Journal of Cardiopulmonary Rehabilitation and Prevention

Published by Lippincott, Williams & Wilkins
Print ISSN: 1932-7501
: To analyze changes in clinical characteristics of patients entering a cardiac rehabilitation program between 1993 and 2006 and to consider the implications on the delivery of cardiac rehabilitation programs in the future. : Data were analyzed for 4692 coronary heart disease patients who joined the Phase II cardiac rehabilitation program between January 1993 and December 2006. : Over the study period mean age increased from 60.0 to 64.0 years (P < .001) and the proportion of participants aged 75 years or older increased from 4.4% to 17.1% (P < .001). In the first 8 years, the percentage of women increased from 17.8% to 23.7% but has changed little since. The most frequent index diagnosis throughout the study was acute myocardial infarction. The percentage of patients with percutaneous coronary intervention increased from 3.5% in 1993-1994 to 21.1% in 2005-2006, which contrasted with a recent decline in percentages of those with coronary artery bypass grafting in the United Kingdom. Prevalence of diagnosed diabetes almost doubled over the study period. The percentage of participants who were current smokers stayed constant at 6% to 9%. The percentage taking statins increased from 2.5% to 94.6% with a corresponding decrease of mean total blood cholesterol 6.00 to 4.07 mmol/L. Prescription of all cardiovascular secondary prevention medications increased significantly. : Overall, cardiac rehabilitation participants are becoming older with a consequent change in their abilities and needs. This may lead to changes in cardiac rehabilitation practice.
The benefits of individualizing risk factor therapies and exercise protocols in patients participating in early outpatient cardiac rehabilitation are reviewed. Risk factor intervention modules for modifications of lipid abnormalities and obesity are outlined. Specific individualized exercise regimens are described for patients characterized by the presence of obesity, older age, intermittent claudication, and chronic heart failure, which provide favorable outcomes related to risk factor measures and physical functioning. With adoption and application of an individualized approach for cardiac rehabilitation patients, programs are evolving to become secondary prevention centers for patients with established coronary heart disease.
Despite recommendations in clinical practice guidelines, evidence suggests cardiac rehabilitation (CR) referral and use following indicated cardiac events is low. Referral strategies such as systematic referral have been advocated to improve CR use. The objective of this policy position is to synthesize evidence and make recommendations on strategies to increase patient enrollment in CR. A systematic review of 6 databases from inception to January 2009 was conducted. Only primary, published, English-language studies were included. A meta-analysis was undertaken to synthesize the enrollment rates by referral strategy. In all, 14 studies met inclusion criteria. Referral strategies were categorized as systematic on the basis of use of systematic discharge order sets, as liaison on the basis of discussions with allied health care providers, or as other on the basis of patient letters. Overall, there were 7 positive studies, 5 without comparison groups, and 2 studies that reported null findings. The combined effect sizes of the meta-analysis were as follows: 73% (95% CI, 39%-92%) for the patient letters ("other"), 66% (95% CI, 54%-77%) for the combined systematic and liaison strategy, 45% (95% CI, 33%-57%) for the systematic strategy alone, and 44% (95% CI, 35%-53%) for the liaison strategy alone. In conclusion, the results suggest that innovative referral strategies increase CR use. Although patient letters look promising, evidence for this strategy is sparse and inconsistent at present. Therefore we suggest that inpatient units adopt systematic referral strategies, including a discussion at the bedside, for eligible patient groups in order to increase CR enrollment and participation. This approach should be considered best practice for further investigation.
Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation about medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.This update of the American Association of Cardiovascular and Pulmonary Rehabilitation and/the American Heart Association scientific statement of 2005 focuses on the unique roles of the cardiac rehabilitation and secondary prevention program medical director, because they relate to program oversight as it related to changes in federal legislation and regulation, as well as in health care delivery and clinical practice.
Obesity is a major health priority in the United States, as well as globally. It is associated with multiple comorbidities and reduced life expectancy. Effective management of obesity involves producing an intervention plan tailored to the individual patient. Potential contributory factors to weight gain, including dietary habits, physical inactivity, associated medical conditions, and medications, should be identified and addressed. Lifestyle interventions comprising diet modification, physical activity, and behavior therapy are foundational to the management of obesity. Caloric restriction is the most important component in achieving weight loss through negative energy balance, whereas sustained physical activity is important in maintaining the weight loss. Adjunctive therapies in the form of pharmacotherapy and bariatric surgery are required in patients who do not achieve targeted weight loss and health goals with lifestyle interventions. Currently there are 3 drugs approved for long-term management of obesity, orlistat, phentermine/topiramate extended release, and lorcaserin, and there are 2 on the horizon, bupropion/naltrexone and liraglutide. Bariatric surgery is an effective strategy recognized to produce durable weight loss with amelioration of obesity-related comorbidities and should be considered a treatment option in eligible patients.
SF-36 scores of patients with open atrial septal defect (ASD) and closed ASD. 
Abbreviations: ASD, atrial septal defect; AT, anaerobic threshold; HR, heart rate; HR/ ˙ VO 2 : heart rate to oxygen uptake slope; OUES, oxygen uptake efficiency slope; RER, respiratory exchange ratio; ˙ VE/ ˙ VCO 2 slope, ventilatory efficiency; ˙ VO 2 /WR slope, oxygen uptake to work rate slope. a P .05 versus matched controls. 
