Journal of Cardiopulmonary Rehabilitation

This study was directed toward establishing whether and to what extent, short-term endurance training influences the insulin blood level, and the binding and degradation of 125I-insulin by erythrocyte receptors in patients undergoing rehabilitation after myocardial infarction. The study was conducted in a group of 60 patients who had had myocardial infarction within the past 1.5 to 3 months and who did not have arterial hypertension and diabetes mellitus. All the patients took a symptom-limited cardiopulmonary exercise test. Before and after the test, venous blood was collected to determine lactic acid and insulin blood levels as well as the binding and degradation of 125I-insulin. The study group was randomized into two subgroups. One subgroup entered into a 3-week in-patient rehabilitation course. The control group was discharged from the hospital and was given no recommendations for physical exercise. The same investigation was repeated 3 weeks later. In the patients (50%) with hyperinsulinemia (insulin resistance index, > 10 microIU/mL), which was detected during the first investigation, insulin blood level decreased from 23.9 +/- 4.4 to 15.0 +/- 1.9 microIU/mL (P < 0.05) after rehabilitation, whereas insulin binding increased from 0.67 +/- 0.05 to 0.85 +/- 0.08 pg 125I/10(11) erythrocytes (P < 0.05). In the control group, which included normal subjects and those with hyperinsulinemia, the results obtained during the first and second investigations showed no statistically significant changes when compared. The results suggest that a 3-week endurance training period during rehabilitation after myocardial infarction reduces insulin resistance in patients with hyperinsulinemia.

Given our approach to the cardiac rehabilitation process, which is reflected in the program structure and services and our high patient volume, this program model is effective for us. The model permits us to treat relatively large number of patients with relatively small numbers of staff. On average, a patient attends 32 supervised exercise sessions at the Centre over the course of 12 months. This is actually fewer supervised sessions than the popular model of 3 times per week for 12 weeks. However, the 12-month program provides an additional 9 months to work with patients on heart-healthy lifestyle modifications. At the same time, we realize our model is not the model of choice for all people in all settings for a variety of reasons. We trust that some elements of our program may be of interest and beneficial to some readers. Undoubtedly, the program will continue to evolve and develop into the future. Currently, we are conducting a cardiac rehabilitation outcomes study in an effort to determine the appropriate duration of cardiac rehabilitation to achieve optimal physiological, psychological, and cost benefits for patients. This study involves more than 700 patients and the results are intended to help us further refine the program structure and selected program elements. As the new millennium approaches, healthcare system reforms and continuing changes in the delivery of medical care to cardiac patients present opportunities, challenges, and some uncertainties for cardiac rehabilitation. To continue our services to patients and the medical community, cardiac rehabilitation programs will need to identify and develop even more innovative and effective concepts in response to ever-changing local, regional, and national issues.

The American Association of Cardiopulmonary Rehabilitation (AACVPR) established guidelines for cardiac rehabilitation (CR) personnel regarding educational degree attainment, licensure, and certification. New England hospital-based CR personnel were surveyed by staff position to determine their adherence to these guidelines. The New England Hospital-Based CR Program Questionnaire was designed to obtain information regarding program characteristics and personnel credentialing. Initially, 117 program directors agreed to participate, and 108 returned completed questionnaires for a response rate of 92.3%. Of the CR programs surveyed, 41% were within hospitals containing 101 to 250 beds, whereas most of those providing inpatient (66.6%) and outpatient (82.4%) CR enrolled less than 200 patients annually. Overall, 40.7% of personnel (n = 450) by staff position reported that they met the minimum recommendations, whereas 7.0% (n = 470) met the preferred AACVPR recommendations. Registered nurses (n = 67) and physical therapists (n = 58) were most compliant with the minimum guidelines: 89.6% and 84.5%, respectively. In contrast, 10.9% of the program directors/coordinators (PD/C; n = 128) met the minimum qualifications, and 5.5% met the preferred AACVPR qualifications. Most PD/C had Advanced Cardiac Life Support Certification (84.4%), but few (18%) attained American College of Sports Medicine (ACSM) certification. Overall, compliance of New England hospital-based CR personnel with the AACVPR minimum/preferred guidelines for educational degree and certification was lacking, as was acquisition of ACSM certification. The effect of these findings on the future status of recommended and required CR personnel qualifications for hire merits attention.

A large number of published studies suggest that physician compliance to the NCEP guidelines (1993) in screening and treating hyperlipidemia in patients with coronary artery disease is poor. In this study, we demonstrate that the frequency of lipid-lowering therapy in patients with coronary artery disease, screened 6 to 8 weeks after an acute coronary event, at entry into CR, has nearly doubled from 1996 to 1999-2000 from 33% to 64%.

Epidemiologic evidence suggests that 8,368 kJ or 2000 kcal per week of moderate physical activity, including walking and stair climbing, can reduce risk of coronary heart disease (CHD). The goal of this study was to assess the effects of this amount of these two activities on physical fitness and risk factors for CHD. Twenty-two healthy, slightly overweight, sedentary, normotensive, normolipemic men, age 22 to 44 years, were randomly assigned to an exercise or control group for 12 weeks followed by a 4-week washout period. The subjects then were crossed-over to the alternate group for an additional 12-week period. Exercise consisted of 5 days per week of supervised treadmill exercise plus stair climbing. Treadmill exercise consisted of walking for 45 minutes at 5.15 km per hour at 2% grade for a total of 19.3 km per week. Subjects also climbed 10 floors of stairs at a time at their own pace without prescribed target heart rates for a total of 50 floors per week. The estimated total weekly energy cost of the treadmill walking plus stair climbing was 8,368 kJ or 2,000 kcal. Mean observed heart rates were 55% and 82% of maximal heart rate during treadmill walking and stair climbing, respectively. Data from the two exercise periods and two control periods were pooled and compared by analysis of variance. Sixteen subjects completed all phases of the study. Maximal oxygen uptake (VO2max) by the Bruce treadmill exercise protocol with metabolic gas measurements was below average for age at baseline, and was not significantly affected by 12 weeks of training. No significant changes were noted between groups in body weight or percent body fat (hydrostatic weighing), although there was a trend for loss of weight and fat with exercise training. Mean systolic blood pressure (119 mm Hg) was unchanged in both groups. However, diastolic blood pressure (72 mm Hg and 78 mm Hg for the treatment and control groups, respectively) showed an unexpected 6 mm Hg increase during the exercise period and a 5 mm Hg decline during the control period. Mean plasma lipid and lipoprotein levels were unaffected by training, except for a 16% reduction in triglycerides (P < .05). However, a 28% increase in plasma high density lipoprotein (HDL)-cholesterol (P < .01) was noted during the initial 12-week training period, which regressed during the washout period, and was not replicated during the second 12-week exercise period. Twelve weeks of walking and stair climbing at a moderate pace and intensity at an energy cost of about 2,000 kcal per week failed to improve physical fitness or risk factors for CHD. A reduction in physical activities other than the prescribed exercise program, as reported by a physical activity recall questionnaire, probably contributed to an absence of an exercise response. A longer and/or a more intense activity program is apparently required to improve these modalities.

