 0.70 to 0.96) but there was no significant impact on the risk of MI (36 trials; RR 0.90, 95% CI 0.79 to 1.04), CABG (29 trials; RR 0.96, 95% CI 0.80 to 1.16) or PCI (18 trials; RR 0.85, 95% CI 0.70 to 1.04).There was little evidence of statistical heterogeneity across trials for all event outcomes, and there was evidence of small study bias for MI and hospitalisation, but no other outcome. Predictors of clinical outcomes were examined across the longest follow-up of studies using univariate meta-regression. Results show that benefits in outcomes were independent of participants' CHD case mix (proportion of patients with MI), type of CR (exercise only vs comprehensive rehabilitation) dose of exercise, length of follow-up, trial publication date, setting (centre vs home-based), study location (continent), sample size or risk of bias.Given the heterogeneity in outcome measures and reporting methods, meta-analysis was not undertaken for HRQL. In five out of 20 trials reporting HRQL using validated measures, there was evidence of significant improvement in most or all of the sub-scales with exercise-based CR compared to control at follow-up. Four trial-based economic evaluation studies indicated exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years.The quality of the evidence for outcomes reported in the review was rated using the GRADE method. The quality of the evidence varied widely by outcome and ranged from low to moderate.

AUTHORS' CONCLUSIONS

This updated Cochrane review supports the conclusions of the previous version of this review that, compared with no exercise control, exercise-based CR reduces the risk of cardiovascular mortality but not total mortality. We saw a significant reduction in the risk of hospitalisation with CR but not in the risk of MI or revascularisation. We identified further evidence supporting improved HRQL with exercise-based CR. More recent trials were more likely to be well reported and include older and female patients. However, the population studied in this review still consists predominantly of lower risk individuals following MI or revascularisation. Further well conducted RCTs are needed to assess the impact of exercise-based CR in higher risk CHD groups and also those presenting with stable angina. These trials should include validated HRQL outcome measures, explicitly report clinical event outcomes including mortality and hospital admissions, and assess costs and cost-effectiveness.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review originally published in 2009.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41), PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with heart failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home- and centre-based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed-effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.29 to 0.08, P = 0.29, random-effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI -0.24 to 0.11, P = 0.47, random-effects; low density lipoprotein cholesterol: MD = -0.06 mmol/L, 95% CI -0.27 to 0.15, P = 0.55, random-effects; systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI -3.37 to 3.75, P = 0.92, random-effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed-effect), or health-related quality of life (not poolable). Small outcome differences in favour of centre-based participants were seen in high density lipoprotein cholesterol (MD = -0.07 mmol/L, 95% CI -0.11 to -0.03, P = 0.001, fixed-effect), and triglycerides (MD = -0.18 mmol/L, 95% CI -0.34 to -0.02, P = 0.03, fixed-effect, diastolic blood pressure (MD = -1.86 mmHg; 95% CI -0.76 to -2.95, P = 0.0009, fixed-effect). In contrast, in home-based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed-effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation.

AUTHORS' CONCLUSIONS

This updated review supports the conclusions of the previous version of this review that home- and centre-based forms of cardiac rehabilitation seem to be equally effective for improving the clinical and health-related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences in healthcare costs between the two approaches, supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme should reflect the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in these short-term trials can be confirmed in the longer term. A number of studies failed to give sufficient detail to assess their risk of bias.

[Evaluation of the clinical, psychological and socio-environmental factors, affecting disability of elderly people undergoing surgical myocardial revascularization]

Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization are considered in the article. The authors demonstrate that for each level of the problem there are their own significant factors. Besides, the most essential correlations between investigated factors are marked out. The results obtained will enable to determine more correctly clinical-and-labor prognosis for patients with ischemic heart disease and develop their efficient rehabilitation programs. It is demonstrated that elderly patients have some features of vital activity restriction which are necessary to take into account while medical social expertise and rehabilitation program development.

[Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization]

Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization are considered. It is demonstrated that each level of the problem in consideration has its own significant factors. Besides, the most essential correlations between investigated factors are marked out. The results obtained would allow determining clinical-and-labor prognosis for patients with ischemic heart disease more correctly and develop the efficient programs aimed at their rehabilitation.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Traditionally centre-based cardiac rehabilitation (CR) programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation.

OBJECTIVES

To determine the effectiveness of home-based cardiac rehabilitation programmes compared with supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life and modifiable cardiac risk factors in patients with coronary heart disease.

SEARCH STRATEGY

We updated the search of a previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2007, Issue 4), MEDLINE, EMBASE and CINAHL from 2001 to January 2008. We checked reference lists and sought advice from experts. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes, in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Studies were selected independently by two reviewers, and data extracted by a single reviewer and checked by a second one. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Twelve studies (1,938 participants) met the inclusion criteria. The majority of studies recruited a lower risk patient following an acute myocardial infarction (MI) and revascularisation. There was no difference in outcomes of home- versus centre-based cardiac rehabilitation in mortality risk ratio (RR) was1.31 (95% confidence interval (C) 0.65 to 2.66), cardiac events, exercise capacity standardised mean difference (SMD) -0.11 (95% CI -0.35 to 0.13), as well as in modifiable risk factors (systolic blood pressure; diastolic blood pressure; total cholesterol; HDL-cholesterol; LDL-cholesterol) or proportion of smokers at follow up or health-related quality of life. There was no consistent difference in the healthcare costs of the two forms of cardiac rehabilitation.

AUTHORS' CONCLUSIONS

Home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of life outcomes in acute MI and revascularisation patients. This finding, together with an absence of evidence of difference in healthcare costs between the two approaches, would support the extension of home-based cardiac rehabilitation programmes such as the Heart Manual to give patients a choice in line with their preferences, which may have an impact on uptake of cardiac rehabilitation in the individual case.