Although exercise capacity is impaired, atrial septal defect (ASD) patients report satisfactory exercise tolerance. This study aimed at (1) evaluating cardiopulmonary exercise testing (CPX) and (2) evaluating the impact of exercise capacity on perceived health status using a self-reported health questionnaire (SF-36) in patients with open and closed ASD. Seventeen patients (mean age 37 ± 17, 9 males) with open ASD and 24 (mean age 37 ± 14, 6 male) with closed ASD were included. All underwent CPX and completed a SF-36 questionnaire. Age- and gender-matched controls were selected for comparison of CPX variables and SF-36 was compared with results from a general population. Patients with open ASD had lower peak oxygen uptake (VO(2)) (27.9 ± 9.7 vs 38.5 ± 9.5 mL · kg(-1) · min(-1). P = .009) and higher VE/VCO(2) slope (31.0 ± 7.7 vs 24.1 ± 4.8; P = .004) than controls. Patients with closed ASD had lower peak VO(2) (26.2 ± 8.4 vs 34.8 ± 9.7 mL · kg(-1) · min(-1). P = .014) and peak heart rate (163 ± 25 vs 178 ± 16 bpm; P = .035) than controls. Perceived health-status was lower in patients with open ASD than the general population. Peak VO(2) correlated significantly with physical functioning, emotional functioning, and bodily pain in open ASD and with physical functioning, bodily pain, role limitation, vitality, and mental health in closed ASD patients. Patients with open and closed ASD had decreased peak VO(2). Patients with open ASD had lower ventilatory efficiency. Closed ASD patients had chronotropic incompetence because of β-blockers. SF-36 was reduced in patients with open ASD but not closed ASD. Reduced exercise capacity affected several domains of perceived health-status in ASD patients.
Because only one-third of eligible patients participate in formal cardiac rehabilitation, home-based programs constitute a suitable alternative. We examined effectiveness of a minimal educational intervention on patient fitness and activity levels through the use of simple motivational tools including verbal encouragement and the provision of a booklet containing exercise guidelines and exercise diary. We enrolled 186 patients (age, 60 – 78 years; mean age, 69 years; 140 men) who were admitted to the outpatient clinic of Warsaw Institute of Cardiology in 2007-2009 after acute myocardial infarction. Of these, 61.3% had coronary angioplasty with stenting and 30.7% had coronary artery bypass. Patients were randomly assigned into an intervention group receiving minimal educational intervention or control. At baseline and 3 months, assessment was made of cardiopulmonary fitness and autonomic tone with exercise testing. Leisure-time physical activity and atherosclerosis risk factors were assessed at baseline and after 3 and 12 months. At baseline, exercise test results and leisure-time activity levels were not significantly different between groups. After 3 months, we noted statistically significant differences in exercise test responses between the intervention group versus control: peak workload 57.3 ± 2.3 versus 47.2 ± 2.2 kJ (P < .04) and heart rate recovery 26.5 3.3 versus 23.7 4.2 bpm (P < .001). Leisure-time activity was greater in the intervention group than in control, 3.9 versus 2.3 h/wk (P < .001). Improvement in atherosclerosis risk factors during the course of the study was similar between groups. Minimal educational intervention is an effective and safe form of promoting physical activity in older patients after myocardial infarction.
Older patients have high rates of physical function impairment and disability following a cardiac event. Exercise training has been shown to favorably affect such limitations, as well as cardiovascular risk factors, symptoms, and mortality post coronary event in middle-aged patients. Aerobic capacity, body strength, quality of life, and physical function are improved with exercise-based cardiac rehabilitation (CR) in patients older than 65 years. However, there have been relatively few studies of the effects of exercise-based CR on physical function recovery in the very old patients (> or =75 years), despite the continuous growth of this segment of the population. After hospitalization for a cardiac event, postacute inpatient CR serves as a bridge between acute care and independent home living for the most disabled older patients. It plays an important role in the physical recovery process, particularly after cardiac surgery. Exercise-based outpatient (phase II) CR, starting early after hospital discharge, is safe in very old patients and studies demonstrate that these patients derive similar benefits from CR, compared with younger patients, regarding physical function improvement. Older patients, however, are less likely than younger cardiac patients to participate in outpatient CR programs. There is a need to find protocols that could increase the referral and participation rates of the frailer and older cardiac patient to exercise-based CR.
Medical therapies for treatment of peripheral artery disease (PAD) are limited. Ginkgo biloba has been reported to increase maximal and pain-free walking distance among patients with PAD; however, the evidence is inconsistent. The objective of this study was to compare the effects of 300 mg/d of Ginkgo biloba (EGb 761) versus placebo on treadmill walking time and related cardiovascular measures among patients with PAD. A double-blind, placebo-controlled, parallel design trial with a 4-month duration was used. Participants were 62 adults, aged 70 +/- 8 years (mean +/- SD), with claudication symptoms of PAD. The primary study outcomes were maximal and pain-free walking time on a treadmill. Secondary outcomes included flow-mediated vasodilation, a measure of antioxidant status as assessed by determining antibody levels to epitopes of oxidized low-density lipoprotein, and questionnaires addressing walking impairment and quality of life. Maximal treadmill walking time increased by 20 +/- 80 and 91 +/- 242 seconds in the placebo and the EGb 761 groups, respectively (P = .12). Pain-free walking time increased by 15 +/- 31 and 21 +/- 43 seconds, respectively (P = .28). No significant differences were detected between groups for any of the secondary outcomes. In older adults with PAD, Ginkgo biloba produced a modest but insignificant increase in maximal treadmill walking time and flow-mediated vasodilation. These data do not support the use of Ginkgo biloba as an effective therapy for PAD, although a longer duration of use should be considered in any future trials.