The purpose was to evaluate the effects of a health promotion curriculum on health knowledge, behavior, cardiovascular fitness, and cardiovascular risk factors. A multi-ethnic, multi-cultural sample (n = 54) of 10th grade males and females participated in a study of cardiovascular health promotion and coronary risk factor reduction. The sample was comprised of Asian-Americans (39%), blacks (33%), Hispanics (11%), whites (2%), and others (15%). Intervention consisted of a 10-week health promotion curriculum of classroom education modules in physical activity, nutrition, smoking cessation, stress management and personal problem solving, and an exercise program of walking and running. A nonintervention control group served as a basis for comparison. Classroom and exercise sessions met on alternate days. Following intervention, a significant treatment effect (P = .007) was observed in lowered total cholesterol, and significant within group improvements (P < .01) were observed in diet habits, percent body fat, and cardiovascular health knowledge. Comparisons of knowledge and social effects revealed higher cardiovascular health knowledge (P < .05) in subjects of nonsmoking compared to smoking parents, higher self-perception of health (P < .01) in more active vs less active subjects and better dietary habits (P < .07) in children whose parents were college educated compared to parents who did not attend college. Preliminary findings suggest that a health promotion curriculum consisting of health education, behavior modification, and regular aerobic exercise lowers cholesterol, improves health behavior and increases health knowledge.

The most common effect of postmyocardial infarction (post MI) rehabilitation is an increase of peak maximal oxygen consumption correlated with changes in calf muscle metabolism, but there are few data on follow-up after rehabilitation on skeletal muscle and maximal oxygen consumption. The purpose of this study was to investigate the respective modifications in skeletal muscle metabolism and peak oxygen consumption (VO2) occurring during a supervised rehabilitation program and 1 year after MI in patients free of heart failure. Fifteen outpatients were studied prospectively after the acute phase of the MI, at the end of the rehabilitation program (2 months after the MI), and 1 year after. The rehabilitation comprised 20 sessions with three sessions per week. The program consisted of exercise training with bicycle, arm ergometer, and treadmill. The program also included respiratory exercises, psychological support, and counseling for secondary prevention of cardiovascular diseases. At each visit, a stress test on a bicycle ergometer was performed and the peak VO2 was measured. Phosphorus magnetic resonance spectroscopy of the gastrocnemius muscle was performed at rest and during a plantar flexion-type exercise against an adjustable load. Data were analyzed using analysis of variance and post-hoc test when appropriate. The mechanical power output measured during the bicycle exercise increased from 111 +/- 28 watts at the post MI test to 136 +/- 40 watts after rehabilitation (post rehab) and decreased to 125 +/- 36 watts at 1 year. The peak VO2 increased significantly (P < 0.05) from 22 +/- 7 ml/kg-1/min-1 (post MI) to 27 +/- 9 ml/kg-1/min-1 (post rehab), and decreased significantly to 24 +/- 8 ml/kg-1/min-1 (1 year). The mechanical power output measured in the magnet during the stress test increased from 2.22 +/- 0.13 watts (post MI) to 2.85 +/- 1.24 (post rehab), and stabilized at 2.78 +/- 1.10 watts at 1 year. At the highest workload attained in the three successive tests, the phosphocreatine/(phosphocreatine + inorganic phosphate) ratio rose significantly (P < 0.05) from 0.46 +/- 0.13 (post MI) to 0.51 +/- 0.13 (post rehab) and remained at 0.51 +/- 0.13 at 1 year. The improvement of the peak VO2 after training post MI is not maintained 1 year later. This decline is not accompanied by muscular metabolic abnormalities. This suggests that the muscle metabolism after MI remains normal, and that the long-term decrease of the peak VO2 reflects a global deconditioning that should be avoided by maintaining a long-term phase III rehabilitation program.

Pulmonary rehabilitation (PR) is an accepted therapy for patients with chronic obstructive pulmonary disease (COPD), improving both exercise capacity and quality of life (QOL). Generic measures of QOL have been criticized as being insensitive to detecting the improvement in QOL after PR in contrast to disease-specific instruments. The authors looked at the Medical Outcomes Survey Short Form 36-item questionnaire (SF-36), a generic QOL measure, to detect changes in QOL in COPD patients after completion of PR. Patients with COPD who participated in a PR program completed the QOL questionnaire before and after completion of PR. Exercise tolerance was assessed by the 6-minute walking test. Quality of life was assessed by the SF-36; the authors calculated its eight dimensions as well as mental (MCS) and physical (PCS) component summary scores. The patients realized a significant improvement in exercise tolerance; 6-minute walking test distance increased from 470 +/- 104 m (mean +/- standard deviation) to 536 +/- 133 m (P = 0.0006) after PR. Quality of life also improved in nearly all dimensions and in both summary scores; PCS improved from 26.1 +/- 8.0 before PR to 30.5 +/- 9.0 after PR (P = 0.008) and MCS improved from 27.9 +/- 7.0 before PR to 34.1 +/- 5.0 after PR (P = 0.0002). The SF-36 and its summary scores are sensitive instruments to detect improvement in QOL in COPD patients after PR.