[The practice of essential self-care after myocardial revascularization]

The aim is to investigate patient's behaviour after the myocardium revascularization surgery. This is an exploratory-descriptive study, carried out at a cardiology clinic of a government hospital, in Fortaleza, Ceará, Brazil, with 52 patients. The following self-care practices were identified: 98.07% patients regularly attended the doctor's appointment and took their medicines; more than 50% presented BMI > 25 Kg/m2, practiced physical exercises, did not smoke or drink, ate healthy foods, said they were usually calm. The conclusion was that patients that participated in this study maintained a satisfactory self-care level, supporting the importance of guidance process developed in group.

Comparing two methods of rehabilitation for risk factor modification after a cardiac event

Because fewer than half of cardiac patients in the United States enroll in cardiac rehabilitation (CR) programs, there is a critical need to test alternative strategies of delivering CR services. This study tested whether a home-based CR (home-CR) program was at least as effective as traditional-CR (trad-CR) in the modification of coronary heart disease risk factors from the beginning of CR (baseline) to 2 and 4 months later. A repeated measures non-inferiority quasi-experimental design was used to examine changes in risk factors. Participants selected which CR program, traditional versus home-based, in which to participate: 37 patients chose trad-CR and 24 patients chose home-CR. The following indicators of risk factors were measured: smoking, blood pressure, frequency of aerobic exercise, cholesterol, amount of dietary fat, frequency of anger, body mass index (BMI), and waist circumference. Home-CR was found to be as effective as trad-CR in modification of cardiac risk factors including BMI, waist circumference, blood pressure, frequency of aerobic exercise, total cholesterol, and a low fat diet. Home-CR was not as effective as trad-CR in reducing the frequency of anger. These findings provide support for an alternative method of delivering cardiac rehabilitation services.

Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life

This study examined the effect of the Ornish Program for Reversing Heart Disease and cardiac rehabilitation (CR) on psychosocial risk factors and quality of life in patients with confirmed coronary artery disease. Participants had previously undergone a revascularization procedure. The 84 patients self-selected to participate in the Ornish Program for Reversing Heart Disease (n = 507 28), CR (n = 28), or a control group (n = 28). Twelve psychosocial risk factors and quality of life variables were collected from all three groups at baseline, 3 months, and 6 months. At 3 and 6 months, Ornish group participants demonstrated significant improvements in all 12 outcome measures. The rehabilitation group improved in 7 of the 12, and the control group showed significant improvements in 6 of the variables. Intensive lifestyle modification programs significantly affect psychosocial risk factors and quality of life.

Is ischemic mitral regurgitation an indication for surgical repair or replacement?

Ischemic mitral regurgitation (IMR) is common in patients with coronary artery disease. While it is well-known that IMR exerts a graded effect upon survival-the greater the degree of IMR, the lower the survival-the indications for surgical treatment and the choice of surgical procedure (repair versus replacement) are controversial. In patients with mild to moderate IMR, the benefit of a mitral valve procedure has not been demonstrated, and surgical practice varies. In patients with severe IMR, mitral valve surgery is the norm, but guidelines for choosing between valve repair and valve replacement do not exist. Furthermore, the survival impact of mitral valve surgery in patients with severe IMR is uncertain. When patients with severe IMR undergo mitral valve surgery, undersized annuloplasty results in durable repair in 70% to 85% of cases. Newly-developed adjunctive repair techniques may further improve results. Currently, mitral valve repair is the procedure of choice in the majority of patients having surgery for severe IMR. However, the most severely ill patients and those with certain echocardiographic characteristics (e.g. severe bileaflet tethering) should be treated with bioprosthetic mitral valve replacement rather than repair.

Effective interventions for lifestyle change after myocardial infarction or coronary artery revascularization

PURPOSE

This science clinical paper reviews medical literature and examines interventions that are currently used to assist patients in achieving lifestyle change after myocardial infarction or coronary artery revascularization. Interventions that focused on both provider- and patient-implemented strategies were included. The effectiveness of these interventions to significantly reduce coronary heart disease risk factors was explored.

DATA SOURCES

Original longitudinal research studies or reviews indexed in PubMed between 1999 and 2004 were included. Eight studies were identified that met the inclusion criteria and presented successful interventions to increase participants' adherence to recommended lifestyle changes.

CONCLUSIONS

Current strategies for achieving recommended risk factor reductions include frequent follow-up, intensive diet changes, individualized and group exercise, coaching, group meetings, education on lifestyle modification and behavior change, and formal cardiac rehabilitation programs.

IMPLICATIONS FOR PRACTICE

Nurse Practitioners can help close the gap between evidence-based recommendations and clinical practice by implementing education programs in their practices and in the community. Recommendations include frequent follow-up visits, negotiating personalized treatment plans, and a general emphasis on therapeutic lifestyle change as an essential component of the treatment plan.

[A new test (VITTORIO Test) for functional fitness assessment in rehabilitation after cardiac surgery]

An adequate assessment of physical function (PF) in Cardiac Rehabilitation (CR) plays a central role in early detection of physical limitations. Traditionally exercise tolerance has been used as an indicator of overall PF. However exercise tolerance has been shown to poorly predict patients' ability to perform daily-life activities. The goal of the present study is to evaluate a new test, named VITTORIO TEST, for assessing various component of daily activities among patients in CR after cardiac surgery. VITTORIO test consists in 8 items that assess lower and upper extremity strength and flexibility, agility, dynamic balance, aerobic capacity. 500 patients (359 males; 141 females) admitted to CR programs following cardiac surgery (349 coronary artery bypass surgery; 151 valvular surgery) were enrolled in the study. They were evaluated with an initial test (T1) (10.7 +/- 6.3 days after cardiac surgery) and a final test (T2) after an in-hospital intensive training program (mean length 16.8 +/- 6.6 days) consisting in stretching, large muscle group and aerobic activity, resistance exercises. Statistical analysis showed a significant improvement of all items at the end of the rehabilitation program. Old patients (>70 years) and particularly females demonstrate exercise improvement comparable to that of younger subjects especially regards lower extremity strength and aerobic capacity. VITTORIO test is inexpensive, simple and easy to perform by the patient. Through the identification and the measurement of different aspects of physical disability, it allows a personalized rehabilitation exercise program. It could be used as an outcome measure of CR programs.