Outcome measurement in cardiopulmonary rehabilitation is required for optimal assessment of program quality, effectiveness of treatments, and evaluation of patient progress. Recent position statements from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), American College of Cardiology, American Heart Association, American Thoracic Society, and American College of Chest Physicians have provided state-of-the-art information on the importance of assessing performance and outcome measures for optimal program effectiveness. Such measures are also required for AACVPR program certification. To meet current standards of practice, the AACVPR developed an Outcomes Matrix that includes 4 domains: Health, Clinical, Behavioral, and Service. Although the Clinical and Health domains have been most commonly used in outcome reporting (eg, 6-minute walk test, quality-of-life survey scores), behavioral measures have received less attention, primarily because they have been perceived as being more difficult to measure and quantify over time. This statement describes 5 common behavioral outcome measures: smoking cessation, medication use, supplemental oxygen use, exercise habits, and nutritional behaviors. Sample questions and calculations for each of these behavioral measures are also provided. By using these measures at program entry and completion, cardiac and pulmonary rehabilitation practitioners can effectively track and document behavioral changes over time for physicians, third-party insurance providers, or hospital administrators and thus demonstrate the effectiveness of exercise and educational interventions on patient overall health and well-being.
Quantifying and analyzing pulmonary rehabilitation (PR) results in the form of an outcome assessment are a means of evaluating patient performance and program effectiveness. Implementation of a structured outcome assessment is feasible and parallels many aspects of the traditional rehabilitation evaluation. This statement outlines key components to PR outcome evaluation in the context of the American Association of Cardiovascular and Pulmonary Rehabilitation PR Outcome Matrix and includes a discussion of some of the popular tools used to collect measurement data.
In 2010, the Healthy Heart (HH) community-based cardiac rehabilitation program was offered at Latrobe Community Health Service in rural Victoria, Australia. The 8-week program, based on National Heart Foundation guidelines, consisted of exercise sessions; health education on diet, stress, and smoking cessation; and behavioral change strategies. Participants were also informed about local community exercise opportunities. A program evaluation was conducted in 2011 to assess whether the content of the program was meeting the needs of participants and to identify what suggestions they had for improvement. Eighteen patients had completed the HH program in 2010. Eight of these participants, 7 men and 1 woman, volunteered to take part in a focus group. Conventional content analysis was used to identify and group the common themes that emerged from the focus group discussions. Three themes were identified that reflected the participant experiences of attending the HH program. The first, "recovering confidence," described participant responses to the content of the sessions. The second, "putting it into practice," referred to their comments about taking responsibility for making lifestyle changes. The third, "feeling abandoned," emerged from the reported difficulty participants expressed about maintaining motivation for change after program completion. Participants rated the HH program as very successful by objective measures. However, they reported struggling to maintain self-management strategies postprogram. There is clearly a need to develop strategies that support cardiac rehabilitation participants over the longer-term.
No effective medical therapy exists for early abdominal aortic aneurysm (AAA) disease. Lower extremity exercise improves aortic hemodynamics and reduces inflammation, but the safety and efficacy of exercise training in AAA disease is unknown. As an interim analysis of our prospective, randomized, longitudinal trial of exercise for AAA suppression, we investigated whether subjects with early disease could safely achieve target metabolic and hemodynamic goals. One hundred eight participants were randomized to exercise training (EX) or usual care (UC). EX subjects participated in a combination of in-house and home exercise training, with efforts directed toward moderate daily exercise participation. Comparisons were made between EX and UC subjects who completed 1 year of follow-up (n = 26 and 31, respectively, mean age 72 ± 8 years). EX and UC groups were compared for safety, cardiopulmonary exercise test responses, weekly energy expenditure, and biometric indices. No paradoxical increase in AAA growth rate or adverse clinical events occurred as a consequence of exercise training. EX participants expended an average of 2269 ± 1207 kcal/wk and increased exercise capacity (42% increase in treadmill time, 24% increase in estimated metabolic equivalents, P = .01 and .08 between groups, respectively). EX participants demonstrated a significant reduction in C-reactive protein and tended to reduce waist circumference and waist-to-hip ratio (P = .06 and .07, respectively). Preliminary analyses suggest that exercise training is well tolerated and sustainable in small AAA subjects over 1 year. Despite age and comorbidities, exercising AAA subjects achieve meaningful exercise targets and significantly modify activity-dependent variables.
