Comprehensive Cardiac Rehabilitation Program Research Articles

The long‐term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life

To investigate the long-term benefits of a six-week comprehensive cardiac rehabilitation programme on physical activity, psychological well-being and quality of life in patients with coronary heart disease. Cardiac rehabilitation (CR) in short term improves exercise capacity and quality of life in patients with cardiac disease. However, the long-term benefits of CR are inconclusive. A prospective CR programme with repeated measures follow-up over 12 months. A six-week outpatient cardiac rehabilitation programme was conducted including 147 patients with coronary heart disease. Patients completed the physical activity energy expenditure (seven-day recall activity), MacNew Heart Disease Health-Related Quality of Life (MacNew) and Hospital Anxiety and Depression scale (HADs) at baseline, six weeks, six and 12 months. One hundred and five (71%) patients (76 male) mean age of 61.8 (SD 9.7) completed the four-measurement points. Analysis of variance revealed that total energy expenditure (F (2, 231) = 131, p < 0.001), HADs (F (2, 237) = 19.3, p < 0.001), depression score (F (2, 235) = 21.06, p < 0.001), anxiety score (F (2,237) = 17.02, p < 0.001) and MacNew (F (2, 197) = 77.02, p < 0.001) were all statistically significant over time. Bonferroni pairwise follow-up confirmed significant positive differences (p < 0.05) between baseline values and all subsequent measures over time. Depression was independently explained in 22% of the variance in quality of life at 6 or 12 months. The energy expenditure was significantly higher for men compared to women (F (1, 103) = 31, p < 0.001). A six-week cardiac rehabilitation programme is beneficial in improving quality of life, physical activity status, anxiety and depression. These benefits were maintained at 12 months. Elevated levels of depression were associated with impaired quality of life. All relevant health care staff should be aware of the benefits of CR and routinely refer and encourage patients with cardiac disease to attend a cardiac rehabilitation programme. Depression and anxiety intervention strategies should be incorporated in cardiac rehabilitation programmes.

Women's Experiences Accessing a Women-Centered Cardiac Rehabilitation Program

The health benefits of cardiac rehabilitation (CR) for women living with heart disease are well documented, yet women remain underrepresented in traditionally structured CR programs. This health service delivery gap has been attributed to a number of sex-related factors experienced by women, including lower rates of physician referral, travel-related barriers, competing work and caregiving responsibilities, greater cardiovascular disease severity, and number of comorbid health conditions. Whether a program specifically designed for women is able to address these barriers and facilitate women's participation is a question that has seldom been explored in the CR literature. As part of a larger study exploring whether 6 predefined principles of women's health (empowerment of women, accessible programs, broad definition of health care, high-quality of care, collaborative planning, and innovative and creative approaches) are reflected in the practices of the Women's Cardiovascular Health Initiative (WCHI) (a comprehensive CR and primary prevention program designed for women), the objective of this analysis was to explore how the principle of "accessible programs" is experienced by women participating in the WCHI. Fourteen women previously enrolled in the WCHI program participated in a single, in-person qualitative interview. Transcripts were analyzed using a constant-comparative approach to identify relevant themes related to program accessibility. Key themes identified included participants' experiences with acquiring physician referral, negotiating transportation issues, and navigating program schedules. Women discussed how peer support and staff members' willingness to address their health-related concerns facilitated their participation. While a women-centered CR/primary prevention program may facilitate and encourage women's participation by providing flexible program schedules as well as peer and professional support, efforts are still required to address persistent barriers for women related to physician referral and transportation to programs.