Results and cost of meeting the National Service Framework for Coronary Heart Disease requirement for 12 month follow-up after acute coronary events

BACKGROUND

The National Service Framework (NSF) for Coronary Heart Disease (CHD) set standards, targets and milestones. In the case of acute myocardial infarction (AMI) or coronary revascularization, Milestone 3 of Standard 12 requires a 12 month audit of exercise and smoking habit and of body mass index (BMI) for patients who have attended cardiac rehabilitation (CR). The targets are that 50 per cent of patients should be exercising regularly, not smoking and have a BMI of <30 kg/m(2). The purpose of this study was to find out whether the targets are realistic and to measure the cost of retrieving the data.

METHODS

A postal questionnaire was used to follow up all the patients who attended our CR programme over a 12 month period. The project was costed.

RESULTS

Four hundred and three CHD patients who had attended the programme between April 2001 and March 2002 were sent questionnaires 12 months after their index event. Their diagnoses were AMI in 147 (36.5 per cent), coronary artery surgery in 157 (39 per cent) and angioplasty in 99 (24.5 per cent). Completed questionnaires were received from 358 (89 per cent). Of the responders, 69 per cent were exercising regularly, 91.6 per cent were not smoking (73 per cent had been non-smokers before their index cardiac event) and 79 per cent had a BMI of <30 kg/m(2)(the figure at the start of rehabilitation had been 79 per cent). The cost of performing the audit was pounds sterling 1204.

CONCLUSION

This audit is inexpensive. The targets for smoking and BMI set by the NSF were achieved by a very large margin before either the index cardiac event or starting CR.

Long-term outcome after implantation of bare metal stents for the treatment of coronary artery disease: rationale for the clinical use of antiproliferative stent coatings

BACKGROUND

The widespread use of drug-eluting stents in patients with coronary artery disease (CAD) is hampered by unequal regulations for reimbursement. Identification of patients with maximal benefit from this technology may be achieved by assessing long-term clinical outcome after implantation of uncoated bare metal stents.

PATIENTS AND METHODS

A consecutive series of 1,000 patients with CAD treated with bare metal coronary stents of various designs from January 1995 to December 1995 was retrospectively followed over 4 years. The primary end points of the study were major adverse cardiac events.

RESULTS

The mean age of patients was 62 +/- 10.3 years, 77.5% were male, and 18% were diabetic. Clinical follow-up was obtained in 821 patients (82.1%) after 4.6 +/- 1.1 years. During this period of time, 31.8% were admitted for repeat PCI, 15.1% underwent CABG operation, 3.5% had myocardial infarctions, and 3.7% died. At 4 years, 46.3% of diabetic patients survived without event versus 57.6% of nondiabetic patients (P < 0.05). Patients with CAD I survived without event in 65.3% versus 54.0% of patients with CAD II and 48.5% of patients with CAD III (P < 0.02).

CONCLUSION

Implantation of uncoated stents provides the worst long-term clinical outcome in patients with diabetes and those with multivessel CAD. Both groups of patients appear to be primary candidates for the use of drug-eluting stents.

Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]

BACKGROUND

Cardiac rehabilitation following myocardial infarction reduces subsequent mortality, but uptake and adherence to rehabilitation programmes remains poor, particularly among women, the elderly and ethnic minority groups. Evidence of the effectiveness of home-based cardiac rehabilitation remains limited. This trial evaluates the effectiveness and cost-effectiveness of home-based compared to hospital-based cardiac rehabilitation.

METHODS/DESIGN

A pragmatic randomised controlled trial of home-based compared with hospital-based cardiac rehabilitation in four hospitals serving a multi-ethnic inner city population in the United Kingdom was designed. The home programme is nurse-facilitated, manual-based using the Heart Manual. The hospital programmes offer comprehensive cardiac rehabilitation in an out-patient setting.

PATIENTS

We will randomise 650 adult, English or Punjabi-speaking patients of low-medium risk following myocardial infarction, coronary angioplasty or coronary artery bypass graft who have been referred for cardiac rehabilitation.

MAIN OUTCOME MEASURES

Serum cholesterol, smoking cessation, blood pressure, Hospital Anxiety and Depression Score, distance walked on Shuttle walk-test measured at 6, 12 and 24 months. Adherence to the programmes will be estimated using patient self-reports of activity.In-depth interviews with non-attendees and non-adherers will ascertain patient views and the acceptability of the programmes and provide insights about non-attendance and aims to generate a theory of attendance at cardiac rehabilitation. The economic analysis will measure National Health Service costs using resource inputs. Patient costs will be established from the qualitative research, in particular how they affect adherence.

DISCUSSION

More data are needed on the role of home-based versus hospital-based cardiac rehabilitation for patients following myocardial infarction and revascularisation, which would be provided by the Birmingham Rehabilitation Uptake Maximisation Study (BRUM) study and has implications for the clinical management of these patients. A novel feature of this study is the inclusion of non-English Punjabi speakers.

Quality of life and self-efficacy: gender and diagnoses considerations for management during cardiac rehabilitation

PURPOSE

Outcome measurement research has extended beyond traditional clinical and physiologic parameters to include psychosocial aspects. Accordingly, the purpose of this study was to investigate quality-of-life (QOL) and self-efficacy disparities for gender and diagnoses during participation in cardiac rehabilitation.

METHODS

For this study, 472 patients (114 women and 358 men) were stratified by gender and then again by diagnosis to include surgical revascularization, myocardial infarction, and percutaneous coronary intervention. Measures obtained at baseline and at the end of the study assessed quality of life (QOL-o = total score), including emotional (QOL-e) and limitation (QOL-l) domains; self-efficacy (SE-o = total score), including ambulatory (SE-a) and muscular (SE-m) domains; and caloric expenditure.

RESULTS

Both self-efficacy and QOL were greater at the end of the study across genders (P <.05). The men had greater self-efficacy values for all domains (P <.05). There was a significant gender-time interaction for QOL-e (P <.05) among the women, and for QOL-o, QOL-l, and all self-efficacy domains (P <.05) among the surgical revascularization patients. Percutaneous coronary intervention patients had higher self-efficacy scores throughout. Caloric expenditure was a consistent positive predictor of self-efficacy and QOL-e (P <.05).

