HISTORY: This 58-year-old shipyard welder suffered a cardiac arrest and was resuscitated on the dock, transported by EMS to nearby major medical center, had another arrest while his EKG was being monitored. He was resuscitated, the admission diagnosis was, myocardial infarction & hypoxic encephalopathy. Examination in the hospital: Ventriculogram - anterior free wall & septum is essentially akinetic, ejection fraction is normal, akinesis of a portion of the mid anterior wall and the infero-apical portion of the left ventricle. Arteriogram - occlusions; LA D 99%, diagonal 100% (irregularly filled distally by collaterals), circumflex- anterior lateral branch 40%, anterior lateral branch 75–85%, right coronary 100% (junction of proximal and middle 1/3), posterior descending 75%. Luminal irregularity of all distal vessels. Cardiologist opinion: Not suitable candidate for bypass operation. On hospital discharge (Sept. 4) patient advised to become content, for the rest of his days, in one room. ôJust thinking of walking across the street could be fatalö. Medications on discharge: propranolol 120 mgm 3x daily, isosorbide dinitrate 20mgm 4x daily, nitroglycerin skin ointment linch applied each night, nitroglycerin grain 1/50 sublingual as needed. Examination: On Sept. 10 the patient arrived in a wheelchair. BP 120/90, heart rate regular at 59/min., skinfold body fat estimation 22.2%. Exercise was test deferred because patient had angina with any exercise. Skin dry, poor turgor & elasticity. OPTIMALLY INDIVIDUALIZE REHABILITATION - DON'T EVER GIVE UP DIFFERENTIAL DIAGNOSIS: Minimal myocardial functional capacity Diffuse arteriosclerosis Low arterial oxygen partial pressure (PaO2) Capillary bed defficiency Defficient oxygen perfusion Defficient oxygen metabolism capacity TEST AND RESULTS: resting blood pressure(BP) 112/68, pulse(HR) 68/min, PaO2 66 mm Hg, exercise test deferred TREATMENT AND OUTCOME: (The goal is to increase body O2 metabolism without excess demand for O2 by the myocardium.) Dipyridamole 50 mg three times daily (to increased capillary bed density, & dilate blood vessels). Monitor EKG & give Nasal 02 4 l/min during 1hr of therapy (Rx) daily. First 6 days Rx- resting 15 min, hyperthermia (sauna 60°C) 15 min, rest 30 min. Next 3 weeks Rx was 15 minutes resting, 15 minutes sauna, 15 minutes resting, 15 minutes bicycling, 15 minutes resting. Exercise intensity adjusted as indicated by HR (88/min on day 7 and daily progress to 104/min by day 12). By Oct. 10, day 30, the PaO2 had increased to 82.1 mm Hg. Which indicates heart oxygen perfusion capacity increased by 59% if myocardial intracellular PO2 was 40mm Hg (O2 perfusion rate is proportional to capillary pressure minus intracellular pressure). Exercise test on treadmill indicated peak HR 116/minutes at 2 mph and 7.5% grade. Then daily Rx changed to 15 minutes resting, 15 minutes exercising on the treadmill at HR 110 to 112/minutes, 15 minutes resting. After four weeks on this regimen O2 administration was discontinued and walking exercise adjusted daily to produce HR of 108 to 112 for three miles daily. Also daily upper body strength training progressively increased as tolerated. After 4.5 months of rehabilitation the patient returned to the shipyard and supervised the welding operations on the 400 yard long dock. Before leaving the shipyard 2.5 years later he was climbing vertical ladders into and out of tankers 75 feet down and up. This case demonstrates that rehabilitation is possible even in patients with severe arterial disease that is not surgically treatable. Challenging the oxygen perfusion capacity while administering medication that has been shown to increase capillary bed density in exercising animals by as much as 28 percent in four weeks of the exercising 30 minutes per day, 5 days each week can greatly improve functional capacity. August Krogh verified that increasing the capillary bed density 17% can increase the oxygen perfusion rate 100% without increasing the flow through the arteries. This was verified in Burton's Textbook on Physiology of the Circulatory System.