The Influence of Cardiac Rehabilitation on Inflammation and Metabolic Syndrome in Women With Coronary Heart Disease

Metabolic syndrome (MetS) and increased inflammatory markers, both predictors of future cardiovascular events, are more prevalent in women with coronary heart disease (CHD). The influence of cardiac rehabilitation (CR) on MetS and inflammatory biomarkers is not well characterized for women. : The purpose of this article was to examine the effects of a 12-week behaviorally enhanced CR exclusively for women compared with traditional CR on components of the MetS and inflammatory markers in women with CHD. The randomized clinical trial used 2 treatment groups, both receiving a comprehensive 12-week CR program, with 1 group receiving a motivationally enhanced intervention exclusively for women. A subset of 91 women (mean age, 61.6 years) from the parent study provided serum samples to examine the effects of CR on high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and intercellular adhesion molecule-1 (ICAM-1). After CR, the total sample of women demonstrated significant reductions in hsCRP (P =.002), IL-6 (P <.001), TNF-alpha (P =.010), and ICAM-1 (P =.016). Women in the gender-tailored CR program significantly improved all biomarker levels compared with baseline (P <.05 for all), whereas those in the traditional group improved only hsCRP (P <.05) and IL-6 (P <.05) levels. The combined study group demonstrated improvements in several components of MetS (triglycerides, waist circumference, and systolic blood pressure) but not in others (high-density lipoprotein cholesterol, fasting glucose, and diastolic blood pressure). Cardiac rehabilitation promotes greater improvements in inflammatory biomarkers than in components of MetS for women with CHD. Improvements in body composition or weight may not be a precondition for the benefits of exercise because of loss of abdominal fat. Examining components of MetS as continuous variables is recommended to prevent lost information inherent in dichotomization.

Patterns and Predictors of Uptake and Adherence to Cardiac Rehabilitation

Despite the recognized effectiveness of cardiac rehabilitation (CR), these programs are frequently reported to be underutilized. This prospective study sought to describe the uptake of and adherence to phase 3 of a CR service in Glasgow, UK. The study recorded psychological, social, and demographic characteristics of patients in an attempt to ascertain variables associated with failure to initiate attendance or poor adherence to the program. Consecutive patients (N = 91) were included in the study before inviting them to participate in a comprehensive CR program. Thirty-one (35%) patients eligible to attend phase 3 CR indicated no intention to attend the program. A further 31 (35%) patients were considered nonadherent to the program. No factors predicting initiation or adherence emerged as significant. More than two-thirds of the patients eligible for CR did not engage in the program either through failure to initiate rehabilitation or poor adherence following initiation. Alternative means of service delivery should be considered to broaden access to CR. Psychological interventions aimed at enhancing motivation and adherence should be developed and appropriately evaluated.

Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend

Cardiac rehabilitation (CR) is well documented, in randomised trials, to reduce mortality risk after myocardial infarction (MI). Selection of healthy patients for CR is a relatively unexplored problem. Our aims were to identify predictors of CR-attendance and to describe the prognosis as concerns mortality, re-admission and invasive treatment among CR-attendees as compared to CR-non-attendees. From a cohort of 138 290 persons aged 30-69 years, we identified consecutive MI patients, between 1 April 2000 and 31 March 2002. There were 206 MI patients, who survived until admission, and among the 200 who survived 30 days, 145 (72.5%) attended a comprehensive CR programme. Data were obtained from patient charts and from Danish population registers, and as a result we had no non-participation for the study. The 2-year mortality proportions for patients surviving the first 30 days of admission were 2.8 and 21.8% among CR-attendees and CR-non-attendees, respectively (P < 0.0001). Among CR-non-attendees, there was a smaller fraction having an invasive treatment performed as compared with CR-attendees. By multiple logistic regression controlling for age and sex, CR-attendance was associated with chest pain, whereas CR-non-attendance was associated with low gross income, single living and inverted T-wave in the electrocardiogram. CR attendance rate was 72.5%. Non-attendees have a higher mortality risk, which in part may be attributed to selection of healthy patients. Non-attendees are older and more likely to have atypical symptoms at admission, a low socioeconomic status and to live alone. Special attention is needed to improve CR attendance among such patients.

Unstructured cardiac rehabilitation and secondary prevention in rural South Australia: Does it meet best practice guidelines?