CONCLUSIONS

Quality of life and self-efficacy improve during cardiac rehabilitation across gender and diagnoses. Female and revascularized patients present with low QOL and self-efficacy scores initially, but improvements in scores similar to or greater than the men can be expected. Because the self-efficacy scores of percutaneous coronary intervention patients are higher and their physical limitations are less prohibitive, these patients can be progressed more aggressively. Improvements in self-efficacy scores parallel caloric expenditure increases.

[Role of echocardiography after cardiac surgery during rehabilitation]

In this review, specific aspects and implications of echocardiography in patients who had undergone recent cardiac surgery will be analysed. This imaging method, which is fully effective in clinical practice, actually possesses diagnostic characteristics, which during assessments of patients, are found to be noninvasive and easily repeatable. They are of great value amongst this particular group of patients for discovering any possible complications from the surgical procedures. Technical problems and methodology will be described regarding the specificity of the patient during the early days after cardiac surgery (for instance the difficulties of executing in certain post-operative conditions such as pain, injuries or worsening of acoustic window). Informative contribution and specific assessment in patients following myocardial revascularisation surgery, reconstructive or valvular replacement surgery, and left ventricle or thoracic aorta surgery will be analysed. The role of echocardiography in the identification and monitoring of the main complications related to the operation will also be described. The increasing diagnostic potential and assessment of the investigation is thanks to its systematic use which lasts for the intensive phase of cardiac rehabilitation, but assumes specific and adequate operator competence for optimum use in clinical examinations.

Effect of cardiac rehabilitation on functional outcomes after coronary revascularization

BACKGROUND

Current guidelines recommending cardiac rehabilitation (CR) after coronary revascularization are largely based on early studies that evaluated only a subset of the population and failed to assess the impact of CR on a patient's perception of their functional status. The main objective of this study was to evaluate the impact of CR in a diverse contemporary population on patient functional outcomes.

METHODS

We studied the effect of CR on 6-month SF-36 Physical Functioning (PF) in 700 patients (mean age 67 +/- 11 years, 37% women) who underwent coronary bypass grafting or percutaneous intervention from August 1998 to July 2000.

RESULTS

Overall CR participation was 24%. At baseline, CR participants had higher PF (mean 62.5 vs 52.5, P <.001). After adjusting for baseline clinical variables and PF score, CR was associated with significant improvement in 6-month PF (+5.0, 95% CI 1.0-9.0). This improvement was observed in all patient subgroups, but tended to be greater in magnitude in men versus women, patients aged <70 years versus > or =70 years, and patients with coronary bypass grafting versus patients with percutaneous intervention. CR participants also tended to be more likely to engage in regular exercise (63% vs 55%, P =.06) and modify their diet (82% vs 73%, P =.07). Rates of rehospitalization and repeat revascularization were similar among CR participants and nonparticipants.

CONCLUSIONS

CR after coronary revascularization is associated with improved functional outcomes and adoption of secondary preventive measures. Innovative strategies to facilitate CR enrollment and tailoring programs to better address the needs of all patient subgroups would extend these benefits to more eligible patients.

Women in cardiac rehabilitation

Women have been underrepresented in both cardiac rehabilitation (CR) clinical care and research studies. This review summarizes the available data on women in CR, including referral and enrollment patterns, baseline characteristics, and sex-specific outcomes reported within each core component of care. Women in CR tend to be older than their male counterparts and to have a greater burden of comorbidities and coronary risk factors and lower functional status. Women and men seem to benefit equally from CR, with improvements in clinical, psychosocial, and behavioral outcomes, but sex-specific data are lacking for several of the core components of care. Future research needs to test single and multiple behavioral interventions in randomized controlled trials, paying particular attention to their sex specificity, feasibility, and cost-effectiveness within CR and secondary prevention programs.

Assessing depression in the cardiac patient. When is the appropriate time to assess depression in the patient undergoing coronary revascularization?

Depression is a well-established risk factor for cardiovascular disease-related morbidity and mortality. It is common to screen for depression in patients undergoing coronary revascularization prior to revascularization; however, the validity of this assessment is unclear as some patients may experience transient, reactive depression rather than persistent depression. The authors evaluated whether an initial or 1-month postprocedure screen was optimal for identifying consistently depressed patients. Depression at 1-month postprocedure was a stronger predictor of depression at months 2 to 6 than baseline depression. After adjusting potential confounding variables, there was a much stronger relationship between 1-month and 6-month depression status (OR = 28.7 if depressed at 1 month, p < .001) than between baseline and 6-month depression status (OR = 6.5 if depressed at baseline, p < .001). Screening for depression at the time of revascularization is not as predictive of depression at 6 months as it is 1 month postprocedure.

[Return to occupational and sexual activity after myocardial revascularization surgery]

A prospective and longitudinal design was used to follow up the return to occupational and sexual activity among 17 males after coronary bypass surgery. The subjects' ages ranged from 35 to 73 years. Data collection was performed by using open interviews which were recorded in field notes during hospitalization after heart surgery and during 6 months following hospital discharge. Of the 14 patients who reported work and sexual activity before surgery, 8 were working again (p = 0.016), and 10 had returned to sexual activity (p = 0.0625). There was change in the subjects' attitudes leading to not returning to work and tendency to not resuming sexual activity in this population.

Modeling women's quality of life after cardiac events

Quality of life (QOL) is presented as a global, unidimensional, and subjective assessment of one's life. This study examined the impact of perceived health status, hope, and optimism on QOL in 93 women after suffering a cardiac event. Construct validity was examined by estimating a model where QOL was measured with four indicators, and perceived health was measured with the SF-36 Health Survey. Hope was measured with the Herth Hope Index and dispositional optimism was measured with the Life Orientation Test. The unidimensionality of QOL and its response to health status, hope, and optimism were tested. Fit indices suggested that the theoretical relations posited were compatible with the data, (chi 2(42) = 44.125, p = .382, RMSEA = .0001, GFI = .942). The model explained 66% of the variance in QOL. Modeling suggested the presence of a complex latent concept composed of hope and optimism that influenced QOL.

