Cardiac Rehabilitation Sessions Research Articles

Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up

ObjectiveTo investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose–response relationship between the proportion of CR sessions attended and...

202 Cardiac Rehabilitation Improves Metabolic Parameters Post-ST Elevation Myocardial Infarction (STEMI) Across Multiple Ethnic Groups

Coronary heart disease is the leading cause of morbidity and mortality in the developed world. Participation in cardiac rehabilitation (CR) reduces morbidity and mortality by 25%. Despite this known benefit, only a minority of eligible patients attend CR. Furthermore, significant disparities in CR attendance and outcomes following ST-elevation myocardial infarction (STEMI) exist. To review the metabolic and anthropometric parameters of patients post-STEMI by ethnicity before and after CR. A multicentre, retrospective cross-sectional analysis of patients discharged home between January 1, 2007 and December 31, 2009 from a metro-Vancouver hospital after a STEMI. Patients living ∂ 20km radius of CR programs were included. Patient data, including demographics, co-morbidities, physical and biochemical parameters, were abstracted from patient records. Ethnicity was assigned as European, South Asian and Chinese using a validated system of unique surnames. There were 692 patients comprising of Europeans (71%), South Asians (14%), and Chinese (15%). A total of 162 (23.3%) of patients attended at least one CR session. Attendance varied significantly by ethnicity (26% of Europeans, 18% of South Asians, 16% of Chinese, p=0.032). Participants (vs. non-participants) had significantly higher weight on entry (80kg vs. 76kg, p=0.008) and BMI on entry (26.9kg/m2 vs. 25.8kg/m2, p=0.019). Amongst participants, there were significant differences by ethnicity at entry (Table 1). Despite Caucasians being heavier, South Asians had higher BMI and waist circumference. Among CR participants, there were significant improvements in weight (1.4% or 1.1kg; p=0.034), BMI (1.1% or 0.30kg/m2;p=0.024), and waist circumference (1.8% or 1.75cm; p=0.007). By ethnicity, positive trends were observed for weight loss, reduction in BMI and waist circumference mainly in Caucasians and Chinese. Among CR participants, exercise capacity improved by 26% (p<0.001) as measured by graded-exercise metabolic equivalents and by 40% (p<0.001) as measured by in-class metabolic equivalents. There were trends towards improvement in lipid profile and blood pressure with CR participation.Tabled 1 Rates of CR participation is low amongst ethnic groups. At entry, South Asians had higher BMI and waist circumference. Participation in CR resulted in improvement in the patients' anthropometric parameters and increased exercise capacity. These improvements were less often seen in South Asians. Optimizing metabolic parameters and exercise capacity plays a role in improving outcomes post-STEMI. Further work is needed to develop strategies to improve CR attendance for all patients and patients at increased risk. Long-term studies are also needed to determine the link between metabolic changes with CR and outcomes.

Variation in Patient Perceptions of Healthcare Provider Endorsement of Cardiac Rehabilitation

Cardiac rehabilitation (CR) is significantly underutilized. However, physician endorsement promotes greater patient utilization. This study examined perceptions of provider endorsement by patients (1) of sociodemographic groups who are often less represented in CR and by clinical indication and (2) by type of healthcare provider and place of referral. Referred cardiac (N = 1156) inpatients from 11 hospitals across Ontario completed a sociodemographic survey inhospital and a mailed followup survey 1 year later. Respondents self-reported perceived healthcare provider endorsement of CR on a 5-point Likert scale, type of referring healthcare provider, and where the referral was initiated. The overall perceived strength of healthcare provider endorsement to CR was 3.75 ± 1.15. Patients who perceived greater endorsement were significantly more likely to enrol (OR = 2.07) and attend a greater percentage of CR sessions (P < .001). Student t tests showed that women (P < .01), those older than 65 years (P < .01), with lower annual family income (P < .001), less than high school education (P < .01), who were retired (P < .01), or had lower subjective social status (P < .01) reported significantly lower perceived healthcare provider endorsement of CR than their respective counterparts. Perception of CR endorsement did not differ significantly on the basis of location of referral initiation (P ≥ .05), but those who discussed CR with family doctors (P < .05), cardiologists (P < .05), or cardiac surgeons (P < .01) reported significantly greater endorsement than those discussing CR with nurses. Given the proven benefits of CR, all healthcare providers are recommended to universally and strongly encourage CR participation among their patients in order to optimize utilization and subsequent recovery.