Comprehensive cardiac rehabilitation programs that address risk factors, psychological problems, and physical activity are essential in optimizing health and reducing the risk of further cardiac events. Behavioural and lifestyle modification support offered through these programs is predicated on initial identification of risk. Many rural populations in Australia do not have access to structured cardiac rehabilitation (CR) programs, and the level of support available to them in the form of unstructured CR is unclear.A retrospective analysis of medical records of patients presenting to hospital with myocardial infarction in rural South Australia over a 12-month period was undertaken to identify documented evidence of assessment of and intervention for lifestyle and behavioural risk factors in-hospital and at follow up in general practice (GP) clinics. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up.Documented evidence of assessment of modifiable risk factors was inadequate for the majority of participants, with the exception of smoking status, hypertension and diabetes. This suggests that the majority of these participants did not receive lifestyle and behavioural interventions in line with current National Heart Foundation Recommendations for Cardiac Rehabilitation.Barriers to comprehensive CR and secondary prevention services in Australia must be addressed, particularly in high risk rural and remote populations. Future research must focus on the ongoing monitoring and evaluation of rural health care services to analyse existing levels of CR and secondary prevention to ensure current guidelines are being implemented, to support the further development and resourcing of CR services and to evaluate the subsequent impact on patient outcomes.

Predictors of drop-out from an outpatient cardiac rehabilitation programme

Objective: To investigate the prevalence and predictors of early drop-out from a cardiac rehabilitation programme and also whether completers and drop-out patients differed in relation to their illness cognitions, gender and psychological distress and quality of life. Design: A six-week outpatient cardiac rehabilitation programme. Setting: A university teaching hospital. Subjects: One hundred and eighty-nine patients were recruited from a consecutive series of outpatient referrals prior to a six-week comprehensive cardiac rehabilitation programme. Outcome measures: The revised Illness Perception Questionnaire, Quality of Life after Myocardial Infarction Questionnaire and the Hospital Anxiety and Depression Scale. Results: One hundred and forty-seven cardiac patients completed the cardiac rehabilitation programme. Forty-two (22%) patients dropped out in the first two weeks. Factors predicting early drop-out were female gender, younger age, higher Hospital Anxiety Depression Scale score, lower illness perception consequences and higher illness perception personal control and lower illness perception treatment control (all P < 0.05). Conclusion: Over a fifth of the patients did not complete this typical cardiac rehabilitation programme. Female patients are more likely to drop out from cardiac rehabilitation than men. Psychological distress, younger age and lower perceptions of consequences, higher perception personal control and lower illness perception of treatment control were predictors of early drop-out from a cardiac rehabilitation programme.

Effects of a comprehensive cardiac rehabilitation program in myocardial infarction elderly patients

Effects of a comprehensive cardiac rehabilitation program in myocardial infarction elderly patients

Investigating patients' preferences for cardiac rehabilitation in Denmark

The objective of this study was to analyze preferences for activities comprised in comprehensive cardiac rehabilitation programs among former cardiac patients from three different hospitals in Copenhagen County, Denmark. A discrete choice experiment was applied to elicit the preferences for the offer of participation in various cardiac rehabilitation program activities: smoking cessation course, physical exercise program, personal meetings with cardiac nurse, group meetings managed by cardiac nurses, and nutritional counseling guidance. The questionnaire was sent to 742 former cardiac patients. We had a response rate of 69 percent. We found that preferences differed with respect to gender and age and that the offer of participation in cardiac rehabilitation activities was not highly valued by older patients, in particular among older men. The discrete choice experiment proved a valuable instrument for the measurement of preferences for cardiac rehabilitation. The study provides important information on patients' preferences for cardiac rehabilitation for healthcare professionals and decision makers.

Exercise Training for Individuals with Coronary Artery Disease or Heart Failure

Purpose: Cardiovascular disease is the leading cause of mortality in Canada, resulting in impaired aerobic capacity (VO2peak) that leads to a reduced ability to perform activities of daily living. We examine the mechanisms responsible for the decline in VO2peak found in individuals with coronary artery disease (CAD) or heart failure (HF). In addition, the role that exercise rehabilitation plays in attenuating the decline in VO2peak and strength is reviewed. Finally, we provide an exercise program that can be used by physiotherapists to improve the overall physical fitness of patients with CAD or HF. Summary of Key Points: Aerobic training and resistance training, as part of a comprehensive cardiac rehabilitation program, have been shown to improve VO2peak, muscle strength, and quality of life while reducing mortality in individuals with CAD or HF. Physiotherapists should incorporate these effective interventions in the rehabilitation of individuals with CAD or HF. Recommendations: Individuals with CAD or HF should be encouraged to perform regular moderate-intensity aerobic and resistance training to improve their physical fitness and quality of life.

Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs

Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs

Clinical profile and outcomes of diabetic and nondiabetic patients in cardiac rehabilitation

Patients with diabetes mellitus have increased risk of cardiovascular disease; however, there are limited data addressing cardiac rehabilitation in these patients. This study assessed the effectiveness of participation in cardiac rehabilitation on clinical outcomes after myocardial infarction and/or revascularization procedures in diabetic and nondiabetic patients. Analysis on 1505 patients completing a minimum of 7 weeks of a 12-week cardiac rehabilitation program included fasting lipid profile and glucose, body mass index, and metabolic equivalent time in patients with diabetes (n = 292) and without diabetes (n = 1213). There were significant improvements in total cholesterol, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) in each group after cardiac rehabilitation. Diabetic women and nondiabetic men had the greatest improvement in HDL-C, with an improvement of 4.9% in diabetic women (P = .02) and an improvement of 4.1% in nondiabetic men (P < or = .0001). On completion of cardiac rehabilitation, both diabetic and nondiabetic patients were at National Cholesterol Education Program Adult Treatment Panel III goals in total cholesterol, LDL-C, HDL-C, and triglycerides at a higher rate. However, patients with diabetes did not reach National Cholesterol Education Program goals for HDL-C, total cholesterol, and triglycerides as effectively as nondiabetic patients. Exercise capacity improved by 28.1% in diabetic patients after cardiac rehabilitation (P < .0001). Improvement in outcomes in the patients with diabetes occurred without significant change in body mass index. These results suggest that participation in a comprehensive cardiac rehabilitation program integrates care of patients with chronic conditions such as diabetes to achieve comparable cardiac risk factor reduction as achieved with nondiabetic patients.

Cardiac Rehabilitation in Patients With Myocardial Infarction: a 10-Year Follow-up Study

Very little information is available on the effect of cardiac rehabilitation programs on long-term survival. The primary aim of this study was to assess the effect of a structured cardiac rehabilitation program on mortality in patients who had suffered acute myocardial infarction. The secondary endpoint was the effect on morbidity. The study included 180 low-risk male patients aged under 65 years. Patients were randomly assigned to one of 2 groups: 90 entered into a comprehensive cardiac rehabilitation program, and 90 served as a control group. The mean follow-up period was 10 years. All-cause mortality was significantly lower in the intervention group: the 10-year survival rate was 91.8% in the intervention group compared with 81.7% in the control group (P=.04). There was also a decrease in cardiovascular mortality, though it was not statistically significant: the 10-year survival rate was 91.8% in the intervention group compared with 83.8% in the control group (P=.10). The incidence of non-fatal complications was lower in the intervention group (35.2% vs 63.2%, P=.03), as was the incidence of unstable angina (15.7% vs 33.9%, P =.02) and cardiac heart failure (3.0% vs 14.4%, P=.02), and the need for coronary intervention (8.4% vs 22.9%, P=.02). The application of a comprehensive cardiac rehabilitation program significantly decreased long-term mortality and morbidity in low-risk patients after acute myocardial infarction.

Role of smokers in the household and of cardiac rehabilitation in smoking behaviour after acute myocardial infarction

This study aims to evaluate the influence of household smokers and of a prolonged, comprehensive home-based Cardiac Rehabilitation Program (CRP) on patient's long term smoking behaviour after AMI. 164 male post-AMI patients, all smokers until the day of AMI, were subdivided into three groups: Group A (n=54): patients with recent AMI, discharged from hospital without enrolment in CRP; Group B (n=55): similar to Group A but enrolled in an 8 weeks hospital-based CRP and then discharged home with routine care; Group C (n=55) enrolled in an 8 weeks hospital-based CRP followed by a further 10 months of formal home-based CRP, with scheduled hospital follow-up visits. Smoking resumption at 12 months was influenced by the presence of household smokers (HS): 38% of patients with HS resumed smoking compared to 27% of patients without HS (p <0.01). Adherence to a CRP was inversely correlated to smoking resumption: there were fewer smoking patients at 12 months from AMI in Group C than in Groups A or B (11% in C vs. 29% and 55% in B and A, respectively, p <0.001). Long term maintenance of CRP seems to be the best way to achieve a reduction of long term smoking habit and maintain adherence to prescription in patients after AMI. Counselling and behavioural intervention should also be extended to family members in order to maximize the benefit of secondary prevention.

