A controlled trial of exercise training in older coronary patients

Walking for hypertension

BACKGROUND

Increased physical activity has been recommended as an important lifestyle modification for the prevention and control of hypertension. Walking is a low-cost form of physical activity and one which most people can do. Studies testing the effect of walking on blood pressure have revealed inconsistent findings.

OBJECTIVES

To determine the effect of walking as a physical activity intervention on blood pressure and heart rate.

SEARCH METHODS

We searched the following databases up to March 2020: the Cochrane Hypertension Specialised Register, CENTRAL (2020, Issue 2), Ovid MEDLINE, Ovid Embase, CINAHL, PsycINFO, SPORTDiscus, PEDro, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also searched the following Chinese databases up to May 2020: Index to Taiwan Periodical Literature System; National Digital Library of Theses and Dissertation in Taiwan; China National Knowledge Infrastructure (CNKI) Journals, Theses & Dissertations; and Wanfang Medical Online. We contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials of participants, aged 16 years and over, which evaluated the effects of a walking intervention compared to non-intervention control on blood pressure and heart rate were included.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Where data were not available in the published reports, we contacted authors. Pooled results for blood pressure and heart rate were presented as mean differences (MDs) between groups with 95% confidence intervals (CIs). We undertook subgroup analyses for age and sex. We undertook sensitivity analyses to assess the effect of sample size on our findings.

MAIN RESULTS

A total of 73 trials met our inclusion criteria. These 73 trials included 5763 participants and were undertaken in 22 countries. Participants were aged from 16 to 84 years and there were approximately 1.5 times as many females as males. The characteristics of walking interventions in the included studies were as follows: the majority of walking interventions was at home/community (n = 50) but supervised (n = 36 out of 47 reported the information of supervision); the average intervention length was 15 weeks, average walking time per week was 153 minutes and the majority of walking intensity was moderate. Many studies were at risk of selection bias and performance bias. Primary outcome We found moderate-certainty evidence suggesting that walking reduces systolic blood pressure (SBP) (MD -4.11 mmHg, 95% CI -5.22 to -3.01; 73 studies, n = 5060). We found moderate-certainty evidence suggesting that walking reduces SBP in participants aged 40 years and under (MD -4.41 mmHg, 95% CI -6.17 to -2.65; 14 studies, n = 491), and low-certainty evidence that walking reduces SBP in participants aged 41 to 60 years (MD -3.79 mmHg, 95% CI -5.64 to -1.94, P < 0.001; 35 studies, n = 1959), and those aged 60 years of over (MD -4.30 mmHg, 95% CI -6.17 to -2.44, 24 studies, n = 2610). We also found low certainty-evidence suggesting that walking reduces SBP in both females (MD -5.65 mmHg, 95% CI -7.89 to -3.41; 22 studies, n = 1149) and males (MD -4.64 mmHg, 95% CI -8.69 to -0.59; 6 studies, n = 203). Secondary outcomes We found low-certainty evidence suggesting that walking reduces diastolic blood pressure (DBP) (MD -1.79 mmHg, 95% CI -2.51 to -1.07; 69 studies, n = 4711) and heart rate (MD -2.76 beats per minute (bpm), 95% CI -4.57 to -0.95; 26 studies, n = 1747). We found moderate-certainty evidence suggesting that walking reduces DBP for participants aged 40 years and under (MD -3.01 mmHg, 95% CI -4.44 to -1.58; 14 studies, n = 491) and low-certainty evidence suggesting that walking reduces DBP for participants aged 41 to 60 years (MD -1.74 mmHg, 95% CI -2.95 to -0.52; 32 studies, n = 1730) and those aged 60 years and over (MD -1.33 mmHg, 95% CI -2.40 to -0.26; 23 studies, n = 2490). We found moderate-certainty evidence that suggests walking reduces DBP for males (MD -2.54 mmHg, 95% CI -4.84 to -0.24; 6 studies, n = 203) and low-certainty evidence that walking reduces DBP for females (MD -2.69 mmHg, 95% CI -4.16 to -1.23; 20 studies, n = 1000). Only 21 included studies reported adverse events. Of these 21 studies, 16 reported no adverse events, the remaining five studies reported eight adverse events, with knee injury being reported five times.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that walking probably reduces SBP. Moderate- or low-certainty evidence suggests that walking may reduce SBP for all ages and both sexes. Low-certainty evidence suggests that walking may reduce DBP and heart rate. Moderate- and low-certainty evidence suggests walking may reduce DBP and heart rate for all ages and both sexes.