The effect of cardiac rehabilitation on anxiety and depression in patients undergoing cardiac bypass graft surgery in Iran.

BackgroundMany patients experience anxiety and depression after cardiac bypass surgery.The aim of this study was to examine the effect of cardiac rehabilitation on anxiety and depression in patients undergoing coronary artery bypass grafting in hospitals affiliated to Shiraz University of Medical Sciences in southern Iran.MethodsFor this randomized controlled trial, 80 patients who met the inclusion criteria were recruited and randomly assigned to case and control groups. Anxiety was measured with the Spielberger Anxiety Scale and depression was measured using Beck’s Depression Inventory at three points in time: on discharge from the hospital, immediately after the intervention, and 2 months after cardiac rehabilitation. After measuring anxiety and depression in both groups upon discharge, the experimental group participated in 8 cardiac rehabilitation sessions over a 4-week period. The control group received only the routine follow-up care.ResultsThere was a statistically significant difference in depression scores between groups at all three time-points (Mean score from 19.6 to 10 in the intervention group and from 19.5 to 14 in the control group, P = 0.0014). However, no significant difference was seen in anxiety scores between the groups (Mean score from 37 to 28 in the intervention group and from 38 to 32 in the control group, P = 0.079).ConclusionsCardiac rehabilitation was effective in reducing depression 2 months after surgery in patients undergoing coronary artery bypass grafting.Trial registrationIRCTN201203262812N8

Can Individuals Participating in Cardiac Rehabilitation Achieve Recommended Exercise Training Levels Following Stroke?

Cardiac rehabilitation (CR) has been recommended to provide exercise guidance poststroke. However, it has not been established whether minimal exercise training levels, sufficient for obtaining health benefits, can be attained in CR. Therefore, we assessed the ability of stroke patients to achieve recommended exercise levels during a single standard CR session following completion of CR. Sixteen patients (10 males and 6 females) with mild/moderate motor impairments who had completed CR participated in the study. Resting metabolic rate and oxygen uptake during 30 minutes each of aerobic and resistance training (AT, RT, respectively) were assessed by ambulatory oxygen monitor. Obtained values were compared with recommended minimal levels, that is, 20 or more minutes of exercise at 40% or more of peak oxygen uptake (VO(2peak)), 30 or more minutes of exercise at 3 or more metabolic equivalents (METs) (multiples of resting metabolic rate), and an energy expenditure of approximately 200 kcal per session. Mean time sustaining 40% or more of VO(2peak) was 47.6 ± 9 minutes, exceeding the minimal target of 20 minutes (P < .001). Time sustaining 3 or more METs was 30.8 ± 12.2 minutes, matching the target of 30 minutes (P = .8). Total energy expenditure (252 ± 49.9 kcal) was significantly greater than the target value of 200 kcal (P = .001). Chronic stroke patients with mild/moderate motor impairments are able to meet or exceed minimal recommended exercise target levels for intensity, duration, and energy expenditure during a typical exercise session consisting of 30 minutes of AT combined with 30 minutes of RT after completing CR. These data contribute to the evidence promoting the efficacy and feasibility of CR for people following stroke.