Assessment of Quality of Life With 5 Different Scales in Patients Participating in Comprehensive Cardiac Rehabilitation After Acute Myocardial Infarction

Measures assessing quality of life (QOL) in patients participating in comprehensive cardiac rehabilitation (CCR) have not been established in Japan. To compare different types of QOL scales and to determine the impact of CCR on QOL in Japanese cardiac patients, 5 different types of questionnaires were assessed in 44 patients participating in CCR after acute myocardial infarction (AMI). After 3-month CCR, peak oxygen uptake (PVO2, p<0.01), Sickness Impact Profile (SIP) total score (p<0.05) and physical function-related QOL scores (Specific Activity Scale (SAS), p<0.01; SIP physical score, p<0.01) significantly improved, whereas psychosocial/mental aspect-related QOL scores (Ministry of Health and Welfare (MHW)-QOL score, SIP psychosocial score, State-Trait Anxiety Inventory, Self-rating Depression Scale) did not change on the average. However, patients with low PVO2 (<21.7 ml.min-1.kg-1) showed significant improvements in all scores after CCR, whereas patients with preserved exercise capacity showed improvements only in physical function-related scores (SAS and physical SIP). Furthermore, patients with anxiety and depression showed significant improvements in these respective measures after CCR. In patients with AMI, physical function-related QOL scores improve after a 3-month CCR program, but psychosocial/mental aspect-related QOL scores improve only in those with impaired exercise tolerance or anxiety/depression. Thus, changes in QOL after CCR depend on type of QOL scale used and the baseline status of the patient. In addition, in Japanese cardiac patients MHW-QOL mainly reflects psychosocial/mental aspect-related QOL, as well as overall QOL.

Development, implementation and audit of a cardiac prevention and rehabilitation programme for patients with coronary artery disease

Objective To establish a comprehensive multi-disciplinary cardiac prevention and rehabilitation programme for patients with coronary artery disease which is reproducible and transferable to other institutions, in order to achieve lifestyle modification, risk factor control and optimal use of proven cardioprotective medication.

Yoga in cardiac health (A Review)

This review studies the efficacy of yoga in the primary and secondary prevention of ischaemic heart disease and post-myocardial infarction patient rehabilitation. Yoga is an unconventional form of physical exercise that has been practised over a long period of time in the Indian sub-continent. It has gained immense popularity as a form of recreational activity all over the world. Its possible contributions to healthy living have been studied and many interesting revelations have been made. Benefits of yoga in the modification of cardiovascular risk factors and in the rehabilitation of the post-myocardial infarction patient are areas of significant importance. It is important to assess the practical significance and the suitability of incorporating yoga into the comprehensive cardiac rehabilitation programme. Majority of the rehabilitation workers believes that incorporating nonconventional forms of physical exercise such as yoga definitely would enhance efficacy and add value. This article attempts to study the history and the science of yoga and evaluate its effects on cardiovascular health.

Development, implementation and audit of a cardiac prevention and rehabilitation programme for patients with coronary artery disease

