Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients

Associations between cardiorespiratory fitness and health-related quality of life

BACKGROUND

There is limited data examining the association between cardiorespiratory fitness (CRF) and health related quality of life (HRQOL) in healthy young adults. We examined the association between CRF and the HRQOL Physical Component Summary (PCS) and Mental Component Summary (MCS) scores in apparently healthy males in the United States Navy.

METHODS

A total of 709 males (18-49 yr) performed a submaximal exercise test and HRQOL assessment (SF-12v2) between 2004-2006. CRF level was classified into fourths depending on age distribution with the lowest fitness quartile serving as the referent group. PCS and MCS scores >or= 50 were defined as above the norm. Logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The age-standardized prevalence of above the norm scores was lowest in the referent CRF quartile, PCS 56.6% and MCS 45.1%. After adjusting for age, systolic blood pressure, body mass index, smoking habit, alcohol habit and using the lowest CRF group as the reference, the OR (95% CI) for PCS scores above the norm across the fitness quartiles (P < 0.003 for trend) were 1.51(0.94-2.41), 2.24(1.29-3.90), and 2.44 (1.30-4.57); For MCS the OR (95% CI) were across the fitness quartiles (P trend < 0.001) 2.03(1.27-3.24), 4.53(2.60-7.90), 3.59(1.95-6.60).

CONCLUSION

Among males in the United States Navy relative higher levels of CRF are associated with higher levels of HRQOL.

Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease

Substantial data have established a sedentary lifestyle as a major modifiable risk factor for coronary heart disease (CHD). Increased levels of physical activity, exercise training, and overall cardiorespiratory fitness have provided protection in the primary and secondary prevention of CHD. This review surveys data from observational studies supporting the benefits of physical activity, exercise training, and overall cardiorespiratory fitness in primary prevention. Clearly, cardiac rehabilitation/secondary prevention (CRSP) programs have been greatly underused by patients with CHD. We review the benefits of CRSP programs on CHD risk factors, psychological factors, and overall CHD morbidity and mortality. These data support the routine referral of patients with CHD to CRSP programs. Patients should be vigorously encouraged to attend these programs.

Exercise-based cardiac rehabilitation for very old patients (> or =75 years): focus on physical function

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.

Effects of a phase III cardiac rehabilitation program on physical status and lipid profiles in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP)

BACKGROUND

Limited data are available regarding the effects of phase III cardiac rehabilitation on the physical status and risk factors in elderly patients with coronary artery disease (CAD).

METHODS AND RESULTS

Thirty-four male CAD patients (>65 years old) were randomly assigned to an intervention group (n=18) or a control group (n=16). The intervention group participated in a phase III cardiac rehabilitation program consisting of exercise training, diet therapy, and weekly counseling for 6 months. In the control group, usual outpatient care was provided. In the intervention group, body mass index, waist size and fat weight significantly decreased; peak VO2 and anaerobic threshold VO2 were maintained; isokinetic peak torques of knee extensor and flexor muscles significantly increased; anterior trunk flexibility was significantly improved. In the control group, all parameters were unchanged except for peak VO2, which significantly decreased. In the intervention group, serum total cholesterol levels significantly decreased after cardiac rehabilitation. However, high-density lipoprotein-cholesterol and apoA-I levels also decreased. In the control group, no significant change in lipid profile was observed.

CONCLUSIONS

The results suggest that phase III cardiac rehabilitation could be beneficial for elderly patients with CAD.

Association of Age and Quality of Life Following Phase II Cardiac Rehabilitation

The benefits of cardiac rehabilitation following a major cardiac event are without question. Less well known, however, is the association of age with improved quality of life following rehabilitation. Subjects (n = 300) completed a 3-month phase II cardiac rehabilitation program following either a coronary artery bypass graft or a valve procedure. There were similar gains in health-related quality of life across all age groups; our results suggest that there needs to be a greater focus on emotional needs among our younger patients.

Trajectories of recovery of quality of life in women after an acute cardiac event

OBJECTIVES

Female cardiac patients' health-related quality of life (HRQoL) during the first year after an acute cardiac event was compared with age-weighted Australian population norms. The impact of age, event type and cardiac rehabilitation (CR) programme attendance on recovery was assessed.

METHODS

The short form 36-item health survey (SF-36) was administered to 229 women aged from 36 to 84 years consecutively admitted to 4 hospitals after acute myocardial infarction (AMI) or to undergo coronary artery bypass graft surgery (CABGS). Data were collected at 4 time points over 12 months. SF-36 subscale scores were compared with age-weighted norms for Australian women. Mplus was used to analyse growth trajectories for SF-36 subscales.