Abstract P268: Weight Change is a Poor Predictor of Change in Body Fatness in Cardiac Rehabilitation Patients

Introduction : Obesity is a common risk factor in cardiac rehabilitation (CR), yet many CR patients do not realize significant weight loss, despite engaging in regular exercise training while in CR. Hypothesis : We hypothesized that standard CR would demonstrate favorable body composition (BC) changes even in the absence of weight loss and sought to measure the performance characteristics of weight loss to predict BC changes. Methods : We included consecutive patients enrolled in early outpatient CR who underwent air displacement plethysmography with measurements of height, weight, and waist circumference at initiation and completion of CR. We calculated the accuracy of weight loss to identify significant improvements in BC. Results : Data from 112 patients were available for analysis; mean age 60±12 yr., 76% male, mean body mass index (BMI) 30.2±5.3 kg/m 2 . The indication for CR was myocardial infarction (n=33), percutaneous coronary intervention (n=29), coronary artery bypass or valve surgery (n=45), and heart transplant (n=5). Repeat testing occurred after a median of 81 days and 21 phase II CR sessions. There was no change in BMI (-0.53±1.3 kg/m 2 , p=0.43) and weight (-1.6±4.0 kg, p=0.51). Fat mass showed a borderline significant decrease of 2.9±3.9 kg (p=0.08). However, BC improved significantly as measured by body fat % (-2.5±3.2%, p=0.03) and waist circumference (-4.6±5.2 cm; p=0.01). There was a correlation between weight loss and fat mass loss (r=0.85, p=0.0001, positive predictive value=0.94), and % fat change (r=0.67, p=0.0001, positive predictive value=0.91). See table 1. However, the negative predictive value to detect no fat change for patients who did not lose weight was low (0.49, when assessed by % body fat loss, and 0.57, when assessed by fat mass loss). Among patients who did not lose weight, 29 (51%) had a greater than 1% body fat loss. Conclusions : The diagnostic performance of weight change to predict favorable BC changes is poor and highlights the potential utility of BC measurements in the CR setting. Table. Diagnostic Characteristics of Weight Loss as a Predictor of Improvements in Body Composition Weight Loss (kg) Body Fat % Loss ≤ 1% Fat Mass Loss (kg) &gt; 1kg &gt; 1% ≤ 1kg &gt; 1kg 49 5 51 3 ≤ 1kg or gain 29 28 25 33 Sensitivity 0.63 0.67 Specificity 0.85 0.92 PPV * 0.91 0.94 NPV ** 0.49 0.57 * PPV = Positive Predictive Valve, ** NPV = Negative Predictive Value

Verbal Memory Performance and Completion of Cardiac Rehabilitation in Patients With Coronary Artery Disease

To assess cognitive performance as a predictor of noncompletion of cardiac rehabilitation (CR) using a standardized verbal memory test. This was a prospective cohort study of consecutive patients with coronary artery disease (n = 131) entering 1-year outpatient CR between April 2007 and May 2009. Verbal memory performance was assessed using the California Verbal Learning Test, Second Edition. Attendance at weekly CR sessions was recorded, and completion or noncompletion was determined according to comprehensive CR criteria. Depression was diagnosed according to DSM-IV criteria as a possible confounder. Verbal memory performance at entry into CR differed significantly (F(1,130) = 7.80, p = .006) between noncompleters and completers (mean [SD] cumulative California Verbal Learning Test, Second Edition, score, -1.15 [2.59] versus 0.47 [3.12]) in analysis of covariance controlling for pertinent clinical confounders. Better verbal memory performance predicted a reduced risk of noncompletion (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.77-0.96, p = .009) in time-to-event analysis adjusted for depression (HR = 2.62, 95% CI = 1.33-5.17, p = .006) and smoking history (HR = 2.03, 95% CI = 0.98-4.22, p = .06). A post hoc analysis suggested that better verbal memory performance predicted a reduced risk of noncompletion for medical reasons (HR = 0.83, 95% CI = 0.70-0.99, p = .03). Poorer verbal memory performance was associated with an increased risk of noncompletion of CR among participants with coronary artery disease. Further studies exploring practical methods for screening and targeted support might improve rehabilitation outcomes.