Walking training is considered as the first treatment option for patients with peripheral arterial disease and intermittent claudication (IC). Walking exercise has been prescribed for these patients by relative intensity of peak oxygen uptake (VO2peak), ranging from 40% to 70% VO2peak, or pain threshold (PT). However, the relationship between these methods and anaerobic threshold (AT), which is considered one of the best metabolic markers for establishing training intensity, has not been analyzed. Thus, the aim of this study was to compare, in IC patients, the physiological responses at exercise intensities usually prescribed for training (% VO2peak or % PT) with the ones observed at AT. Thirty-three IC patients performed maximal graded cardiopulmonary treadmill test to assess exercise tolerance. During the test, heart rate (HR), VO2, and systolic blood pressure were measured and responses were analyzed at the following: 40% of VO2peak; 70% of VO2peak; AT; and PT. Heart rate and VO2 at 40% and 70% of VO2peak were lower than those at AT (HR: -13 +/- 9% and -3 +/- 8%, P < .01, respectively; VO2: -52 +/- 12% and -13 +/- 15%, P < .01, respectively). Conversely, HR and VO2 at PT were slightly higher than those at AT (HR: +3 +/- 8%, P < .01; VO2: +6 +/- 15%, P = .04). None of the patients achieved the respiratory compensation point. Prescribing exercise for IC patients between 40% and 70% of VO2peak will induce a lower stimulus than that at AT, whereas prescribing exercise at PT will result in a stimulus above AT. Thus, prescribing exercise training for IC patients on the basis of PT will probably produce a greater metabolic stimulus, promoting better cardiovascular benefits.
Assessment of the reliability of performance measure (PM) abstraction is an important step in PM validation. Reliability has not been previously assessed for abstracting PMs for the referral of patients to cardiac rehabilitation (CR) and secondary prevention (SP) programs. To help validate these PMs, we carried out a multicenter assessment of their reliability. Hospitals and clinical practices from around the United States were invited to participate in the Cardiac Rehabilitation Referral Reliability (CR3) Project. Twenty-nine hospitals and 23 outpatient centers expressed interest in participating. Seven hospitals and 6 outpatient centers met participation criteria and submitted completed data. Site coordinators identified 35 patients whose charts were reviewed by 2 site abstractors twice, 1 week apart. Percent agreement and the Cohen κ statistic were used to describe intra- and interabstractor reliability for patient eligibility for CR/SP, patient exceptions for CR/SP referral, and documented referral to CR/SP. Results were obtained from within-site data, as well as from pooled data of all inpatient and all outpatient sites. We found that intra-abstractor reliability reflected excellent repeatability (≥90% agreement; κ ≥ 0.75) for ratings of CR/SP eligibility, exceptions, and referral, both from pooled and site-specific analyses of inpatient and outpatient data. Similarly, the interabstractor agreement from pooled analysis ranged from good to excellent for the 3 items, although with slightly lower measures of reliability. Abstraction of PMs for CR/SP referral has high reliability, supporting the use of these PMs in quality improvement initiatives aimed at increasing CR/SP delivery to patients with cardiovascular disease.
Acceptance, a cognitive-behavioral concept successfully applied to chronic pain and chronic illness in an HIV/AIDS population, was examined for applicability in patients in a cardiac rehabilitation program. The study examined the internal reliability of the Activities Engagement (AE) and Illness Willingness (IW) scales of the Chronic Illness Acceptance Questionnaire (CIAQ), their relationships with functional outcomes, and their ability to predict functional outcomes after controlling for demographic and medical variables. Subjects were 36 patients recruited from a cardiac rehabilitation program at an urban Midwestern Medical Center. Subjects completed the CIAQ and physical and emotional functional outcome measures including the Minnesota Living with Heart Failure Questionnaire, 36-item Short Form Health Survey (SF-36), and Beck Depression Inventory. Internal reliability scores of the AE and IW scales of the CIAQ were modest. The AE scale was significantly related to measures of emotional functioning, but not physical functioning. The IW scale was not related to any of the emotional or physical outcomes. In multiple regression analyses, AE was a significant predictor of the 2 emotional outcome measures beyond demographic and medical variables, but not the physical measures. Illness Willingness was not predictive of any of the functional outcome variables. The AE aspect of acceptance was related to emotional outcomes and predicted these outcomes beyond demographic and medical variables. Lack of a relationship between IW and any outcomes may have been due to a small sample size or that acceptance is a one-dimensional construct.
While systematic referral strategies have been shown to significantly increase cardiac rehabilitation (CR) enrollment to approximately 70%, whether utilization rates increase among patient groups who are traditionally underrepresented has yet to be established. This study compared CR utilization based on age, marital status, rurality, socioeconomic indicators, clinical risk, and comorbidities following systematic versus nonsystematic CR referral. Coronary artery disease inpatients (N = 2635) from 11 Ontario hospitals, utilizing either systematic (n = 8 wards) or nonsystematic referral strategies (n = 8 wards), completed a survey including sociodemographics and activity status. Clinical data were extracted from charts. At 1 year, 1680 participants completed a mailed survey that assessed CR utilization. The association of patient characteristics and referral strategy on CR utilization was tested using χ. When compared to nonsystematic referral, systematic strategies resulted in significantly greater CR referral and enrollment among obese (32 vs 27% referred, P = .044; 33 vs 26% enrolled, P = .047) patients of lower socioeconomic status (41 vs 34% referred, P = .026; 42 vs 32% enrolled, P = .005); and lower activity status (63 vs 54% referred, P = .005; 62 vs 51% enrolled, P = .002). There was significantly greater enrollment among those of lower education (P = .04) when systematically referred; however, no significant differences in degree of CR participation based on referral strategy. Up to 11% more socioeconomically disadvantaged patients and those with more risk factors utilized CR where systematic processes were in place. They participated in CR to the same high degree as their nonsystematically referred counterparts. These referral strategies should be implemented to promote equitable access.