Gender differences in referral to cardiac rehabilitation programs after revascularization

BACKGROUND

This study examines the influence of gender on the healthcare provider's secondary prevention instruction and cardiac rehabilitation (CR) referral after coronary revascularization procedures such as balloon angioplasty/coronary stenting and coronary bypass surgery (CABG). Cardiac rehabilitation decreases mortality and morbidity, yet only a small percentage of women and men are referred to these programs. The patient population of our university-affiliated CR program consisted of 88% men and 12% women.

METHODS

In a matched case observational study, 80 patients (40 men, 40 women) who had undergone coronary revascularization procedures between 1997 and 1998 completed a questionnaire on secondary prevention instruction and written referral to CR programs. Patients were matched for age and coronary revascularization procedure.

RESULTS

Women were less likely to be instructed on secondary prevention strategies and CR or referred to CR as compared to men despite being matched for age and undergoing the same procedure. The data demonstrate a gender difference in hospital teaching and referral information for CR after revascularization (P < 0.001). Being a woman was associated with a decreased likelihood of receiving a physician referral to CR after revascularization (P < 0.001).

CONCLUSION

The instruction of patients concerning secondary prevention and CR postrevascularization procedures is poor. Within that group, women were far less likely to have CR discussed or referrals made by healthcare professionals. This study demonstrates the need for education initiatives of all healthcare providers on the comprehensive nature and benefits of CR in the secondary prevention of cardiovascular disease, with a particular emphasis on women.

Impact of cardiopulmonary resuscitation training on perceived control in spouses of recovering cardiac patients

The objectives of this study were to determine whether there are differences in emotional distress among spouses of recovering cardiac patients based on level of perceived control, and to determine whether perceived control can be enhanced by cardiopulmonary resuscitation (CPR) training. A total of 219 spouses of cardiac patients recovering from an acute cardiac event were enrolled and 196 completed the study. Spouses were assigned to either a no-treatment control group or one of two CPR training groups. Perceived control and emotional adjustment were measured at baseline and again 1 month after subjects received CPR training. Spouses with high perceived control were less anxious, less depressed, and less hostile at baseline. Perceived control increased significantly in spouses after both CPR training groups, but was unchanged in the control group. After a partner's cardiac event, perceived control is important for psychological recovery in spouses and can be increased by CPR training.

[Manual therapy in the rehabilitation of patients with ischemic heart disease in the early period following myocardial revascularization]

Therapeutic complexes eliminating anginal and nonanginal pain syndromes including physiotherapy and manual therapy have been developed and tried in 57 patients with coronary heart disease early after surgical treatment. The addition of manual therapy in the rehabilitation complex shortens duration of rehabilitation, corrects post-operative angina and reflex pain syndrome in the chest and shoulders.

[Outcome of a four-week ambulatory cardiac rehabilitation (phase II) on cardiovascular risk factors, physical fitness and occupational reintegration in patients after myocardial infarct, dilatation treatment and heart operation]

From October 1994 to July 1996, 128 patients (30 women, 98 men) participated in an outpatient cardiac rehabilitation program (phase II). Our objectives were to demonstrate risk-factor modification and increased workload capacity resulting directly from the rehabilitation in terms of primary results and long-term effects 6 and 12 months (n = 118, Figure 1) respectively 1.5 and 2 years (n = 87) after termination of the program (Tables 9 to 12). We observed how many of the patients were able to be occupationally reintegrated after completion of phase-II rehabilitation. Workload capacity significantly increased from 1.2 W/kg upon entry to 1.5 W/kg (p < or = 0.05) upon completion of 4 weeks cardiac rehabilitation. Workload capacity remained consistently high at 6 months and 1 year (1.5 W/kg) and at 1.5 and 2 years (1.7 W/kg). Total cholesterol decreased significantly from 247 to 201 mg/dl (p < or = 0.05) during the 4-week program. Significant cholesterol (p < or = 0.01) reductions persisted at 6 months (216 mg/dl) and 1 year (215 mg/dl). After 1.5 and 2 years, the total cholesterol was less than 14% and 17% below the mean of cholesterol at the beginning of the program. Similarly, LDL cholesterol was 185 mg/dl before entering the program, 146 mg/dl after 4 weeks, 151 mg/dl after 6 months and 149 mg/dl after 1 year. Triglyceride levels showed a significant reduction (p < or = 0.01) with levels 189 mg/dl before entering the program, 148 mg/dl after 4 weeks, 151 mg/dl after 6 months and 154 mg/dl after 1 year. LDL cholesterol and triglyceride levels did not significantly increase after 1.5 and 2 years. The HDL cholesterol increased slightly as a long-term effect (from 51 mg/dl before entering the program to 55, 56 and 54 mg/dl after 1, 1.5 and 2 years, respectively). Seventy-three percent of the patients questioned (n = 73) found the program very good, 27% said it was good and no patient was dissatisfied. Fifty-one (81%) of the 63 patients who were actively employed before becoming ill and later entering our program were immediately able to be reintegrated into their previous occupation. In several cases reintegration took 7 weeks. Seven (11%) patients applied for pension, 5 (8%) patients remained unemployed on sick-leave.

[Ambulatory/partial inpatient phase II rehabilitation of heart patients in a Rhine-Main district rehabilitation clinic]

According to the guidelines and standards for a comprehensive phase II rehabilitation a new outpatient/part-time outpatient program was developed and started at an existing rehabilitation center in January 1997. All patients of the new program were included in a follow-up study and compared with patients of the same center, who met the inclusion and exclusion criteria for the outpatient mode, but wanted to perform their rehabilitation in the full-time residential mode. Both groups were examined before, at the end and 6 months after the program. Until December 1998 118 patients after an acute cardiac event such as myocardial infarction, PTCA or heart surgery were rehabilitated in the outpatient/part-time outpatient mode. The short- and medium-term results concerning somatic outcomes, e.g. the risk factor profile or the improvement of the maximum work capacity, were equal in both groups. Comparing the direct costs for a 4-week rehabilitation, the part-time outpatient program was 26%, the outpatient program even 52% cheaper than the standard full-time residential program. The new program is as effective as the residential rehabilitation, but it is cheaper. Because of the in- and exclusion criteria it is suitable for only a subgroup of cardiac patients, because of the demands and standards the new program it can be offered only in special rehabilitation centers.