ObjectiveTo establish a comprehensive multi-disciplinary cardiac prevention and rehabilitation programme for patients with coronary artery disease which is reproducible and transferable to other institutions, in order to achieve lifestyle modification, risk factor control and optimal use of proven cardioprotective medication. Design A descriptive study. Setting A hospital based 12 week out-patient programme. Interventions A multi-professional family based programme of lifestyle and risk factor modification was offered to patients presenting with new onset angina and unstable angina, following acute myocardial infarction or after coronary artery bypass surgery. Main outcome measures Non smoking status, body mass index (BMI), blood pressure, cholesterol, and use of prophylactic drug therapies. Patients were assessed at the beginning and at completion of the programme (re-screening) and also 1 year after completing the programme. Results Of 537 patients eligible for the programme, 443 (83%) were recruited, of whom 404 could potentially have completed the programme at the time of this analysis. Of these 308 (76%) participated and 215 (53%) completed the programme. 92% were non-smokers at the end of the programme (86% at 1 year). Mean BMI on completion of the programme was 27.2 kg/m2 (SD 4.3) which was maintained at 1 year (mean 27.0 SD 4.1). 76% of patients achieved their BP target (140/85 for nondiabetics, 130/80 for diabetics) on completion of the programme. This fell to 53% at 1 year, but absolute systolic BP changed only from a mean of 125mmHg (SD 17) on completion to 135mmHg (SD 18) at 1 year. 87% achieved a fasting total cholesterol <5.0 mmol/l at re-screening (78% at 1 year). 95% of participants were taking antiplatelet therapy on completion of the programme (94% at 1 year). Conclusions A multi-disciplinary cardiac prevention programme can achieve and sustain effective secondary prevention. The principles of this programme are transferable to other institutions.

Psychological interventions for coronary heart disease.

Psychological interventions can form part of comprehensive cardiac rehabilitation programmes (CCR). These interventions may include stress management interventions, which aim to reduce stress, either as an end in itself or to reduce risk for further cardiac events in patients with heart disease. To determine the effectiveness of psychological interventions, in particular stress management interventions, on mortality and morbidity, psychological measures, quality of life, and modifiable cardiac risk factors, in patients with coronary heart disease (CHD). We searched CCTR to December 2001 (Issue 4, 2001), MEDLINE 1999 to December 2001 and EMBASE 1998 to the end of 2001, PsychINFO and CINAHL to December 2001. In addition, searches of reference lists of papers were made and expert advice was sought. RCTs of non-pharmacological psychological interventions, administered by trained staff, either single modality interventions or a part of CCR with minimum follow up of 6 months. Adults of all ages with CHD (prior myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, angina pectoris or coronary artery disease defined by angiography). Stress management (SM) trials were identified and reported in combination with other psychological interventions and separately. Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information. Thirty six trials with 12,841 patients were included. Of these, 18 (5242 patients) were SM trials. Quality of many trials was poor with the majority not reporting adequate concealment of allocation, and only 6 blinded outcome assessors. Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality, or revascularisation. There was a reduction in the number of non-fatal reinfarctions in the intervention group (OR 0.78 (0.67, 0.90), but the two largest trials (with 4809 patients randomized) were null for this outcome, and there was statistical evidence of publication bias. Similar results were seen for the SM subgroup of trials. Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression. Few trials reported modifiable cardiac risk factors or quality of life. Overall psychological interventions showed no evidence of effect on total or cardiac mortality, but did show small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately. However, the poor quality of trials, considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infarction insecure.

Predictors of left ventricular remodeling in patients with acute myocardial infarction participating in cardiac rehabilitation.

This study was designed to determine the factors influencing the development of left ventricular (LV) remodeling in patients participating in a comprehensive cardiac rehabilitation (CR) program after acute myocardial infarction (AMI), with special reference to exercise intensity and frequency. A total of 72 patients with AMI participated in CR consisting of exercise training of moderate intensity (heart rate reserve 40-60%) and education for 12 weeks. Plasma concentration of brain natriuretic peptide (BNP) was measured at the beginning and the end of CR. Echocardiography was performed before and 1 year after CR. An increase in LV end-diastolic dimension (delta-LVDd) from baseline was used as an index of remodeling. Delta-LVDd was significantly greater in patients with an anterior AMI than with other infarct locations (p<0.05) and correlated significantly with baseline BNP concentration (p<0.05). Delta-LVDd >5 mm occurred exclusively in patients with baseline BNP >150 pg/ml. Variables representing the intensity and frequency of exercise training did not correlate with delta-LVDd. In patients with AMI participating in CR, those having both anterior infarction and baseline BNP concentration >150 pg/ml are at high risk for subsequent LV remodeling, whereas neither exercise intensity nor participation frequency in CR appears to be associated with LV remodeling.