RESULTS

Patients had impaired HRQoL at baseline (except in general health), with progressive improvement over time. Recovery to normative levels was fastest in the areas of bodily pain and mental health (by 2 months) and slowest in the area of physical functioning, and physical and emotional role limitations (by 12 months). By 4 months, general health scores had surpassed population norms. For all scales, most improvement occurred in the first 2 months, with little subsequent improvement. CABGS patients showed significantly more improvement than AMI patients in several areas, partly due to the poorer functioning of CABGS patients at baseline. Rate of improvement was not influenced by patients' age or frequency of CR attendance.

CONCLUSIONS

Impairment of HRQoL in female cardiac patients is most pronounced at the time of the event, with most recovery occurring during early convalescence and full recovery in all domains by 12 months post-event.

Potential benefits of physical activity for children with acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is the most common form of paediatric leukaemia. The survival rate in children with ALL has improved significantly over the past several years, which makes quality of life an important focus for researchers. Some of the side effects of treatment (i.e. osteoporosis and obesity) are not realized until years after conclusion of therapy. Few studies have addressed the impact of physical activity (PA) on the side effects that occur during treatment of children with ALL. This paper discusses the increased risk for both osteoporosis and obesity due to treatment for ALL and suggests ways that PA may attenuate bone loss and risk of obesity by discussing what is known about effects of PA in healthy children and children with other chronic diseases. Recommendations will be made for PA interventions and future research in children with ALL.

A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention

OBJECTIVE

To evaluate the long-term effect of a cardiac rehabilitation and prevention program (CRPP) on quality of life (QOL) and its cost effectiveness.

DESIGN

Prospective, randomized controlled trial.

SETTING

University-affiliated outpatient cardiac rehabilitation and prevention center.

PARTICIPANTS

A total of 269 patients (76% men; mean age, 64+/-11 y) with recent acute myocardial infarction (AMI; n=193) or after elective percutaneous coronary intervention (PCI; n=76) were randomized in a ratio of 2 to 1.

INTERVENTION

Patients received either CRPP (an 8-wk exercise and education class in phase 2) or conventional therapy without exercise program (control group). They were followed until they had completed all 4 phases of the program (ie, 2 y).

MAIN OUTCOME MEASURES

QOL assessments, by using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and Symptoms Questionnaire, were performed at the end of each phase. Direct health care cost was calculated, whereas cost utility was estimated as money spent (in US dollars) per quality-adjusted life-year (QALY) gained.

RESULTS

In the CRPP group, 6 of the 8 SF-36 dimensions improved significantly by phase 2 and were maintained throughout the study period. Patients were less anxious and depressed, and felt more relaxed and contented. In the control group, none of the SF-36 dimensions were improved by phase 2, and bodily pain was increased. In phase 4, only 4 dimensions were improved. Symptoms were unchanged except for increased hostility score. There was a significant gain in net time trade-off in the CRPP group after phase 2. The direct health care expenses in the CRPP and control groups were 15,292 dollars and 15,707 dollars per patient, respectively. Therefore, the cost utility calculated was 640 dollars saved per QALY gained. Savings attributable to CRPP were primarily explained by the lower rate (13% vs 26% of patients, chi2 test=3.9, P <.05) and cost of subsequent PCI (P =.01).

CONCLUSIONS

In an era of managing patients with coronary heart disease, a short-course CRPP was highly cost effective in providing better QOL to patients with recent AMI or after elective PCI. In addition, the improvement of QOL was quick and sustained for at least 2 years after CRPP.

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

BACKGROUND

Measures assessing quality of life (QOL) in patients participating in comprehensive cardiac rehabilitation (CCR) have not been established in Japan.

METHODS AND RESULTS

To compare different types of QOL scales and to determine the impact of CCR on QOL in Japanese cardiac patients, 5 different types of questionnaires were assessed in 44 patients participating in CCR after acute myocardial infarction (AMI). After 3-month CCR, peak oxygen uptake (PVO2, p<0.01), Sickness Impact Profile (SIP) total score (p<0.05) and physical function-related QOL scores (Specific Activity Scale (SAS), p<0.01; SIP physical score, p<0.01) significantly improved, whereas psychosocial/mental aspect-related QOL scores (Ministry of Health and Welfare (MHW)-QOL score, SIP psychosocial score, State-Trait Anxiety Inventory, Self-rating Depression Scale) did not change on the average. However, patients with low PVO2 (<21.7 ml.min-1.kg-1) showed significant improvements in all scores after CCR, whereas patients with preserved exercise capacity showed improvements only in physical function-related scores (SAS and physical SIP). Furthermore, patients with anxiety and depression showed significant improvements in these respective measures after CCR.

CONCLUSION

In patients with AMI, physical function-related QOL scores improve after a 3-month CCR program, but psychosocial/mental aspect-related QOL scores improve only in those with impaired exercise tolerance or anxiety/depression. Thus, changes in QOL after CCR depend on type of QOL scale used and the baseline status of the patient. In addition, in Japanese cardiac patients MHW-QOL mainly reflects psychosocial/mental aspect-related QOL, as well as overall QOL.