Cardiac rehabilitation is an integral component of comprehensive care for patients with coronary heart disease. Although the typical programmatic delivery of outpatient cardiac rehabilitation services often involves 36 sessions over 12 weeks, that format is based more on historical practice than on outcome data. This study aimed to determine the point at which during 52 weeks of outpatient cardiac rehabilitation, patients achieved peak values for selected outcomes, and whether the number of supervised exercise sessions had any effect on these outcomes. In this study, 623 male patients with coronary heart disease admitted to an outpatient cardiac rehabilitation program were randomized to one of two 52-week program formats. One format (CR1) used one supervised exercise session per week over 52 weeks, and the second format (CR2) used weekly supervised sessions for 26 weeks followed by one supervised session per month for the remaining 26 weeks. Both formats used four unsupervised, documented exercise sessions per week. Selected clinical, physiologic, and psychological variables were measured at baseline, then at 4, 12, 26, 38, and 52 weeks. The program costs for both the CR1 and CR2 formats were calculated from known expenses. Because there were no significant intercohort differences between CR1 and CR2 and no significant interaction (time x group), data from the two cohorts were pooled for statistical analysis. Peak oxygen intake (VO(2peak)) significantly increased by 4.4 mL/kg per minute at 38 weeks, and the greatest percentage of patients (30.1%) also achieved their highest VO(2peak) at this time. The largest gain in Medical Outcomes Survey Short Form 36 role physical scores was from baseline to 38 weeks (52.4 versus 85.2), and the highest percentage of patients (72%) with role physical scores in the excellent category occurred at 38 weeks. Clinical depression at baseline (Beck Depression Inventory score > 10) had no significant effect on the dropout rate or the gain in VO(2peak) with exercise training. Program costs for these alternative formats of service were similar to the cost for a standard program format of 36 sessions. Patients achieved their highest functional capacity after 38 weeks of outpatient cardiac rehabilitation using a program format of only 29 to 38 supervised exercise sessions. The results of this study show that an outpatient cardiac rehabilitation program combining supervised with unsupervised exercise sessions and continuing for 38 weeks results in the greatest improvement in these selected outcomes.

The reported outcomes statement is an update to the previous recommendations for outcomes evaluation in cardiac rehabilitation/secondary prevention programs. The purposes of outcomes evaluation are reviewed, and practical information with examples is provided to help programs implement an outcomes-directed approach within routine patient care and program management functions.

Increasing evidence suggests that abdominal obesity may be a better predictor of disease risk than total fatness. This study sought to determine how obesity and fat distribution measured by readily available anthropometric and dual-energy x-ray absorptiometry (DXA) methods is related to abdominal obesity assessed by magnetic resonance imaging (MRI). Men (n = 43) and women (n = 47), ages 55 to 75 years, were assessed for body mass index, waist-to-hip ratio, waist circumference, and skin folds by anthropometric methods; for percentage of body fat by DXA; and for abdominal total, subcutaneous, and visceral fat by MRI. In stepwise regression models, the waist-to-hip ratio explained 50% of the variance in abdominal visceral fat among men (P <.01), and body mass index explained an additional 6% of the variance (P <.01). Among women, waist circumference was the only independent correlate of abdominal visceral fat, accounting for 52% of the variance (P <.01). Among men, the percentage of body fat was the only independent correlate of abdominal subcutaneous fat, explaining 65% of the variance (P <.01). Among women, the percentage of body fat explained 77% of the variance in abdominal subcutaneous fat and body mass index explained an additional 3% (P <.01). Obesity and body composition obtained by readily available anthropometric methods and DXA provide informative estimates of abdominal obesity assessed by MRI imaging.

The purpose of this study was to determine the ability of the Caltrac accelerometer to assess habitual daily physical activity levels. The ability of the Caltrac accelerometer to assess 24-hour physical activity (PA) levels was studied in 28 men and 50 women, age 20 to 59 years, with varying levels of self-reported PA. Twelve days of Caltrac readings obtained over 1 year's duration were compared to simultaneously recorded 48-hour PA records. Additionally, 28 days of Caltrac readings obtained over 1 year's duration were compared to mean values of the following validation measures assessed repeatedly over a 1-year period: a 4-week version of the Minnesota Leisure Time Physical Activity Questionnaire (FWH); VO2peak; and percent body fat. The Caltrac measurements of movement (in MET minutes per day-1) were significantly associated with the following: PA record indices of total (r = .51) and heavy (r = .34) and PA; FWH indices of total (r = .30), heavy R = .36) and moderate (r = .23) PA;, and VO2peak (r = .24). However, the Caltrac measurements of caloric PA record and FWH indices of PA, although there were directly associated with percent body fat (r = .50) and inversely associated with VO2peak (r = -.26). Caltrac measurements of movement exhibited a moderate associated with several criterion measures related to habitual PA, whereas Caltrac measurements of total energy expenditure, were not reflective of varying levels of PA.

Activity monitoring is considered a highly relevant outcome measure of respiratory rehabilitation. This study aimed to assess the usefulness of a new accelerometric method for characterization of walking activity during a 3-week inpatient rehabilitation program. After individual calibration of the accelerometer at different walking speeds, whole-day physical activity was recorded for 15 patients with chronic obstructive pulmonary disease on the first and the last days of the program, and for 10 healthy subjects. Data were expressed as percentage of time spent in inactivity, low level activity, and medium level activity, with the latter corresponding to usual walking speed. The patients spent more time being inactive and less time walking than healthy subjects. At the end of the rehabilitation program, medium level activity had increased from 4% to 7% of total recording time. However, the change was not significant after periods of imposed exercise training were excluded. Walking activity increased to a greater degree among the patients with preserved limb muscle strength at entry to the program. Although health status scores improved, the changes did not correlate with the changes in walking activity. The findings lead to the conclusion that this new accelerometric method provides detailed analysis of walking activity during respiratory rehabilitation and may represent an additional useful measure of outcome.