[Clinical follow-up 6 months after ambulatory/partial inpatient after-care rehabilitation. Further results of the Cologne model of ambulatory cardiac phase II rehabilitation]

Three hundred and thirty patients with coronary artery disease (CAD) (288 men, 42 women, age of 55.5 +/- 10.0 years) participated in a 4-week ambulatory cardiac rehabilitation program (ACR) (Table 1). The cardiovascular indication for ACR was in 229 cases a myocardial infarction. In 101 patients a CAD with invasive revascularization but without a history of MI was present. In 92 patients with myocardial infarction additionally an invasive revascularization was performed. Eighty-three patients were included after a CABG-procedure (Tables 2 to 5). Six months after the ACR 290 (87.9%) patients presented for clinical reevaluation. In 235 (81.0%) of the 290 examined patients the cardiovascular diagnosis was unaltered. In the first 6 months after ACR in 76 (26.2%) patients a coronarography was performed, in 44 patients a restenosis was diagnosed. In 36 patients an additional invasive procedure (in 28 patients a PTCA, in 5 patients with additional stent-implantation, in 1 case with rotablation, in 8 patients CABG) was performed. In 1 patients a pace-maker was implanted. Since the ACR 1 patient experienced a myocardial infarction and 2 a recurrent myocardial infarction. In 1 patient myocardial fibrillation occurred. Totally, 70 patients (24.1%) required stationary-hospital treatment during the first 6 months after ACR (Table 6). In 11 cases an acute admission to hospital treatment because of cardiovascular reasons was documented. The majority of the hospital admission was elective, because of diagnostic or therapeutic procedures. In 6 patients a CABG-surgery was performed. In approximately 80% of the patients the cardiovascular status was stable during the first 6 months after ACR. Though 24.1% of the patients required stationary hospital treatment, the majority of the admissions was elective of interest, there was a high rate of hospital admissions in the PTCA-group in combination with recoronarographies and revascularization because of early reocclusion.

Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life

BACKGROUND

The authors examined the importance of the frequency of aerobic exercise training in multidisciplinary rehabilitation in improving health-related quality of life in the short run in patients with documented coronary artery disease.

METHODS

Patients (114 males and 16 females; age range, 32-70 years) were randomized into either a high-frequency or a low-frequency exercise training program (10 versus 2 sessions per week, respectively) as part of a 6-week multidisciplinary cardiac rehabilitation program. The General Health Questionnaire and the RAND-36 were used to assess changes in psychological distress and subjective health status.

RESULTS

After 6 weeks, high-frequency patients reported significantly more positive, change in "psychological distress" (P < 0.05), "mental health" (P = 0.05), and "health change" (P < 0.01), than low-frequency patients. Apart from changes in mean scores, individual effect sizes indicated that a significantly greater percentage of high-frequency patients experienced substantial improvements in "psychological distress" (P < 0.01), "physical functioning" (P < 0.05), and "health change" (P < 0.05), compared with low-frequency patients. In addition, deterioration of quality of life was observed in a considerable number of high-frequency patients (ranging from 1.7% to 25.8% on the various measures).

CONCLUSIONS

The frequency of aerobic exercise has a positive, independent effect on psychological outcomes after cardiac rehabilitation. However, this benefit after high-frequency rehabilitation appears to be limited to a subgroup of patients. Further investigation is required to identify these patients. Results provide input into recent controversies regarding the role of exercise training in cardiac rehabilitation.

High-intensity strength training of patients enrolled in an outpatient cardiac rehabilitation program

PURPOSE

This randomized controlled study assessed whether adding a program of high-intensity strength training (80% of maximum) to an outpatient cardiac rehabilitation program would be a safe and effective means of improving muscle strength and body composition.

METHODS

Thirty-eight cardiac patient volunteers (29 men and 9 women) were randomized to either high-intensity strength training or flexibility training added concurrently to a 12-week outpatient cardiac rehabilitation aerobic exercise program. Muscle strength, local muscle endurance, joint flexibility, maximum treadmill tolerance time, and body composition were measured before and after completion of the training.

RESULTS

The strength-trained patients (n = 18) had greater increases in mean strength (90 +/- 19% versus 9 +/- 4%, P < 0.0001) and local muscle endurance (20 versus 6 times, P < 0.0001), and decreases in mean perceived exertion for lifting the initial one repetition maximum load (11 +/- 1 versus 15 +/- 1, P < 0.0001) when compared with flexibility-trained patients (n = 16). The strength group lost more body fat (2.8 +/- 2.0 versus 1.3 +/- 2.0 kg, P < 0.01), tended to gain more lean tissue (1.5 +/- 2.3 versus 0.5 +/- 1.2 kg, P < 0.10), and had greater improvements in treadmill time (2.3 +/- 1.3 versus 1.2 +/- 1.0 minute, P < 0.02) than did the flexibility group. Improvements in joint flexibility were similar for each group. None of the subjects had evidence of cardiac ischemia or arrhythmia during the training sessions.

CONCLUSIONS

Medically supervised high-intensity strength training is well tolerated when added to the aerobic training of cardiac rehabilitation programs and allows patients to aggressively gain the strength and endurance they will need to complete daily living tasks at lower perceived efforts. Strength training also reduces cardiac risk factors by improving body composition and maximum treadmill exercise time.

The effects of body composition changes to observed improvements in cardiopulmonary parameters after exercise training with cardiac rehabilitation

STUDY OBJECTIVE

To discriminate the effects of body fat reduction on improvements in peak aerobic capacity made following exercise training during cardiac rehabilitation.

DESIGN

Observational, prospective study.