Cardiac rehabilitation reduces the rate of major adverse cardiac events after percutaneous coronary intervention

BACKGROUND

Despite multiple publications on effects of rehabilitation in cardiac patients, rehabilitation is not fully known to be of value in post-percutaneous coronary intervention (PCI) patients.

AIMS

To investigate the influence of cardiac rehabilitation on the incidence of major adverse cardiac events (MACEs) in post-PCI patients.

METHODS

Retrospectively and nonrandomized 140 post-PCI patients (107 males, mean age 62 (7) years) participated in a 3-month rehabilitation program, starting 2 weeks post-PCI, while 83 post-PCI patients (54 males, mean age 68 (8) years) did not and were all followed up for 15 months. Data on cardiac medication prescription and incidence of MACE (including angina pectoris with or without reintervention, restenosis, myocardial infarction, revascularisation with re-PCI or CABG, and death) were collected. The relationship with cardiovascular risk factors including sex, smoking behaviour, obesity, diabetes mellitus, hypertension, familiar predisposition, and hypercholesterolemia was analysed.

RESULTS

The incidence of total MACE in the rehabilitation group is significantly lower than in the control group (24% vs. 42%, respectively; P<0.005). The incidence of documented restenosis, angina pectoris with resulting reintervention, all revascularisations, and death is significantly lower in the rehabilitation group, compared with the control group.

CONCLUSION

The incidence of MACE and restenosis is significantly lower when PCI patients are included in a cardiac rehabilitation program.

Exercise Capacity in Adult African-Americans Referred for Exercise Stress Testing

STUDY OBJECTIVES

To determine the factors associated with exercise capacity.

DESIGN

Retrospective evaluation of large stress-testing database.

SETTING

Multispecialty tertiary care center.

PATIENTS

A total of 5,069 consecutive patients who were referred for exercise stress testing.

MEASUREMENTS

We compared levels of fitness in 641 African-Americans (52% male) with 4,428 whites (73% male), and performed univariate and multivariate analyses to determine the predictors of fitness (including race).

RESULTS

Compared with African-American men (mean [+/- SD] age, 60 +/- 11 years), white men (mean age, 63 +/- 11 years) have significantly higher exercise capacity (10.7 +/- 3.5 vs 11.4 +/- 3.4 metabolic equivalents [METs], respectively; p < 0.001). The exercise capacity in African-American and white women was similar (8.5 +/- 2.9 vs 8.7 +/- 3.0 METs, respectively). However, body mass indexes (BMIs) were significantly higher in both African-American men (29.1 +/- 4.3 vs 28.2 +/- 4.3 kg/m(2), respectively; p < 0.001) and women (30.2 +/- 5.7 vs 27.9 +/- 5.5 kg/m(2), respectively; p < 0.0001) compared to their white counterparts, as was the prevalence of obesity (men, 44% vs 33%, respectively; women, 37% vs 27%, respectively; both p < 0.001). Although a model containing age, gender, BMI, and race only accounted for 32% of exercise capacity, all independently (p < 0.0001) predicted higher exercise capacity, as follows: younger age (r(2) = 0.14); male gender (r(2) = 0.12); BMI (r(2) = 0.06); and white race (r(2) = 0.004).

CONCLUSIONS

In an adult population of individuals who were referred for exercise stress testing, African-Americans were more obese and had significantly lower exercise capacity than their white counterparts. Emphasis on weight reduction and increasing physical fitness is particularly needed for the prevention of cardiovascular diseases in African-Americans.

[Strength training with elastic bands: measure of its effects in cardiac rehabilitation after coronary diseases]

OBJECTIVES

To compare high intensity strength training with weightlifting exercises or with elastic bands.

SETTING

Outpatient unit of cardiac rehabilitation. TYPE: Prospective randomised clinical trial.

POPULATION

Inclusion of coronary patients in phase II after medical or surgical treatment of a myocardiac infarction, without cardiac insufficiency; beta-blockers were accepted.

METHOD

Evaluation of coronary patients at beginning and at the end of a 4 week cardiac rehabilitation program. It included progressive aerobic training according to Karvonen method for all the patients, associated with weightlifting exercises (Koch press) in the control group, or use of elastic bands in the experimental group. Cardiac rate, oxygen consumption at rest and at maximum power were the main criteria with also muscle strength of quadriceps, hamstrings, biceps brachii, latissimus dorsi and triceps brachii, body mass indexes, quality of life with SF-36, anxiety (stay T test) and perceived exertion with the Borg 10-point category-ratio scale, myotendinous injuries (Shaw scale).