This study aimed to assess the acceptability of a low-fat vegan diet, as compared with a more typical fat-modified diet, among overweight and obese adults. Through newspaper advertisements, 64 overweight, postmenopausal women were recruited, 59 of whom completed the study. The participants were assigned randomly to a low-fat vegan diet or, for comparison, to a National Cholesterol Education Program Step II (NCEP) diet. At baseline and 14 weeks later, dietary intake, dietary restraint, disinhibition, and hunger, as well as the acceptability and perceived benefits and adverse effects of each diet were assessed. Dietary restraint increased in the NCEP group (P <.001), indicating a greater subjective sense of constraint with regard to diet requirements, but was unchanged in the vegan group. Disinhibition and hunger scores fell in each group (P <.001 and P <.01, respectively). The acceptability of both diets was high, although the vegan group participants rated their diet as less easy to prepare than their usual diets (P <.05) and the NCEP participants foresaw continuation of their assigned diet to be more difficult than continuation of their baseline diets (P <.05). There were no between-group differences on any acceptability measures. The acceptability of a low-fat vegan diet is high and not demonstrably different from that of a more moderate low-fat diet among well-educated, postmenopausal women in a research environment.

Bus drivers frequently encounter difficulty in returning to their former employment after recovery from myocardial infarction. The risk that a recurrence of myocardial infarction may cause a personal-injury accident is analyzed. The Cumulative Medical Index and Current Contents was searched systematically from 1980 to date, accepting papers irrespective of language. Relevant earlier material was drawn from the author's published reviews on bus driving and myocardial infarction and vehicle accidents. One hundred twenty-three articles were included in the database, of which 110 were used in the review. The risk of a personal injury accident or fatality from a sudden cardiovascular incident is calculated as the product of typical driving time per day (Td = 0.167), vehicle characteristics (V) (a low factor of 0.167 for an urban bus because of slow speed and use of reserved curb lanes), the risk of recurrence of a sudden cardiovascular incident (SCI) (.015, somewhat greater in bus drivers than in the general population), and the risk that such an incident will cause a personal-injury accident (Ac) (at 0.005, probably lower than in the general population because of low vehicle speeds and the bus driver's experience in defensive driving). The overall risk is 0.00002, 1 in 50,000 driver-years, is lower than accepted for passenger-car operators, and only slightly greater than for the older symptom-free adult. Bus drivers who meet the current standards of the Canadian Cardiovascular Society should be encouraged to return to their former employment.

Although clinicians often rely on patients' retrospective reporting of dyspnea, it is not known if dyspnea scores recalled after exercise are equivalent to dyspnea scores during exercise. The objective of this study was to determine whether patients could accurately recall after exercise the maximum ratings of the intensity of dyspnea and the anxiety associated with it that they experienced during exercise. Forty-nine patients with chronic obstructive pulmonary disease (COPD) (forced expiratory volume in 1 second 0.92 +/- 0.23 L) participating in a randomized clinical trial of the impact of coached versus monitored exercise training on dyspnea rated dyspnea intensity (shortness of breath [SOB]) and dyspnea-related anxiety (DA) on a visual analog scale every 2 minutes during treadmill exercise. After each of 12 training sessions each subject was asked to rate the worst level of the two sensations that they recalled having experienced during exercise. For the groups as a whole, actual maximum scores for SOB and DA during exercise were highly correlated with recalled maximum values after exercise (r > or = 0.85, P < 0.0001) and the average differences were small (0-10.9 mm on a 200-mm scale). However, individual variation was substantial, limiting predictability for individual ratings. After exercise, patients with COPD as a group can accurately recall the worst SOB and DA that they experienced during exercise. This finding supports the further study and use of retrospective symptom ratings as a method for dyspnea assessment during exercise training in pulmonary rehabilitation.

Exercise prescription in patients with left ventricular systolic dysfunction (LVSD) is difficult. Exercising beyond ventilatory threshold (VT) can have negative physiologic effects; therefore, exercise prescribed above VT may be detrimental. A majority of cardiac rehabilitation programs use the Karvonen/heart rate reserve (HRR) method, rating of perceived exertion (RPE), and/or a percentage of oxygen consumption to prescribe exercise intensity. The purpose of this study was to determine if these methods correlate with an exercise intensity below VT in LVSD patients. The authors studied 52 patients (37 males, 15 females; age 52 +/- 13 years; left ventricular ejection fraction 27% +/- 8%) who underwent a symptom-limited cardiopulmonary exercise test and reached VT to determine functional capacity and exercise prescription. Peak heart rate (HR) as well as HRR derived minimum (60%), midpoint (70%), and maximum (80%) HR were highly correlated (P < 0.001) with HR at VT. Using these three different HR cutoff formulas from HRR, 15% to 62% of patients were prescribed exercise outside the range of VT-HR +/- 10%. The midpoint (70% HRR) best predicted exercise HR in the VT-HR +/- 10% range (73% of patients). Mean oxygen consumption at VT was 83 +/- 9% of peak oxygen consumption. There was no correlation (P < 0.16) between RPE and VT. The Karvonen/HRR method failed to estimate HR-VT +/- 10% in a large percentage of patients with LVSD. There was no correlation between RPE and VT. Based on these data, exercise training intensity should ideally be prescribed based on the HR identified at VT using cardiopulmonary exercise testing in patients with LVSD.

The findings of this review demonstrate that women appear to use CR services less frequently than men and, when they enroll, present differently at entry to CR. Women often are older, likely because they experience later onset of CHD; present with greater medical comorbidities; and perceive greater psychosocial challenges such as less social support and quality of life. Given these additional burdens experienced by female CR participants, women may have fewer physical and emotional resources for fully attending, adhering to, and, ultimately, benefiting from CR than men. Previously reported studies have indicated that men and women participating in CR appear to experience improvements in exercise capacity and QOL. However, whether women in particular are able to sustain these benefits has not been examined. There is some emerging evidence that women may struggle more psychosocially than their male counterparts. Whether these psychosocial challenges persist in the years after participation in CR, or whether these challenges influence long-term medical outcomes such as incidence of restenosis, reinfarction, or CHD mortality remains unanswered and continues to be an important focus for future research.

Numerous secondary prevention trials emphasizing nutrition have demonstrated that cardiac patients can benefit from several inclusionary nutrient-dense, fiber-rich dietary patterns with varying macro- and micronutrient compositions. In many cases, reductions in morbidity and mortality are achieved independently of significant improvements in established CVD risk factors. These reductions likely are influenced by a synergism of multiple nutritional components that positively effect putative risk factors. The current AHA and NCEP ATP III heart healthy nutrition recommendations offer excellent guidance for achieving an efficacious dietary pattern that emphasizes an inclusionary paradigm. The specific dietary pattern that is encouraged should include consideration of individual risk factors and patient preferences to optimize the probability of long-term compliance.