SETTING

Outpatient cardiovascular health center at regional academic center. PATIENT INTERVENTIONS: Peak oxygen uptake (pkVO2), percent body fat, lean body mass (LBM), and other anthropometric measures were assessed before and after a 3-month program of cardiac rehabilitation and exercise training in 500 consecutive cardiac patients following a major coronary event. Baseline pkVO2 was corrected for LBM (pk/VO2 lean) and compared with posttraining values.

RESULTS

Following exercise training, percent body fat decreased 5% from 26.2+/-8.0 to 24.8+/-7.5 (p<0.0001), and LBM increased 1% from 61.3+/-12.5 to 61.7+/-11.8 kg (p=0.02). pk/VO2 increased 16% from 16.0+/-4.1 to 18.5+/-4.8 mL/kg/min (p<0.0001), and pkVO2 lean increased 13% from 21.7+/-5.3 to 24.6+/-6.0 mL/kg/min (p<0.0001). Isolating the effects of reduction in body fat, we discern that these changes contributed to 0.3 of the 2.5 mL/kg/min increase in pkVO2 or 12% of the increase in pkVO2 observed.

CONCLUSIONS

Changes in body composition, as a consequence of dietary and exercise modification, contribute to 12% of the "observed" improvement noted in weight-adjusted peak aerobic capacity following cardiac rehabilitation and exercise training. Changes in pkVO2 lean should be used by investigators to assess the singular effects of exercise conditioning alone.

[Transmyocardial laser revascularization and rehabilitation]

Transmyocardial laser revascularization (TMLR) is a new technique for patients with CAD or heart attack to revascularize ischemic areas of the myocardium in which the localisation or the condition of the vessels does not allow bypass grafting. This study shows the results in observation of patients before and during the first 3 months after TMLR. Of 110 patients operated on from 1994 to 1996, 86 were evaluated for well being (quality of life), using NYHA- and CCS-classification, stress test and nitril-scintigraphy at rest and under stress conditions. 51 patients, of whom 11 were females, underwent TMLR combined with coronary artery bypass graft (CABG). 35 male patients were treated singularly with TMLR. The average age in both groups was 59 years (+/- 23). All patients were subject to phase I rehabilitation in specialised institutions after being mobilised in the operating hospital. The evaluations took place on the day of admission to the hospital prior to surgery, within 10 days after surgery and 3 months following. The average stay in the rehabilitation-institution was between 4 and 6 weeks. Our findings demonstrate that both groups profited from the procedures, while the TMLR/CABG group showed a faster recovery and a better outcome. In comparison to 57% of the TMLR group, 85% of the patients in the TMLR/CABG group reported an improvement ranging from good to significant in quality of life assessments. The TMLR/CABG rated from an average of initially 3.4 (+/- 0.6) to 2.1 (+/- 0.8) after 3 months at NYHA- and 3.3 (+/- 0.7) to 1.7 (+/- 0.8) at CCS-classification. The TMLR group rated from 3.6 (+/- 0.5) to 2.4 (+/- 0.8) in NHYA- and from 3.4 (+/- 0.5) to 1.9 (+/- 0.7) on the CSS-scales. A remarkable improvement was noted in the stress test with an increase in power and endurance from 21 to 89 watts for the combined group and 8 to 81 watts for the TMLR treated patients, who generally recovered more slowly. The perfusion scan showed the same tendencies as previously reported but in some cases the results were not congruent with other findings. Overall, our findings indicate that there is a benefit for terminally symptomatic CAD patients after TMLR, but an observation period of 3 months does not allow for final conclusions on this matter. Rehabilitation seems to be of value for TMLR-patients since they have shown a markedly better performance following 3-month treatment, but further data from clinical randomised trials are needed to determine the influence of TMLR with short- and long-term rehabilitation on the prognosis of the disease.

[Rehabilitation of aged patients with bicycle ergometer after coronary surgery]

This study was undertaken to assess the contraindications to rehabilitation by exercise testing on a bicycle ergometer and the tolerance of this procedure in elderly patients recovering from coronary surgery. One hundred and eighty-four patients aged over 65 years were included (Group I). The rehabilitation program consisted of exercise testing on admission period. The results were compared with those of 146 patients aged 65 or less (Group II). Twenty-six per cent of the elderly patients had a contraindications to this type of rehabilitation compared with only 4.8% in Group II. The main contraindications were extracardiac (21.7%), including infectious causes (4.3%), neuropsychiatric (3.3%), respiratory (2.7%) and rheumatological conditions (2.2%). Cardiac causes represented only 4.3% of the contraindications. In the patients undergoing the training program, the maximum power and the duration of exercise testing increased respectively from 81 +/- 17 to 97 +/- 21 watts (+21% ; p < 10(-3)) and 7 +/- 1.7 to 9 +/- 2 minutes (+28.6%, p < 10(-3)). The change in these parameters was comparable in the other group: 94.5+/- to 118 +/- 26 watts (+24.8% ; p < 10(-3)) and 8.5 +/- 1.9 to 10.9 +/- 2.4 minutes (+28.2% ; p < 10(-3)). On the other hand, the rate-pressure product decreased slightly in the elderly patients (-5.5% ; p = 0.07, compared with -13% in Group II, p = 0.001). Complications were rare: 1.6% of temporary interruption of a session (versus 0.6%). No serious complications were observed. The authors conclude that, after coronary surgery, the majority of elderly coronary patients can participate in physical training programs on bicycle ergometers without major complications. In the absence of contraindications, patients, and even elderly patients, should be encouraged to enroll for these programs after coronary bypass surgery.

[Early physical conditioning of patients surgically treated for myocardial revascularization. Influence on the functional capacity]

PURPOSE

To evaluate the early physical conditioning (PC) effect [initiated 15 days after the myocardial revascularization surgery (MRS)] in the functional capacity.

METHODS

Twenty-two male patients (mean-age of 52y-o), divided in two groups (A and B, 11 patients each), were studied. Group A started PC 3 months after MRS (phase III), with a training intensity of about 70% of the maximum heart rate reserve, during three months, three sessions per week with one hour duration. Group B started PC 15 days after the MRS (fase II), with a training intensity up to five metabolic unities, three times a week, 1 hour and 15 duration. The post-MRS period of three months was designated as the time I (beginning of fase III) and six months as time 2. Stress test, Kraus-Weber flexibility test, coxo-femural flexibility test (flexion, elevation and abduction) and scapule-umeral flexibility test (flexion, extension and abduction) were applied.