RESULTS

Twenty-six coronary patients, all male from 45 to 65 years old, all receiving beta-blockers, were included, 13 in each group. Control and experimental groups were initially similar. At the end of the 4 week program, all the two groups improved significantly their strength and power and there were no differences between the two groups. Perceived exertion was lower in the group using elastic bands and there were no myotendinous lesions.

CONCLUSION

Strength training with elastic bands is a low-cost, attractive, playful technique, proposed to a group of coronary patients, which appears as effective in cardiac rehabilitation as individual weightlifting training.

Outcomes of cardiac rehabilitation participants and nonparticipants in a rural area

Nationally, only 11%-20% of cardiac patients, on average, enroll in cardiac rehabilitation programs after their cardiac events. The purpose of this study was to examine: (a) differences in functional health outcomes, clinical risk factor outcomes, and lifestyle behaviors between patients who participated in cardiac rehabilitation (CR) and those who did not during the first year after their cardiac event; and (b) to examine predictors of and reasons for CR participation and non-participation in a Midwestern, rural clinical population. Green's health education framework guided the study. A cross-sectional, comparative design was used to mail surveys to 538 cardiac patients who were hospitalized over a 1-year period at a regional medical center; 255 surveys were returned, and the final sample numbered 222. Of these, 154 (69%) attended CR. Compared to nonparticipants (n = 68), participants reported significantly higher levels of functioning on 7 of the 8 subscales of the Medical Outcome Study Short Form-36 (SF-36). In relation to clinical risk factor outcomes, participants had a significantly lower body mass index than nonparticipants. Patients who attended CR reported that they had switched to low-fat foods, started an exercise program, lost weight, lowered stress, lowered blood pressure, and reduced blood cholesterol at significantly higher rates than non-participants. Patients were more likely to participate in CR if their physician explained its benefits, if they were told about it during their hospitalization, and if they lived close to a CR program. Patients with coronary heart disease need to be referred to CR for improved physical and psychosocial functioning and successful risk factor modification.

Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP)

The purpose of this prospective randomized controlled trial was to assess the impact of phase III comprehensive cardiac rehabilitation (CR) on health-related quality of life (HRQOL) in elderly patients with coronary artery disease (CAD). Thirty-eight elderly males (mean age, 70 years) with CAD were stratified as the intervention group (n=20) and the control group (n=18). In the intervention group, patients participated in CR for 6 months, whereas in the control group, they received standard care. Validated questionnaires were obtained to evaluate HRQOL using the Medical Outcome Study Short-Form 36 Health Status Survey (SF-36), State-trait anxiety inventory questionnaire (STAI) and Self-rating Depression Scale (SDS) at baseline and after 6 months. At baseline, scores of SF-36 except for general health, STAI and SDS were not different in either group. After 6 months, in the intervention group, scores of bodily pain, general health, vitality and mental health of SF-36 improved significantly compared with baseline. State anxiety scores also improved significantly (p<0.01), but SDS depression scores were not improved. In the control group, none of the parameters significantly changed. These results indicate that elderly patients with CAD should be vigorously encouraged to pursue CR even in chronic phase III.

Benefits of cardiac rehabilitation and exercise training programs in elderly coronary patients

The authors review several studies from the Ochsner Heart and Vascular Institute showing the benefits of formal phase II cardiac rehabilitation and exercise training programs in elderly patients with coronary artery disease, including benefits on plasma lipids, obesity indices, exercise capacity, peak oxygen consumption, behavioral characteristics (especially depression), and quality of life. Marked benefits were noted in elderly women and all elderly patients over the age of 75 years. The authors conclude that the therapy has proved to be safe and effective for elderly coronary patients, and that these individuals should be routinely referred to, and vigorously encouraged to attend, cardiac rehabilitation programs following major coronary events.

Cardiac rehabilitation in the elderly

BACKGROUND

Although patients >/=65 years old account for the majority of cardiac admissions and procedures in the United States, studies of cardiac rehabilitation have traditionally focused on younger patients. Only recently has the effectiveness of cardiac rehabilitation in the elderly population begun to receive more attention.

METHODS

We present a comprehensive literature review of studies that have looked specifically at the effectiveness of cardiac rehabilitation in the elderly. We discuss the methodologic limitations of studies to date, compare outcomes among elderly rehabilitation patients with those of younger patients, and examine barriers to participation among the elderly.

RESULTS

The majority of studies published to date have been small observational case series. Despite these limitations, these studies generally show consistent improvements in exercise capacity, cardiac risk factors, and quality-of-life parameters in elderly cardiac rehabilitation patients. These benefits appear to be similar to those seen in younger patients. In spite of this, participation rates among the elderly are low, primarily because of less aggressive referral.

CONCLUSIONS

Although further studies are necessary, the current literature shows that cardiac rehabilitation is associated with improved outcomes after a cardiac event, regardless of age. However, innovative recommendation and referral strategies are needed because few elderly patients actually enroll.