Outcomes measurement in cardiac rehabilitation presents a unique challenge because of the multifaceted nature of the service. The value of measuring outcomes is many-fold, and has been discussed previously. The AACVPR recommends measurement of at least one outcome in each of three domains: clinical, behavioral, and health. A number of states have designed state/regional outcomes projects in order to collect aggregate data for comparison.

Acupressure is a therapy in which gentle pressure is applied with fingers at specific acupoints on the body. It is reported to relieve pain and have other beneficial effects. This study was designed to ascertain the value of self-administered acupressure as an adjunct to a pulmonary rehabilitation program (PRP) for relief of dyspnea and other symptoms in patients with chronic obstructive pulmonary disease (COPD). A single-blind pretest-posttest, cross-over design was used. Thirty-one new patients beginning a 12-week PRP at two private hospitals were randomly assigned to one of two groups. Patients in group 1 were taught acupressure and practiced it daily at home for 6 weeks, then sham acupressure for the following 6 weeks. In group 2, the order of acupressure and sham acupressure was reversed. During weeks 1, 6, and 12, patient dyspnea, other symptoms associated with COPD, activity tolerance, lung function, and functional exercise capacity were assessed. Real acupressure was more effective than sham acupressure for reducing dyspnea as measured by a visual analog scale (P = .009, one-tailed), and was minimally effective for relieving decathexis (P = .044, one-tailed). Sham acupressure seemed to be more effective than real acupressure for reducing peripheral sensory symptoms (P = .002, two-tailed), but the presence of these symptoms may also be an indication that the acupressure is affecting the body. Acupressure seems to be useful to patients with COPD as an adjunct to a PRP in reducing dyspnea. Some persons who are not initially familiar with traditional Chinese medicine can learn and will accept self-administered acupressure as part of their self-care.

The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) clinical trial was designed to test whether intervening on depression or low perceived social support reduces mortality and reinfarction in patients with acute myocardial infarction (MI). This report analyzes the effect of the intervention on quality of life (QOL), which was an important secondary outcome. ENRICHD was a randomized controlled clinical trial comparing a psychosocial intervention based on cognitive behavioral therapy to usual medical care in 2,481 patients from 8 clinical centers. Patients with acute MI were included if they met criteria for depression, low perceived social support, or both. QOL was assessed at the 6-month clinic visit in the first 1,296 patients. QOL measures included the Medical Outcomes Study Short Form summary measures of physical functioning (SF12-PCS) and mental functioning (SF12-MCS), a Life Satisfaction Scale (LSS), and a measure of overall QOL based on the ladder of life (LOL) technique. There were significant treatment differences on the SF12-MCS (difference 2.2, 95% confidence interval [CI] 1.2-3.2), the LSS (difference 1.0, 95% CI 0.5-1.5), and the LOL (difference 0.3, 95% CI 0.1-0.6), but not on the SF12-PCS (difference 0.8; 95% CI = -0.5-2.0). Effect sizes for the intervention on QOL outcomes were modest. Psychosocial interventions of limited duration confer modest QOL benefits in post-MI patients who are depressed or have low perceived social support. Interventions of longer duration or greater intensity may be required to produce more substantial improvements in QOL in these patients.

The objective of this study was to review studies systematically, in which the acute effects of noninvasive ventilatory support (NIVS) during exercise were evaluated in patients with chronic obstructive pulmonary disease (COPD). In addition, a quantitative analysis was performed on the effects of NIVS on exertional dyspnea and exercise endurance. Literature was searched in electronic databases, and by scanning lists of references of studies and abstract books of annual congresses of the American Thoracic Society and European Respiratory Society. Preliminary data of a study by our own group into the effects of NIVS on exercise endurance in patients with COPD were added. The systematic review was carried out on the basis of a validated methodological screening list. For the quantitative analysis, Glass delta of individual studies were pooled to aggregate a summary effect size. Fifteen studies were identified. Seven of these studies met the inclusion criteria, including a total of 65 patients with COPD. The methodological quality of the included studies varied from 31% to 54% of the maximum score of 13 points. Statistically significant summary effect sizes were found in the analysis of exertional dyspnea (P <.05) as well as in the analysis of exercise endurance (P <.001), indicating improvements in these outcomes in favor of NIVS. The present systematic review suggests that NIVS during exercise may acutely reduce exertional dyspnea and improve exercise endurance, in patients with COPD.

Health-related quality of life (HRQL) instruments provide valid and responsive outcome measures to assess the impact of disease and the response to interventions. However, they have not been applied widely to studies of rehabilitation after myocardial infarction. To examine the extent to which baseline sociodemographic and clinical characteristics predict baseline and change in generic and specific HRQL. A randomized controlled trial of an 8-week cardiac rehabilitation intervention or usual care, with follow-up for 12 months, in 201 patients with acute myocardial infarction (MI). Multiple regression analysis was used to identify predictors of HRQL. Specific HRQL scores and exercise tolerance improved significantly more in rehabilitation patients than usual care patients by the end of the 8-week intervention. All HRQL measures and exercise tolerance in both groups improved significantly during the 12 month follow-up period but the differences between the groups were trivial. A poor baseline HRQL was the predominant predictor of improved generic and specific HRQL. Furthermore, greater improvement in HRQL consistently was associated with lower levels of cardiovascular risks such as absence of a previous MI or coronary artery bypass surgery, absence of angina, less smoking, and higher exercise tolerance. Improved generic and specific HRQL was associated with poorer baseline HRQL and less baseline cardiovascular risk. This reinforces the importance of addressing health behavior changes as soon as possible after MI and the usefulness of assessing both generic and specific HRQL in evaluating treatment effectiveness.