Effect of Exercise-Based Cardiac Rehabilitation Following Coronary Artery Bypass Surgery on Ventricular Repolarization Indices

Indices of ventricular repolarization heterogeneity are associated with future arrhythmias and sudden cardiac death. We investigated the effect of exercise-based cardiac rehabilitation (CR) on these indices in a sample of Iranian patients. Patients (N 122), who had undergone coronary artery bypass surgery (CABGS), were enrolled in this cohort study. Sixty patients attended 15 or more sessions of CR (CR group) and the remaining 62 patients attended 5 or fewer sessions of CR (control group). A standard 12-lead electrocardiogram was recorded for each patient. QT interval dispersion (QTd), RR interval variability (RRV), and heart rate-corrected QTd (QTc-d) were measured 3 times as follow: just before surgery, at the beginning of the first session of the CR program, and at the end of the 15th session for the CR group or the last session for the control group. Following completion of the exercise-training program, the CR group showed a significant decrease in QTd (Δ = -49.4%, P < .0001) and QTc-d (Δ = 52.8%, P .0001), but not in the control group (Δ = 13.4% and 17.9%, respectively, P > .05 for both). In both groups, no statistically significant change in RRV was observed. After adjustment for variables such as age, gender, digoxin use, β-blocker use, and prerehabilitation ejection fraction, CR remained the independent predictor of QTd and QTc-d. Results suggest that cardiac rehabilitation and exercise training programs significantly improve the indices of ventricular repolarization heterogeneity in patients with coronary artery disease who received CABGS.

Recent Advances in Preventive Cardiology and Lifestyle Medicine

Multifactorial risk factor modification and control, especially interventions designed to reduce total cholesterol, systolic blood pressure, smoking prevalence, overweight/obesity, diabetes mellitus, and physical inactivity, can have a profound and favorable impact on decreasing the incidence of initial and recurrent cardiovascular events. Between 1980 and 2000, mortality rates from coronary heart disease (CHD) fell by >40%. Using a previously validated statistical model (IMPACT), researchers attempted to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in risk factors among US adults aged 25 to 84 years. Approximately half of the decline in cardiovascular deaths was attributed to reductions in major risk factors (obesity and diabetes mellitus were notable exceptions), and approximately half was attributed to evidence-based medical therapies (eg, secondary prevention medications, rehabilitation, and initial treatments for acute myocardial infarction [AMI]).1 In contrast, emergent and elective revascularization accounted for only 7% of the overall decline in deaths from CHD. Recently, similar results were reported in a Canadian study that evaluated the decrease in CHD mortality between 1994 and 2005.2 Over the past decade, mortality rates from CHD and stroke in the United States decreased by >25% (Figure 1).3 Although there were also impressive reductions in the prevalence of uncontrolled high blood pressure, elevated blood cholesterol, and, to a lesser extent, cigarette smoking, there was only limited impact on other risk factors, including increases in the prevalence of obesity and diabetes mellitus, and a small reduction in those not engaged in moderate or vigorous physical activity.3 These indicators represent major challenges to achieving future goals for cardiovascular health promotion and disease reduction. Figure 1. Mortality rates from coronary heart disease and stroke, rate of uncontrolled blood pressure, and prevalence of high cholesterol from 2004 to 2008. Reproduced …

Adult Congenital Heart Disease Patient Participation in a Traditional Cardiac Rehabilitation Program

Due to advancements in the treatment of individuals born with congenital heart disease, 90% will now reach adulthood. Patients with adult congenital heart disease (ACHD) suffer from low exercise capacity, which results in increased risk for hospitalization and mortality. Cardiac rehabilitation (CR) is a comprehensive outpatient disease management program that improves exercise capacity. PURPOSE: To examine the effects of CR participation, specifically program adherence, exercise capacity, treadmill walking time and adverse events among ACHD patients who participated in a non-modified traditional CR program. METHODS: The CR program offers 32 sessions of ACSM guideline-based supervised exercise. The charts of all enrolled ACHD patients were retrospectively reviewed. Graded exercise test results and treadmill walking time pre and post CR, as well as adverse events related to exercise participation were extracted. Results were described and a repeated-measures t-test was performed to assess change from pre to post-CR. Ten ACHD patients were referred to CR from 2005-2010; 4 patients had repair for defects of great complexity (pulmonary atresia; complete transposition of the great arteries; Eisenmenger syndrome; congenitally corrected transposition of the great arteries), and 6 had repair for defects of moderate complexity (tetralogy of Fallot [n=2]; atrioventricular septal defect with severe pulmonary hypertension; coarctation of the aorta; bioprosthetic valve [n=1 aortic, n=1 aortic and mitral] replacements). RESULTS: Six (60%) of patients attended the full 32 sessions of CR and reasons for non-completion were unrelated to ACHD diagnosis. Exercise capacity on the graded exercise tests improved in all patients who completed the program (8.33±1.09 vs. 9.33±0.99 Mets, p<0.05, n=6). Treadmill walking time in CR from the first to the last session improved (8.9±0.5 minutes vs. 19.4±0.6 minutes, p<0.05, n=10) in all patients whether they completed the full CR program or not. There were no reports of adverse events during CR participation despite 60% incidence of prior atrial and/or ventricular arrhythmias. CONCLUSION: Participation in CR was safe and resulted in significantly increased exercise capacity for this selected group of adults with congenital heart disease.