Access to cardiac rehabilitation (CR) remains at approximately 30%, despite a national target of 70%. This study evaluated cardiac specialist and CR program perceptions of CR access and referral strategies. Postal and online surveys of Canadian CR specialists and CR programs were administered. Responses were received from 71 of 765 CR specialists (9.3%) and 92 of 149 CR programs (61.7%). Respondents rated perceptions on 5-point Likert scales. Specialists rated patient access to CR as moderate (2.9 ± 1.4). While they reported that they refer 65.9% of their patients, they most frequently do not refer because their patients report disinterest (23.4%) or geographic barriers to access (23.4%). Cardiac rehabilitation programs reported having capacity to serve a median of 275 patients annually, yet reportedly serving up to 350. The most commonly used methods of referral included discharge order sets (over 60%) and allied health care provider support. Electronic referral was perceived to be highly effective (4.1 ± 1.0) yet the least frequently used. Cardiac rehabilitation programs perceived more patients are accessing CR because of these referral strategies, but increased patients strain program resources. Some of the least frequently used referral strategies were perceived as, and are also empirically demonstrated to be, most effective. Broader implementation of these strategies, while better-resourcing CR programs, may improve the continuum of care for cardiac patients.
Because health care costs in the United States have been growing disproportionately compared to inflation for many years, without a clear connection to improved quality or increased access to care, employers and payers have begun to test new models of health care delivery and payment. These models are linked to the concepts of affordability, accountability, and accessibility and incorporate the premise that there must be shared responsibility for improving meaningful patient outcomes, with attention to the coordination of team-based and patient-centered care, and value for services purchased. This article explores emerging health care delivery and payment models, including expanded access to care related to the Affordable Care Act of 2010, patient-centered medical homes and neighborhoods, accountable and coordinated care organizations, and value-based purchasing and insurance design, with an emphasis on implications for cardiovascular and pulmonary rehabilitation programs and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Cardiac rehabilitation (CR) has been recommended to provide exercise guidance poststroke. However, it has not been established whether minimal exercise training levels, sufficient for obtaining health benefits, can be attained in CR. Therefore, we assessed the ability of stroke patients to achieve recommended exercise levels during a single standard CR session following completion of CR. Sixteen patients (10 males and 6 females) with mild/moderate motor impairments who had completed CR participated in the study. Resting metabolic rate and oxygen uptake during 30 minutes each of aerobic and resistance training (AT, RT, respectively) were assessed by ambulatory oxygen monitor. Obtained values were compared with recommended minimal levels, that is, 20 or more minutes of exercise at 40% or more of peak oxygen uptake (VO(2peak)), 30 or more minutes of exercise at 3 or more metabolic equivalents (METs) (multiples of resting metabolic rate), and an energy expenditure of approximately 200 kcal per session. Mean time sustaining 40% or more of VO(2peak) was 47.6 ± 9 minutes, exceeding the minimal target of 20 minutes (P < .001). Time sustaining 3 or more METs was 30.8 ± 12.2 minutes, matching the target of 30 minutes (P = .8). Total energy expenditure (252 ± 49.9 kcal) was significantly greater than the target value of 200 kcal (P = .001). Chronic stroke patients with mild/moderate motor impairments are able to meet or exceed minimal recommended exercise target levels for intensity, duration, and energy expenditure during a typical exercise session consisting of 30 minutes of AT combined with 30 minutes of RT after completing CR. These data contribute to the evidence promoting the efficacy and feasibility of CR for people following stroke.
To investigate the hypothesis that some patients are hyperproducers of cholesterol while others are hyperabsorbers by comparing the low-density lipoprotein (LDL) responses to statins versus ezetimibe adjunct therapy. Consecutive patients (N = 109), who received statin monotherapy followed by ezetimibe adjunct therapy, were prospectively studied. The expected LDL levels for each patient on statin and on ezetimibe adjunct therapy were calculated. The difference between expected and actual LDL levels on statin and on ezetimibe adjunct therapy was calculated for each patient and subsequently correlated. The mean LDL levels (mg/dL) were baseline, 168.7 ± 3.6; on statin, 104.2 ± 2.6; on ezetimibe adjunct, 74.2 ± 2.2. Statins reduced LDL by 36.7 ± 1.5%, while adding ezetimibe resulted in a further reduction of 28.1 ± 1.4%. The percent LDL reduction by statin was negatively correlated to the percent reduction by ezetimibe adjunct therapy (r = -0.29, P = .002). The difference between expected and actual LDL levels on statin was negatively correlated to that on ezetimibe adjunct therapy (r = -0.38, P < .001). This study demonstrated that the LDL response to ezetimibe is inversely related to the response to statin. This lends support to the hypothesis that some patients may be hyperabsorbers of cholesterol while others may be hyperproducers. This suggests that a less than expected response to the initial dose of statin in a patient would likely require the addition of ezetimibe to achieve the recommended target levels in spite of the use of maximum dose statin therapy.