Strenuous exercise in animal studies has been shown to cause acute oxidative stress due to the generation of oxygen-centered free radicals reflected in lower levels of glutathione (GSH), higher levels of glutathione disulfide (GSSG), and a drop in GSH:GSSG ratios, the maintenance of which is crucial for a variety of cell functions. Human studies on this topic are limited. The purpose of this study was to investigate the effects of a maximal graded exercise test GXTmax (modified Bruce protocol) on GSH as a marker of acute oxidative stress, and whether full recovery will occur at 60 minutes postexercise. Eighty sedentary subjects were used as a sample of convenience. Venous blood samples for GSH and GSSG were collected directly before, immediately after, and 60 minutes post-GXTmax. Repeated-measures analysis of variance and Bonferroni adjusted t tests (post-GXTmax) versus resting, and 60 minutes recovery versus resting) were used for data analysis. As an acute response to maximal exercise, the GSH levels dropped significantly from a resting baseline value of 1025.75 microM to an immediate post-GXTmax value of 893.30 microM (pooled SE = 7.17 microM). The GSSG levels significantly increased from 2.24 microM to 3.15 microM (pooled SE = 0.03 microM). The GSH:GSSG ratio levels significantly dropped from baseline 462.12 to 276.40 postexercise (pooled SE = 5.98). The blood GSH, GSSG, and GSH:GSSG ratio levels showed no significant difference at 60 minutes post-GXTmax when compared with resting values, indicating full recovery. The current results indicated that in sedentary individuals, a maximal treadmill GXT is an effective technique for inducing acute oxidative stress as evidenced by GSH system responses, with full return to resting baseline levels within 60 minutes of recovery. The potential for using this model in assessing oxidative stress responses to cardiac and pulmonary rehabilitation is of clinical interest, with a need for further investigation.

Cardiac rehabilitation after acute coronary syndrome is an important but underused therapeutic intervention. The aim of the French nationwide PREVENIR survey was to improve knowledge on the management of cardiovascular risk factors, especially during cardiac rehabilitation after acute coronary syndrome. The purpose of this study was to specify the characteristics of patients referred to cardiac rehabilitation. The survey was performed in 77 of 501 (15.4%) public or private French coronary care units. All French regions were involved. All the patients admitted to the hospital during January 1998 who survived an acute coronary syndrome were included in the survey. Data on rehabilitation practice were collected from patient medical records, either during an outpatient consultation or from the patient and the general practitioner during the 6-month follow-up period. Of the 1394 patients included in the study (779 with myocardial infarction and 615 with unstable angina), only 310 (22%) underwent cardiac rehabilitation. Significant differences in patient characteristics were found between the cardiac rehabilitation and non-cardiac rehabilitation groups, respectively, in terms of gender (82% male vs 68%; P <.001), age younger than 65 years (56% vs 39%; P <.001), type of acute coronary syndrome (75% myocardial infarction vs 50%; P <.001), left ventricular ejection fraction less than 35% (6% vs 13%; P <.0004), and prevalence of percutaneous intervention (54% vs 46%; P <.02). Two risk factors were more common in the rehabilitated group: dyslipidemia (52% vs 44%; P <.02) and current smoking (51% vs 37%; P <.0001). In the multivariate analysis, female gender (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.44-0.87) and older age (>75 years vs. <65 years; OR, 0.40; 95% CI, 0.3-0.7) predicted decreased cardiac rehabilitation prescription. Conversely, previous history of dyslipidemia (OR,1.4; 95% CI, 1.04-1.8), post-myocardial infarction (OR, 2.8; 95% CI, 2.13-3.89), and a percutaneous intervention (OR,1.9; 95% CI, 1.3-2.7) predicted increased cardiac rehabilitation prescription. Severe left ventricular impairment (< or =35% vs >50%) was not an independent factor for cardiac rehabilitation prescription. At 6-month follow-up assessment, rehabilitation patients had a lower rate of hypertension (18% vs 27%), elevated low-density lipoprotein cholesterol (54% vs 62%), and continued smoking (34% vs 50%). The results of the PREVENIR survey underscore the low level of cardiac rehabilitation prescription in France, and the relative exclusion of women and elderly people. Among the risk factors, dyslipidemia and current smoking are more frequent among rehabilitated patients. These findings may help to modify the strategy for using cardiac rehabilitation after acute coronary syndrome, although it is an effective intervention for secondary prevention.

Coronary heart disease is the number one cause of death for both men and women. While adults 65 years of age and older comprise the largest percentage of those who experience an acute myocardial infarction (AMI), investigators to date have failed to examine the knowledge of this population about AMI symptoms. The purpose of this study was to document knowledge about cardiovascular disease and AMI symptoms in older individuals with coronary heart disease to identify the characteristics associated with increased knowledge of cardiovascular disease. A descriptive design was used with a convenience sample of (N = 115) older adults at risk for AMI. Data were collected during face-to-face interviews in the participants' homes and analyzed using frequencies, percentages, chi, and multiple regression analysis. Men and women were not significantly different in their knowledge of AMI symptoms except for jaw pain. More than 95% of the both men and women knew typical symptoms of AMI, such as chest pain, pressure, shortness of breath, arm or shoulder pain, and sweating. Less than 75% of both men and women knew that symptoms such as neck pain, nausea or vomiting, back pain, heartburn, and jaw pain could be symptoms of AMI. Thirty-one percent did not know about reperfusion therapies in the treatment of AMI. Having a cardiologist involved in care was weakly predictive of less knowledge. Education and counseling of older patients at high risk for heart disease is complex, but should emphasize atypical symptoms and treatment options.

To determine if weight training used during cardiac rehabilitation as soon as 4 weeks after myocardial infarction (MI) is safe, and if weight training combined with aerobic exercise improves aerobic fitness and muscle strength more than aerobic exercise alone. Twenty-three men within 6 weeks of an acute MI and without exercise-induced ischemia, complex arrhythmias, anterior Q wave MI, or ejection fraction < 40% were randomly assigned to combined weight and cycle training versus cycle training for 10 weeks. The main measures were change in maximal oxygen uptake (VO2max), muscle strength, resting left ventricular (LV) wall segment motion and early diastolic filling by resting echocardiograms, exercise ECG, heart rate, and blood pressure responses [corrected]. VO2max increased 14% (P < 0.01) and cycle time increased 10% (P < 0.01) in the combined training group. The 8% increases in VO2max (P = 0.15) and cycle time (P = 0.08) in the cycling group were not significant. Arm and leg strength increased (P < 0.01) in each group. However, the change was greater for the combined training group--31% versus 16% (P < 0.03) for leg strength and 20% versus 10% (P < 0.001) for arm strength. There were no changes for either group in resting hemodynamics, body weight and composition, LV wall segment motion, LV fractional shortening, and early diastolic function, and no adverse clinical events or exercise-related complications. Combined training soon after MI improved aerobic and muscle fitness more than cycling alone, and was performed without complication.