Quality of Life Following Participation in Cardiac Rehabilitation Programs of Longer or Shorter than 6 Months: Does Duration Matter?

Cardiac rehabilitation (CR) participation results in significant health benefits. However, there is wide variation in program duration, and little is known about the optimal duration of CR for patient outcomes. The objective of this study was to compare quality of life (QoL) of patients who participated in CR programs of < or ≥6 months duration versus patients who did not attend CR. A total of 1056 cardiac outpatients completed mailed surveys at baseline and 9 months later. Patients were categorized based on CR participation in one of 31 programs: a program of < or ≥6 months duration, or nonattendance. Outcomes were body mass index, activity status, depressive symptoms, physical activity, QoL, posttraumatic growth inventory (PTGI), and percentage of CR sessions attended. Generalized estimating equations were used. A total of 148 (14%) patients participated in a program of < 6 months, and 183 (17.3%) participated in a program of ≥6 months. Patients who participated in the former completed a greater percentage of CR sessions (P = 0.02). Activity status (P = 0.002), several domains of QoL (P > 0.0001), and PTGI (P = 0.007) were significantly greater regardless of CR duration when compared to those who did not attend CR. There were no significant differences in outcomes when comparing patients attending CR programs of < or ≥6 months duration. Patients achieve greater activity status and QoL when compared to those who did not attend CR, regardless of program duration. This could be a result of greater program adherence among those who attend shorter programs. Future research is needed using a randomized design to assess effects of program duration on cardiac events and mortality.

Gender Differences in Improvement of Function Capacity and Psychological Status Following Cardiac Rehabilitation Program after Different Cardiac Interventions

Background: Because of lower exercise capacity and energy as well as function score in women, improvement of these indices following cardiac rehabilitation (CR) may be of greater clinical benefit to women than to men. The purpose of the present study was to determine if there were gender differences in risk profiles and function capacity as well as perceptions of quality of life and depression-anxiety status in CR patients. Methods: Three hundred and eleven consecutive patients who underwent various cardiac interventions and attended 20 or more of the CR sessions in an exercise-based CR program at the Tehran Heart Center between August 2008 and August 2009 were included. The main outcome measures were differences in the changes of exercise parameters, the health-related quality of life (QOL) (assessed by a standardized self-rating Short Form 36 Health Questionnaire), as well as depressed and anxious mood (assessed by the Costello-Comrey Depression and Anxiety Scale). Results: The metabolic equivalent (METs) level of men was higher than that of women at baseline and at the end of CR, but its changes was not significant between the two genders. At the end of the three-month program, although men had higher post-exercise systolic blood pressure, peak heart rate and peak O2 consumption than women, improvements in these parameters were not statistically different between them. Regarding health-related quality of life scores, both men and women improved in all scores, although men reported more increase in their level of general health, however the changes of all QOL scores and depression-anxiety level were globally similar in both genders. Conclusion: Improvement in exercise parameters, QOL, and depression-anxiety state is similarly occurred in men and women following complete CR program.