Lifestyle habits and cardiovascular disease (CVD) risk factors are closely linked. Unfortunately, few individuals meet the goals for cardiovascular health that are recommended in public health initiatives. The purpose of this study was to determine the effect of an intensive lifestyle intervention program on the achievement of a group of recognized heart health characteristics as well as on the reduction of individual CVD risk factors. Of 200 military healthcare beneficiaries with coronary artery disease or CVD risk factors (mean age = 61 years) who entered a 1-year, prospective, cohort, multicomponent lifestyle intervention study (lacto-ovo vegetarian diet, exercise, stress management, group support), 186 subjects enrolled and 144 participated for 1 year. At 3 months and 1 year compared with baseline, the proportion of subjects meeting 5 recognized heart health characteristics improved (P < .001): fiber intake >25 g/d (94% and 72% vs 35%); exercise > or =150 min/wk (79% and 58% vs 31%); low-density lipoprotein cholesterol <100 mg/dL (75% and 63% vs 46%); body mass index <25 kg/m (34% and 38% vs 23%); and blood pressure <140/90 mm Hg (84% and 83% vs 69%). At 1 year, more subjects (72% vs 32% at baseline), especially those with intervention adherence above (94%) versus below (58%) the study population median (P < .0005), achieved 3 or more of these characteristics. An intensive lifestyle intervention promotes achievement of important heart health characteristics that, if maintained, may substantially reduce CVD events.
Cardiac rehabilitation staff members consider interprofessional practice to be the standard for delivering effective care. However, it is not known how interprofessional teams collaborate or what they consider to be important elements of collaboration. Thus, it is important to investigate how healthcare professionals plan and communicate care, work together, and define their roles as members of the cardiac rehabilitation teams. The purpose of this report was to provide an analysis of current literature related to interprofessional practice in cardiac rehabilitation, with a particular focus on examining the terms interprofessional practice and collaboration. For this review, published articles in peer-reviewed journals for the preceding 20-year period were included from online databases (CINAHL, MEDLINE, EBM Reviews, PubMed, and Google Scholar). Key words used in the search included "cardiac rehabilitation," "cardiac recovery," and "interprofessional and interdisciplinary practice and collaboration." Of the 67 articles reviewed, 7 met inclusion criteria specifically addressing interprofessional practice in cardiac rehabilitation. Analysis revealed that (1) the terms interprofessional and multidisciplinary are commonly used interchangeably in healthcare, revealing a lack of clarity regarding interprofessional practices and approaches, and (2) there are few articles that clearly describe, define, or discuss interprofessional practice or collaboration in cardiac rehabilitation settings, rendering it difficult for practitioners to adhere to published practice guidelines. It is unclear why and how professional team members practice in specific ways to form cardiac teams. Further research is required to increase an understanding of these issues and to develop possibilities for the enhancement of cardiac rehabilitation practice.
Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low- to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low- to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide.
Purpose: Recent studies have demonstrated that patients who attend more cardiac rehabilitation (CR) sessions have lower subsequent mortality rates than those who attend fewer sessions. Methods: We analyzed the impact of several phased-in policy and process changes implemented to increase patient participation in CR. In March 2010, our CR program changed from a policy of individualizing the recommended number of CR sessions per patient to a policy that recommended all 36 CR sessions. In October 2010, we introduced a 7-minute video describing the benefits of CR. In August 2011, we introduced a motivational program that rewarded patients after every sixth CR session. The number of CR sessions attended was determined through review of billing records. Enrollment and completion were defined as attending ≥1 session and ≥30 sessions, respectively. Results: We identified 1103 patients sequentially enrolled in CR between May 2009 and January 2012. Overall, the median number of sessions per patient improved from 12 to 20 (P < .001). Completion rate improved from 14% to 39% (P < .001). The motivational program increased attendance by a median of 3 sessions per patient (P = .04), but this effect was limited to local CR participants. Financial analysis suggested that for every $100 spent on motivational rewards, patients attended an additional 6.6 (95% CI, -1 to 14) sessions of CR. Conclusions: Quality improvement activities significantly increased CR participation. Wide implementation of such programs may favorably impact patient participation in CR and potentially decrease the rate of subsequent cardiac events.