Psychosocial factors, such as depression, have been identified as important predictors of morbidity and mortality in individuals with coronary heart disease; however, little research has been done examining hopelessness in this population. This investigation examined the frequency and severity of hopelessness and depression in the early recovery period after hospitalization for acute coronary syndrome (ACS), the relationship between hopelessness and depression, and patient characteristics leading to these 2 variables. A total of 525 post-ACS patients at 5 hospitals in Michigan were interviewed. Measures included the cognitive expectations factor of the Beck Hopelessness Scale and the Center for Epidemiologic Studies-Depression Scale. Hopelessness symptoms were frequent and moderate to severe in 27% of the sample, whereas depression was frequent and moderate to severe in 36% of subjects. Hopelessness was moderately correlated with depression, yet a number of different patient characteristics were predictive of each. Lower educational level predicted hopelessness, but not depression. Patients who had coronary artery bypass surgery or coronary angioplasty were more hopeless, but not more depressed. Female gender predicted depression, but not hopelessness. Hopelessness and depression had a shared variance of 33%. Hopelessness and depression were frequent and moderate to severe in a portion of patients in the early ACS recovery period. An association between hopelessness and depression exists, while different patient characteristics were more strongly associated with each. Longitudinal analysis is needed to examine hopelessness and depression in later phases of the ACS recovery period.

Psychosocial factors, such as emotional distress and social isolation, have been increasingly recognized as important risk factors for patients' recovery from acute myocardial infarction (AMI). This study examined age, gender, and ethnic differences in depression and general distress, social support, and health-related quality of life after AMI. Data came from a series of 88 patients aged 62.1 +/- 14.2 years (46% female) who were hospitalized for AMI at eight different US clinical centers participating in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Pilot Study. Standardized psychometric measures were administered to assess three psychosocial domains: (1) depression and general distress (mental health functioning), (2) social support, and (3) health-related quality of life. Multivariate analysis of variance was used to examine the effects of age, gender, and ethnic differences in each of the three psychosocial domains. Female patients reported higher levels of depression and distress compared with male patients (P = .040). Gender differences in mental health functioning differed by age (P = .046), with the greatest differences observed among younger female patients. Older patients (P = .014) and female patients (P = .025) reported lower levels of social support compared with younger and male patients, respectively. Minority patients did not differ from nonminority patients in mental health functioning or social support, and there were no significant differences in post-AMI quality of life on the basis of age, gender, or ethnicity. The psychosocial risk profile after AMI may be different for male and female patients, and interventions may need to take account of each gender's specific needs.

This study was designed to assess the safety and effectiveness of walking when using 1-lb walking poles in Phase III/IV cardiac rehabilitation patients. Following instruction on the proper use of the poles and adequate time to practice, each subject completed two 8-minute walking trials on a level treadmill either with or without walking poles. Each trial was conducted at an identical speed for each subject in a randomized order. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and ratings of perceived exertion (RPE) were recorded every 2 minutes during each trial, while ECG responses (ST segment changes and dysrhythmias) were monitored continuously. Walking with poles significantly (P < .05) increased the energy cost of walking by 21% (3.8 mL/kg/min) compared to walking without poles. There were also significant (P < .05) increases in HR (14 bpm), SBP (16 mm Hg), and DBP (4 mm Hg) when comparing conditions. Calculated oxygen pulse (mL O2.heart beat) values indicated that changes in HR were consistent with the increase in VO2 and were not related to a pressor response mechanism. The only dysrhythmias noted were isolated PVCs, with no differences in the frequency of occurrence between trials. There were no adverse ST segment changes with either trial. These data demonstrate that at a given speed, the use of 1-lb walking poles can safely increase the intensity of walking exercise in Phase III/IV cardiac rehabilitation patients.

To investigate whether the acute benefits of rollator use are consistent over time in individuals with moderate to severe chronic obstructive pulmonary disease. Thirty-one stable subjects with chronic obstructive pulmonary disease (13 men, 18 women), aged 68 +/- 8 years, with a forced expiratory volume in 1 second of 0.7 +/- 0.2 L (33% +/- 12% predicted) and a baseline 6-minute walk (6MW) of 261 +/- 68 m, were recruited from a respiratory clinic after completion of a pulmonary rehabilitation program. Two 6MWs were performed at baseline, 4 weeks, and 8 weeks, one walking unaided and the other walking with the assistance of a rollator. The test order was randomly chosen at baseline, and the same test order was used at each time point. The primary outcome measures were distance walked in 6 minutes (meters), perceived dyspnea using a modified Borg scale, and number of rests taken. Subjects achieved higher 6MW distances during assisted compared with unassisted walking at baseline (292 +/- 67 vs 263 +/- 67 m), 4 weeks (296 +/- 62 vs 275 +/- 63m), and 8 weeks (283 +/- 65 vs 259 +/- 68 m) (P = .013), with no time effect (P = .5). In addition, use of a rollator resulted in a significant improvement in dyspnea (P = .004) at baseline, 4 weeks, and 8 weeks, with no time effect (P = .7). The use of a rollator also reduced the number of rests taken during the 6MW (P < .001), with no time effect (P = .9). Rollator use resulted in improvements in performance in the 6MW, which were consistent over time among individuals with moderate to severe chronic obstructive pulmonary disease who walk less than 375 m during an unaided 6MW.

Simultaneously measured oxygen uptake (VO2) and Doppler echocardiography could verify if an alteration in the VO2 response to progressive and constant load work is due to reduced cardiac output. The study group consisted of nine patients after acute myocardial infarction (MI), five age-matched healthy subjects (HE), and five young well-trained subjects (WT). Each subject performed a progressive exercise test and two bouts of constant load work at power outputs equated to 10% below (W1) and 10% above (W2) their ventilatory thresholds. VO2 and cardiac output were measured continuously and simultaneously during the tests. VO2 was significantly reduced for the MI group during the initial stages of the progressive exercise test (P < .02) and remained lower throughout the entire test. During the first 60 seconds of constant load work (W2), VO2 was lower for MI (P < .05). At steady state exercise during W2, cardiac output was significantly less for MI (P < .05). VO2 for the MI group was more reliant on cardiac output during lower power outputs and differences in the arterial and venous O2 content (a-VO2 difference) during greater power outputs. Cardiac rehabilitation programs must be aware of this delayed VO2 and cardiac output response when setting training workloads or selecting the magnitude of the workload increments during progressive exercise tests.