“You're always hearing about the stats … death happens so often”: new perspectives on barriers to Aboriginal participation in cardiac rehabilitation

TO THE EDITOR: Engaging patients in cardiac rehabilitation (CR), a program of secondary prevention measures, is crucial to improving outcomes after myocardial infarct. Rates of participation in CR by Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are extremely low. We conducted a qualitative study on barriers to CR use from November 2007 to March 2008 with 15 Aboriginal cardiac patients (seven women and eight men, aged 31–74 years) living in Perth, Western Australia. Six had participated in some outpatient CR sessions; nine had not. Participants were interviewed face-to-face usi g a semistructured interview guide, with questions exploring their views and experiences of CR, barriers to use and suggestions for improvement. Recurring themes included challenges associated with extended family responsibilities and sociocultural inappropriateness of the program. These themes, along with less commonly discussed issues of poor knowledge of CR and the connection between colonialism and health services, reflect findings from previous studies. However, two new themes — media heart health messages and the younger age of the affected Aboriginal population — highlight further factors influencing participation (Box 1). We found that some patients feel constantly reminded of, and therefore come to expect, poor health outcomes, due to dire statistics repeated in the media. While the dominant theme in the Australian media of Aboriginal fatality and futility has been discussed, heart health messages are often disempowering, negatively affecting motivation to engage with health programs. This is likely reinforced by regular attendance at funerals for Aboriginal people, who die very prematurely from cardiovascular disease (CVD). This highlights the need for a shift in media and public health campaigns from “shock” headlines and statistics to a focus on strengths and successes, inspiring the groups involved and supporting them to make changes. Younger Aboriginal participants also spoke about feeling isolated in CR sessions among non-Aboriginal people who were 20–30 years older than them. The age demographic of CR program attendees generally reflects CVD epidemiology in the wider community, but the burden of CVD occurs at much younger ages in the Aboriginal population. This widening differential demands rethinking of how CR should work for this very different demographic group (Box 2). CR programs addressing the needs of younger people may improve receptivity and opportunities for primary prevention in the family and broader community. Although these two themes were reported by a small number of patients, further research into issues for Aboriginal patients with CVD is warranted. Importantly, it will contribute to understanding of how younger Aboriginal people think about their health, and feel motivated and supported by wider society to do something about it.

Effect of Resistance Training and Aerobic Conditioning on Muscular Strength and Submaximal Fitness for Individuals with Chronic Heart Failure: Influence of Age and Gender

The hallmark characteristic of chronic heart failure (CHF) is exercise intolerance. This study evaluated a combined exercise program that would be consistent with current cardiac rehabilitation guidelines. The program consisted of progressive resistance training (intensity progressing from 50 to 80% maximum) and aerobic conditioning (70% of heart rate reserve). Outcomes included muscular strength measured as 8-repetition maximum and submaximal aerobic fitness indicators (measured at 50% of predicted maximal oxygen consumption) including heart rate, blood pressure, and rate pressure product. Subjects were taken retrospectively from a database of CHF patients who underwent cardiac rehabilitation between 1998 and 2004 with the Cardiac Rehabilitation Center of River Cities Cardiology in Jeffersonville, IN. The same data set was used to evaluate 2 research questions: to compare training outcomes between gender (men and women) and to compare outcomes between young (<or=65 years) and old (>65 years) subjects. Forty-two subjects (15 women and 27 men; 19 were <or=65 and 23 were >65 years of age) met inclusion and exclusion criteria and underwent 36 sessions of cardiac rehabilitation over a 14-week time period. Repeated-measures analysis of variance was used to test whether strength and submaximal responses differed across gender or age. Analysis indicated that regardless of gender or age, subjects significantly increased their strength on each of 6 strength tests. Heart rate, systolic blood pressure, and rate pressure product were lower after training indicating increased aerobic efficiency. Progressive resistance training and aerobic conditioning prescribed in a manner consistent with cardiac rehabilitation guidelines resulted in similar improvements regardless of gender or age for individuals with CHF suggesting that no training program adjustments are necessary to accommodate age or gender.

Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries

For patients with coronary heart disease, exercise-based cardiac rehabilitation improves survival rate and has beneficial effects on risk factors for coronary artery disease. The relationship between the number of sessions attended and long-term outcomes is unknown. In a national 5% sample of Medicare beneficiaries, we identified 30 161 elderly patients who attended at least 1 cardiac rehabilitation session between January 1, 2000, and December 31, 2005. We used a Cox proportional hazards model to estimate the relationship between the number of sessions attended and death and myocardial infarction (MI) at 4 years. The cumulative number of sessions was a time-dependent covariate. After adjustment for demographic characteristics, comorbid conditions, and subsequent hospitalization, patients who attended 36 sessions had a 14% lower risk of death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 to 0.97) and a 12% lower risk of MI (HR, 0.88; 95% CI, 0.83 to 0.93) than those who attended 24 sessions; a 22% lower risk of death (HR, 0.78; 95% CI, 0.71 to 0.87) and a 23% lower risk of MI (HR, 0.77; 95% CI, 0.69 to 0.87) than those who attended 12 sessions; and a 47% lower risk of death (HR, 0.53; 95% CI, 0.48 to 0.59) and a 31% lower risk of MI (HR, 0.69; 95% CI, 0.58 to 0.81) than those who attended 1 session. Among Medicare beneficiaries, a strong dose-response relationship existed between the number of cardiac rehabilitation sessions and long-term outcomes. Attending all 36 sessions reimbursed by Medicare was associated with lower risks of death and MI at 4 years compared with attending fewer sessions.

Continuous ST-Segment Monitoring: 3 Case Studies in Progressive Care

Continuous ST-Segment Monitoring: 3 Case Studies in Progressive Care

Improving Weight Loss in Cardiac Rehabilitation

In the current issue of Circulation , Philip Ades and his associates at the University of Vermont College of Medicine have provided us with an innovative and important article demonstrating the feasibility and benefits of an enhanced exercise option in cardiac rehabilitation.1 In this study, 74 patients were randomized to a standard cardiac rehabilitation exercise program versus a high-calorie-expenditure exercise program. All patients were provided with 16 hours of group dietary counseling and given a dietary target deficit of 500 calories per day. One group was given a standard exercise program typically used in cardiac rehabilitation (25 to 40 minutes, 3 times per week) and the other an enhanced program targeting 45 to 60 minutes, 5 to 7 times per week, or a total caloric expenditure of 3000 to 3500 kcal/week. The length of the intervention was 5 months, though 1-year data collection was also performed. Patients were of course followed up closely to promote compliance. Article see p 2671 The primary outcome of the study was weight loss. Subjects in the high-calorie-expenditure exercise program lost more than twice as much total body weight (8.2±4 versus 3.7±5 kg) and fat mass (5.9±4 versus 2.8±3 kg). Waist circumference also decreased by a greater amount (7±5 versus 5±5 cm). The enhanced exercise program was also associated with a greater benefit on a number of coronary risk factors including insulin resistance, total/high-density lipoprotein cholesterol ratio, and metabolic syndrome. Most of the weight loss and the difference between the groups were retained at 1-year, though some weight regain occurred (1.3 kg for the enhanced exercise group and 0.9 kg for the standard exercise group). Guidelines for the secondary prevention of coronary heart disease2 and for management of specific coronary risk factors3–4 emphasize the importance of lifestyle change, including weight loss, but …

Concordance of self- and program-reported rates of cardiac rehabilitation referral, enrollment and participation

Despite potential bias, researchers often rely on patient self-reported data of health care use. However, the validity and accuracy of self-reported data on cardiac rehabilitation (CR) use are unknown. To assess the concordance between patient self-report and site-verified CR referral, enrollment and participation. A consecutive sample of 661 coronary artery disease inpatients (mean [+/- SD] age 61.27+/-1.31 years; 157 women [23.8%]) treated at three acute care sites was recruited (75% response rate) as part of a larger study comparing automatic with usual referral methods. CR referral, enrollment (attendance at intake assessment) and participation (percentage of program attended) were discerned in a mailed survey nine months following discharge (n=506; 84.3% retention). A total of 24 CR sites were contacted for verification. A total of 276 participants (54.5%) self-reported CR referral, and CR sites verified receipt of 262 referrals (51.8%) (Cohen's kappa 0.899). A total of 232 participants (45.8%) self-reported CR enrollment, with site-verification for 208 participants (41.1%) (Cohen's kappa 0.846). Self-reported data indicated that participants attended a mean of 81.78+/-25.84% of prescribed CR sessions, with CR sites reporting that participants completed 80.75+/-31.27% of the program (r=0.662; P<0.001). Equivalency testing revealed that the self-reported and site-verified rates of program participation were equivalent (z<1.96). The almost perfect agreement between the self-reported and site-verified use of CR services suggests that self-administered items are highly valid in this population.