Purpose: Chronic obstructive pulmonary disease (COPD) is a progressively debilitating disease, which, over time, may compromise patient ability to perform activities of daily living (ADL). The purpose of this study was to examine the relationships between selected parameters of physical fitness and performance of ADL in COPD patients. Methods: A convenience sample of 23 COPD patients (11 men and 12 women, age 6869 years) was studied at the conclusion of an exercise rehabilitation program. Patients were assessed using the Continuous Scale Physical Functional Performance 10 Test (PFP-10) battery, chest press, leg press, and a symptom limited graded exercise test. Results: The PFP-10 global score was 54 ± 12, and 11 patients fell below a global score of 57, which has been established as the threshold for independence. Peak oxygen uptake (VO(2peak)) was 20 ± 4 mL·kg(-1)·min(-1), the forced expiratory volume in 1 second/forced expiratory volume ratio was 0.58 ± 0.12, grip strength was 61 ± 16 kg (both hands), and chest press and leg press were 4 ± 3 and 12 ± 7 kg/kg body weight, respectively. The associations between the PFP-10 VO(2peak) and leg press were modest (r = 0.501, P = .014; and r = 0.547, P = .008) as was grip strength (r = 0.418, P = .047). There was no association between the PFP-10 and forced expiratory volume, forced expiratory volume in 1 second/forced vital capacity, or chest press (r = -20.040, P = .856; r = 20.212, P = .330; and r = 0.120, P = .595), respectively. Conclusion: The results of this investigation suggest that lower body strength is important in optimizing ADL performance in COPD patients.
The purpose of this study was to delineate the effect of chronic obstructive pulmonary disease (COPD) on a broad range of valued life activities (VLAs) and make comparisons to effects of other airways conditions. We used cross-sectional data from a population-based, longitudinal study of US adults with airways disease. Data were collected by telephone interview. VLA disability was compared among 3 groups defined by reported physician diagnoses: COPD/emphysema, chronic bronchitis, and asthma. Multiple regression analyses were conducted to identify independent predictors of VLA disability. About half of individuals with COPD were unable to perform at least 1 VLA; almost all reported at least 1 VLA affected. The impact among individuals with chronic bronchitis and asthma was less but still notable: 74%-84% reported at least 1 activity affected, and about 15% were unable to perform at least 1 activity. In general, obligatory activities were the least affected. Symptom measures and functional limitations were the strongest predictors of disability, independent of respiratory condition. VLA disability is common among individuals with COPD. Obligatory activities are less affected than committed and discretionary activities. A focus on obligatory activities, as is common in disability studies, would miss a great deal of the impact of these conditions. Because individuals are often referred to pulmonary rehabilitation as a result of dissatisfaction with ability to perform daily activities, VLA disability may be an especially relevant outcome for rehabilitation.
Changes in (A) Average Resting Borg score, (B) Modified Medical Research Council Scale score, and (C) Maximal inspiratory pressure (PiMax) over time for each of the 3 study groups. Abbreviations: A PR, acupuncture pulmonary rehabilitation; PR, pulmonary rehabilitation only.
Changes in lung function for each of the 3 study groups are shown. (A) Forced vital capacity (FVC), % predicted. (B) Forced expiratory volume in first second (FEV1), % predicted. (C) inspiratory capacity (IC), % predicted. Abbreviations: A PR, acupuncture pulmonary rehabilitation; PR, pulmonary rehabilitation only.
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and by both systemic and airway inflammation. In COPD, acupuncture has been shown to improve quality-of-life scores and decrease breathlessness; similar findings have also been reported after pulmonary rehabilitation (PR). The hypothesis of this study was that acupuncture in conjunction with pulmonary rehabilitation would improve COPD outcome measures compared to pulmonary rehabilitation alone. The design was a randomized prospective study; all subjects had COPD. There were 19 controls, 25 who underwent PR, and 16 who had both acupuncture and PR. The primary outcome measure was a change in measures of systemic inflammation at the end of PR and at 3 month followup. Lung function, including maximum inspiratory pressure (PiMax), quality-of-life scores, functional capacity including steps taken, dyspnea scores, and exercise capacity, were secondary endpoints. After PR, both groups had significantly improved quality-of-life scores, reduced dyspnea scores, improved exercise capacity, and PiMax, but no change in measures of systemic inflammation compared with the controls. There were no differences in most of the outcome measures between the 2 treatment groups except that subjects who had both acupuncture and PR remained less breathless for a longer period. The addition of acupuncture to PR did not add significant benefit in most of the outcomes measured.
Hopelessness has been associated with a higher risk of fatal and nonfatal coronary heart disease, yet very few studies have examined hopelessness after a cardiac event. This investigation examined hopelessness as an independent predictor of participation in a hospital-based cardiac rehabilitation exercise program. A total of 207 patients with acute coronary syndrome were interviewed at 3 and 8 months after hospital discharge. Measures included 1 factor of the Beck Hopelessness Scale, the Center for Epidemiological Studies Depression Scale, the Activity Status Index, the Charlson Comorbidity Index, a sociodemographic variables tool, and a cardiac rehabilitation exercise participation questionnaire. Random-effects logistic regression analysis revealed that hopelessness persisted over time and was an independent predictor of lower exercise participation. In contrast, depression showed no significant influence on exercise participation. Study findings suggest the importance of assessing hopelessness in patients with acute coronary syndrome and identifying approaches to exercise recommendations that directly address hopelessness. Interventions focused on the prevention and treatment of hopelessness symptoms may contribute to improved recovery of patient with acute coronary syndrome.