RESULTS

The maximum oxygen uptake and the total work increased significantly from time 1 to time 2 in both groups, but there was no significant difference between the two groups, either in time 1 or 2. Flexibility in the Kraus-Weber test and in the scapule-umeral flexibility test when in flexion, were significantly greater in group B than A, in both times (1 and 2). Other flexibility variables studied show no significant difference, neither between the studied groups nor in the times 1 and 2 of evaluation.

CONCLUSION

Early PC after MRS increased the value of two variables that measure flexibility. However, it has not increased other flexibilities variables and the aerobic capacity.

[The use of infrared laser radiation in the rehabilitation of IHD patients after the surgical revascularization of the myocardium]

Application of epicutaneous infrared laser radiation early in the course of postoperative aftercare of patients with coronary heart disease who have undergone myocardial revascularization contributes to improved functioning of the cardiorespiratory system. The laser therapy is indicated in the absence of serious intra- and postoperative myocardial infarctions, postoperative arrhythmia and mediastinitis.

[Evaluation of physical rehabilitation in myocardial revascularization using echocardiography]

The authors investigated 155 patients, mean age 50.6 years, after revascularization of the myocardium. The group was divided at random into a group with a high intensity of physical rehabilitation (A) and a medium and low rehabilitation group (B). The rehabilitation programme comprised physical exercise at least three times per week for at least 30 mins. with a dynamic load up to 80% of the maximum heart rate in group A and up to 40% in group B. The mean initial haemodynamic indicators in both groups were equal (LVEDP 17.5 mm Hg and 16.5 resp. and EF 52.3% and 50.5% resp. in group A and B). Six months after revascularization the mean values of work tolerance increased in group A more than in group B (58.6 kJ, as compared with 44.2 kJ) and this difference is even greater after three years (70.4 kJ as compared with 51.5 kJ). The mean values of the ejection fraction (EF) at rest do not differ in the two groups after 6 months nor after 3 years (51.3% in group A, as compared with 54.6% in group B after 6 months, and 55.2% vs. 53.7% resp. after three years). The EF after a dynamic load after 6 months and 3 years does not differ in the two groups either (57.2% vs. 56.4% after 6 months and 55.1% vs. 54.5% after three years). Similar results were also obtained on evaluation of the mobility index of the walls at rest and after a dynamic load.(ABSTRACT TRUNCATED AT 250 WORDS)

[Return to work after myocardial revascularization]

Six hundred and seventy-two patients classified in four strata with one hundred sixty-eight in each were evaluated during the fourth month after myocardial revascularization, with coronary artery bypass graft and/or internal mammary artery and coronary angioplasty, in order to verify the return or not to work as well as the conditions under which this was done. The four strata constituted by occupational profile were the following: I--entrepreneurs and managers; II--professionals with university degree; III--technicians; IV--unskilled and semi-skilled professionals. The aim of this research project was to discover how variables like demographics, education, procedure and support after procedure, were related to the return to work. Return to work did not occur in 20.8% of all cases. The non-return contingent in each of the four strata was the following: I = 11.9%; II = 15.5%; III = 26.2% and IV = 29.8%. Among those submitted to angioplasty the proportion of non-return was lower than that of those submitted to surgery.

Issues in contemporary cardiac rehabilitation: a historical perspective

Cardiac rehabilitation consists of exercise, psychosocial support and education and is prescribed most often for patients with coronary heart disease. Its purpose is to facilitate readaptation to normal life through the achievement of maximal functional capability and to reduce heart disease risk factors. It began historically with progressive ambulation after myocardial infarction and by 1980 became a standardized inpatient therapy performed according to a stepped procedure. Predischarge exercise testing was added and has become a meaningful contribution to the concept of risk stratification after an acute coronary event. Rehabilitation has subsequently become part of the outpatient environment and is delivered by multiple models. Meta-analyses have shown that rehabilitation reduces overall and cardiovascular deaths by about 20% and sudden death by about 37% during the year after an acute myocardial infarction. The significance of this, however, must now be modulated by the dynamic role of aggressive coronary intervention. Selection for such intervention has become an important adjunctive aspect of rehabilitation. Newer findings suggest that those stratified at low risk will benefit most by the modification of coronary risk factors, and that patients previously thought to be poor candidates for rehabilitation (such as those with significant left ventricular dysfunction and low work capacity) may experience substantial relative functional benefit. Beyond risk stratification, important contemporary issues include surveillance of patients after angioplasty, the effectiveness of rehabilitation in the attenuation or reversal of both native and vein graft atherosclerosis and consideration of such currently emphasized end points as quality of life and economic evaluation.

Supervised versus unsupervised exercise training following myocardial infarction and myocardial revascularisation procedures

Exercise training is an important component of rehabilitative care for patients following myocardial infarction or myocardial revascularisation procedures. Participation of the patient in supervised exercise training, however, is not always practical, and home exercise training may be a reasonable alternative for low-risk patients. The relatively routine predischarge exercise test, performed for risk stratification, can identify low-risk patients and guide their exercise prescription during the early weeks at home. Advantages of home exercise training include increased availability and convenience and lower cost. Comparable improvements in functional capacity have been documented to result from home exercise and supervised group programmes. Drawbacks, however, involved the limited ability to teach patients the necessary safety precautions for exercise, the lack of opportunity to teach and encourage modification of coronary risk-related behaviours and lifestyles, and the lack of peer support. Several techniques have been proposed to overcome some limitations of home exercise and to encourage long-term adherence to the exercise regimen. Among these are telephone interaction between patients and nurses or other health professionals, transtelephonic exercise ECG recording, and the use of home exercise training videocassette. Comparative studies of the safety, efficacy, and costs of these approaches are needed; and means must be devised to provide the nonexercise-related information and counselling available to coronary patients in a supervised exercise setting.