Pedometer Step Counts Predict Cardiac Risk Factors at Entry to Cardiac Rehabilitation

Walking exercise favorably affects cardiac risk factors (CRF) and reduces total and cardiovascular disease-related mortality. The purpose of this study was to describe walking levels, prospectively measured by pedometer, in individuals commencing phase II cardiac rehabilitation (CR) and to correlate step counts with CRF. Participants (n = 107) wore a pedometer for 7 consecutive days starting the day after their first formal phase II CR exercise training session. Primary outcome was total steps taken, with CR and non-CR days analyzed separately. We examined the relationship between daily step counts and CRF. Participants achieved significantly higher step counts on CR versus non-CR days (7,387 +/- 3,387 vs 5,315 +/- 3,336, P < .0001). Total daily step count correlated significantly, in descending order, with peak oxygen uptake, the number of days since the index cardiac event, diagnosis of diabetes mellitus, physical function score, waist circumference, body mass index, age, and high-density lipoprotein cholesterol (HDL-C). By multivariate analysis, peak oxygen uptake, HDL-C, and the diagnosis of diabetes mellitus independently correlated with daily non-CR step count (cumulative total r = 0.62, adjusted R2 = 0.35, P < .0001). Regression analysis, using step counts on CR days, produced similar results. Daily steps taken by patients during the first week of phase II CR are quite low. Despite the low step counts, significant correlations between steps taken and CRF were found including fitness, centrally distributed adiposity, and HDL-C. Our results suggest that, even early after a coronary event, higher levels of walking are favorably related to CRF.

Distance and Transportation as Barriers to Cardiac Rehabilitation in Urban and Rural Coronary Artery disease Outpatients

Background: Cardiac rehabilitation (CR) is a proven means to reduce morbidity and mortality among cardiac outpatients but is grossly under-utilized. Transportation, distance and travel time are frequently cited barriers to participation. The purpose of this study was to compare CR participation rates between urban and rural cardiac outpatients and examine perceived distance and transportation barriers.&#x0D; &#x0D; Methods: 255 cardiac outpatients (mean age 68+11 years; 76%(194) male) of 97 Ontario cardiologists completed a survey within an on-going prospective study. The second digit of A0A in the postal code designated rural status and was verified with Statistics Canada 2001 Census. Using a 5-point Likert scale outpatients indicated the degree to which transportation and distance were barriers and self-reported travel time to CR and percentage of sessions attended.&#x0D; &#x0D; Results: 87% (223) of outpatients lived in an urban area, while 13% (32) were rural. Overall, 44%(113) participated in CR, with 46% (102) urban and 34% (11) being rural (P &gt; 0.05). Transportation barriers were significantly related to CR participation (P &lt; 0.01), whereas distance was not. Data were split by geographic area and transportation was only significantly related to CR participation among urban outpatients (P &lt; 0.01). Urban outpatients reported a mean travel time of 25±18 minutes compared to 68±53 for rural outpatients (P &lt; 0.0001). The mean percentage of CR sessions participated in was 84±28%, which did not differ by geographic status.&#x0D; &#x0D; Conclusions: Contrary to previous research, living in a rural area and perceived distance were not related to CR participation. However data collection is ongoing. Rural outpatients had longer travel times yet perceived no distance or transportation barriers. Transportation barriers for urban outpatients may be related to population density and traffic delays. Efforts to reduce transportation-related barriers in urban areas such as improving public transportation or increasing home-based CR provision may be warranted.