: While cardiac rehabilitation has been established as an essential part of comprehensive cardiac care, participation rates for female patients are substantially lower than for male patients. Lower referral rates and higher ages of female patients partly explain this underutilization. Gender differences in recovery goals of cardiac patients have not been examined. : Five hundred ninety patients (22.2% women) admitted to the hospital because of an acute myocardial infarction answered a questionnaire regarding 24 goals in 5 domains of recovery (physical functioning, risk-factor modification, psychological well-being, independence in daily life, and return to work). In addition, psychological symptoms and medical data were assessed. Gender differences were tested by using χ and Student t tests, as well as multivariate logistic and linear regression models. : Gender differences were found in 7 of the 24 recovery goals. After adjustment for psychosocial and clinical characteristics, women still reported a higher importance of "performance of household duties" (odds ratio [OR] = 8.62; 95% confidence interval [CI], 5.43-13.66), "independence in activities of daily living" (OR = 2.38; CI, 1.58-3.59), and "emotional equilibrium" (OR = 1.58, CI, 1.01-2.46). Men rated "physical endurance" and "reducing strain at workplace" as more important goals (OR = 0.64; CI, 0.42-0.97 and OR = 0.39; CI, 0.17-0.93). Except for psychological distress, gender differences in health status were not related to differences in goals. : Gender roles and differences in social-life conditions may have an important influence on the recovery goals of patients after an acute myocardial infarction. Recovery goals should be explored when planning intervention programs for individual patients.
Supervised exercise programs have been demonstrated to improve overall glycemic control but less well characterized is the evolution of glucose response to exercise during an exercise program. We addressed this issue, using an observational cohort design, among overweight adults with type 2 diabetes. We hypothesized that during the course of the program, glucose levels during exercise would become more stable, as insulin sensitivity improved. Among adults with type 2 diabetes, glucose levels often decline acutely during exercise. Thirty-five adults with type 2 diabetes underwent capillary blood glucose (CBG) testing before and after supervised exercise during a 24-week program (48 sessions). After-exercise CBG values were subtracted from before-exercise values (CBG difference). Through repeated measures analysis, we examined CBG difference, before-exercise values, and after-exercise values during the program. Assuming that some initial period of exercise training is necessary to impact CBG difference, in exploratory analyses, we varied the time period analyzed (eg. Weeks 2-24, Weeks 3-24, etc). CBG difference appeared stable throughout the program when all available data were considered. In models that examined periods following Week 11, however, the magnitude of CBG difference declined progressively, as did before-exercise values. After-exercise values remained stable for all time periods examined. Our exploratory analyses suggest that following 11 weeks of exercise supervision, before-exercise CBG values decline progressively but after-exercise values remain stable, resulting in a progressive decline in CBG difference.
Purpose: The aim of this study was to determine whether short-term cardiac rehabilitation (CR), including dietary counseling, had an impact on changing eating habits in patients after acute coronary syndrome (ACS), treated with primary percutaneous coronary intervention (PCI). Methods: The controlled, prospective, nonrandomized study was performed on 44 patients, early following ACS/PCI, who underwent 2- to 3-week inpatient CR with dietary counseling and compared to 18 patients who did not participate in CR. An analysis of the daily diet composition was performed at baseline, at 3 months post-ACS, and at 1 year post-ACS. Results: In the CR group, comparing baseline with 3 months post-ACS, daily calorie intake was significantly reduced from a mean ± SD of 2260 ± 525 kcal to 2037 ± 514 kcal (P < .05), and daily cholesterol intake from 509 ± 237 to 394 ± 199 mg (P < .05). The daily energy intake of saturated fatty acids was also significantly reduced from 13.6% at baseline to 12.2 ± 4.5% at 3 months and further reduced at 1 year post-ACS to 10.2 ± 4.3% (P < .05). Although both groups exhibited increased body mass index, the increase was significantly greater in the nonrehabilitation group than in the CR group at 1 year post-ACS (2.61 ± 2.23 vs 0.86 ± 1.67 kg/m, respectively, P < .001). Conclusions: The analysis suggests that a short-term CR program following ACS, which includes educational meetings on dietary prevention of atherosclerosis, may result in some favorable and lasting modifications of eating habits of post-ACS patients.
To determine whether an early rehabilitation program was safe and feasible for patients during an acute exacerbation of chronic obstructive pulmonary disease (COPD). In this phase 1 randomized controlled trial, patients with an acute exacerbation of COPD admitted to the hospital were randomly allocated to a low-intensity exercise group, a moderate- to high-intensity exercise group, or a control group, who received routine physical therapy. In addition to routine physical therapy, patients in the exercise group had to participate in an exercise program. The program consisted of twice-daily aerobic and resistance exercise sessions. Primary outcomes were the number and classification of adverse events and program adherence. In 174 exercise sessions, there was 1 serious adverse event of arrhythmia in the low-intensity exercise group that resolved within 1 hour. There were 12 other minor adverse events involving 5 patients with no significant differences between groups. Patients completed an average of 80% of their scheduled sessions with no significant between-group differences. The exercise groups improved significantly in walking distance; however, no significant between-group differences were observed. There was preliminary evidence that it was safe and feasible to implement an exercise program for patients during an acute exacerbation of COPD. Additional studies with larger sample sizes are required to accurately evaluate program effectiveness.
Top-cited authors
Steven Hawken
  • Ottawa Hospital Research Institute
Victor F Froelicher
  • Stanford Medicine
Karlman Wasserman
  • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
James E Hansen
  • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
Jae H Kang
  • Brigham and Women's Hospital