The report aims to review the literature and describe the methods used for retention of patients in a clinical study. The Enhanced Recovery in Coronary Heart Disease (ENRICHD) trial was a multicenter, randomized clinical trial designed to evaluate the effects of a psychosocial intervention on cardiovascular morbidity and mortality. A total of 2481 patients met the criteria for depression, low social support, or both after a myocardial infarction and needed to be followed. Follow-up evaluation consisted of telephone interviews 3, 9, 12, 24, 36, and 48 months after enrollment and clinic visits scheduled at 6, 18, 30, 42, and 54 months. Creative strategies used to achieve optimum retention of this complex patient population over a long follow-up period are presented. Strategies to enhance adherence throughout the course of the trial required adequate tracking of patients to ensure minimum dropout, follow-up evaluation optimized through multiple methods of contact to guarantee completeness of data collection; and development of procedures to address the needs of patients at risk for dropout. Patients in the group that completed the study participated for a mean of 28.3 months, and those lost to follow-up evaluation participated for a mean of 19 months. Retention was not substantially different by gender or minority status. The results of this project can assist investigators in planning studies that require patient follow-up evaluation, and can provide clinicians with specific strategies for maximizing retention-to-treatment recommendations. As a result of the retention strategies described in this report, 93.02% of the patients completed their study participation or died. This is a very high retention rate given the complexity of the study sample, protocol, and required duration of follow-up evaluation.

Systolic left ventricular dysfunction is a weak predictor of exercise tolerance in patients with chronic congestive heart failure. This study aimed to determine physiologic and other predictors of effort tolerance and adaptability to training in a wide variety of patients with coronary artery disease. One hundred seventy-one patients (group 0) with documented coronary artery disease and various degrees of left ventricular dysfunction were enrolled into a medically supervised exercise training program for 6 months. One hundred six patients had an ejection fraction greater than 50% (group 1), 38 patients between 35% and 50% (group 2), and 27 patients less than 35% (group 3). Resting parameters of systolic and diastolic left ventricular function did not predict the effort tolerance of patients with coronary artery disease at any level of left ventricular impairment. Noncardiac factors including age, gender, Broca index, and forced vital capacity explained 50% of the variation in peak oxygen uptake in group 0. Peak oxygen uptake, ventilatory threshold, and treadmill time to exhaustion increased significantly after training in all groups. The magnitude of the improvement in these variables was the same for all groups. Noncardiac factors were better predictors of the effort tolerance of patients with coronary artery disease than parameters of left ventricular function at entry to an exercise program or after 6 months of training. A similar degree of adaptation to training was seen in all patients regardless of their degree of left ventricular systolic or diastolic dysfunction.

Training adaptations in patients with coronary artery disease (CAD) have been reported previously, but little is known about central and peripheral adaptations in those recovering from coronary artery bypass graft surgery (CABG). The purpose of this study was to examine the effects of 12 weeks of endurance exercise training on exercise performance and left ventricular and peripheral vascular reserve in a group of uncomplicated CABG patients. Thirty-one patients were recruited and began training 8 to 10 weeks after uncomplicated CABG. Patients underwent progressive exercise training consisting of walking and jogging, at 75% to 80% maximal oxygen intake (VO2max). Measures of left ventricular function included ejection fraction (EF), ventricular volumes, and the pressure volume ratio, an index of contractility. Peak ischemic exercise calf blood flow and vascular conductance was determined using strain-gauge plethysmography. Maximal oxygen intake and submaximal blood lactate concentration also was determined. A significant improvement in VO2max (1497 +/- 60 mL/min versus 1691 +/- 71 mL/min) was observed after training. This change was accompanied by an increase in the EF during submaximal exercise (60 +/- 3% versus 63 +/- 2% at 40% VO2max; 61 +/- 3% versus 64 +/- 3% at 70% VO2max) (P < 0.05), and the change in EF from rest to exercise (delta EF). No changes were observed for ventricular volumes during exercise, although there was a trend for a higher stroke volume at 70% VO2max. A significant increase (18%) was observed for peak ischemic exercise calf blood flow and vascular conductance. In addition, submaximal blood lactate concentration was lower after training. These data indicate that exercise training for 12 weeks in patients recovering from CABG can elicit significant improvements in functional capacity that, for the most part, are secondary to peripheral adaptations, with limited support for improvement in left ventricular function.

Literature reviews typically have concluded that personality factors are unrelated to adherence to treatment programs, including adherence to exercise prescribed in cardiac rehabilitation. This study constitutes a reconsideration of this conclusion. Using the California Psychological Inventory (CPI), a well-validated inventory of general personality tendencies, personality variables, and appointment-keeping in cardiac rehabilitation were examined. Forty-nine men entering a cardiac rehabilitation program completed the CPI. Exercise capacity was measured on entry into the 4-month phase II/III program and at completion. Adherence indicators were appointment-keeping and completion or non-completion of the program. General appointment-keeping and hospital admissions during the subsequent year were tracked. Appointment-keeping accounted for 35% of the variance in posttreatment exercise capacity, controlling for pretreatment exercise capacity. Scores on the CPI scales that were significantly related to appointment-keeping were Well-Being (perception of physical/emotional health), Socialization (acceptance of rules and regulations), and Communality (view of self as similar to others). These correlations ranged from 0.49 to 0.38. Those who completed the program (n = 39) had higher scores than those who did not (n = 10) on nearly all of the CPI scales. The differences were significant on the Socialization and Good Impression scales (desire for others to have a favorable impression of oneself). The Socialization score was correlated with keeping appointments in the follow-up year. Personality variables were associated with appointment-keeping adherence. The consistency of our results with those of other recent studies of personality and adherence is discussed, along with implications for cardiac rehabilitation.