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

Health related quality of life assessment in acute coronary syndrome patients: the effectiveness of early phase I cardiac rehabilitation

BACKGROUND

Acute Coronary Syndrome (ACS) is one of the most burdensome cardiovascular diseases in terms of the cost of interventions. The Cardiac Rehabilitation Programme (CRP) is well-established in improving clinical outcomes but the assessment of actual clinical improvement is challenging, especially when considering pharmaceutical care (PC) values in phase I CRP during admission and upon discharge from hospital and phase II outpatient interventions. This study explores the impact of pharmacists' interventions in the early stages of CRP on humanistic outcomes and follow-up at a referral hospital in Malaysia.

METHODS

We recruited 112 patients who were newly diagnosed with ACS and treated at the referral hospital, Sarawak General Hospital, Malaysia. In the intervention group (modified CRP), all medication was reviewed by the clinical pharmacists, focusing on drug indication; understanding of secondary prevention therapy and adherence to treatment strategy. We compared the "pre-post" quality of life (QoL) of three groups (intervention, conventional and control) at baseline, 6 months and 12 months post-discharge with Malaysian norms. QoL data was obtained using a validated version of Short-Form 36 Questionnaire (SF-36). Analysis of variance (ANOVA) with repeated measure tests was used to compare the mean differences of scores over time.

RESULTS

A pre-post quasi-experimental non-equivalent group comparison design was applied to 112 patients who were followed up for one year. At baseline, the physical and mental health summaries reported poor outcomes in all three groups. However, these improved gradually but significantly over time. After the 6-month follow-up, the physical component summary reported in the modified CRP (MCRP) participants was higher, with a mean difference of 8.02 (p = 0.015) but worse in the mental component summary, with a mean difference of -4.13. At the 12-month follow-up, the MCRP participants performed better in their physical component (PCS) than those in the CCRP and control groups, with a mean difference of 11.46 (p = 0.008), 10.96 (p = 0.002) and 6.41 (p = 0.006) respectively. Comparing the changes over time for minimal important differences (MICD), the MCRP group showed better social functioning than the CCRP and control groups with mean differences of 20.53 (p = 0.03), 14.47 and 8.8, respectively. In role emotional subscales all three groups showed significant improvement in MCID with mean differences of 30.96 (p = 0.048), 31.58 (p = 0.022) and 37.04 (p < 0.001) respectively.

CONCLUSION

Our results showed that pharmaceutical care intervention significantly improved HRQoL. The study also highlights the importance of early rehabilitation in the hospital setting. The MCRP group consistently showed better QoL, was more highly motivated and benefitted most from the CRP.

TRIAL REGISTRATION

Medical Research and Ethics Committee (MREC) Ministry of Health Malaysia, November 2007, NMRR-08-246-1401.

Changes in cardiorespiratory fitness in cardiac rehabilitation patients: a meta-analysis

BACKGROUND/OBJECTIVES

Improving patients' cardiorespiratory fitness is an important therapeutic outcome in cardiac rehabilitation. The ability of cardiac rehabilitation to reduce mortality and morbidity has been evidenced through several meta-analyses. Whether cardiac rehabilitation can increase cardiorespiratory fitness and which factors may influence such gains are less well quantified.

METHODS

We performed detailed literature searches of electronic databases and manually searched papers concerning changes in cardiorespiratory fitness in cardiac rehabilitation patients. We performed random-effects meta-analysis of mean improvements in cardiorespiratory fitness and subgroup analyses to determine potential sources of heterogeneity.

RESULTS

Data from 31 studies produced 48 groups (n=3827) with a mean improvement of 1.55 (95% CI 1.21-1.89) METs, (p<0.001); equivalent to standardised effect size of ES=0.97 (95% CI 0.80-1.13). As this value was highly heterogeneous (Q=852, p<0.001) we performed subgroup analyses on the effect size data. Gains in fitness were highest in patients receiving >36 exercise sessions in studies where fitness was assessed using the Naughton Protocol. Patient characteristics associated with the highest fitness gains were age (being young) and sex (being male training in a male-only exercise group). Changes in fitness were unrelated to programme type (comprehensive or exercise-only), duration or study design. There was no association with patient's baseline fitness levels.

CONCLUSION

This is the first meta-analysis of changes in cardiovascular fitness in cardiac rehabilitation patients and shows clinically significant improvements in a large sample of patients from a variety of rehabilitation programmes. This analysis helps describe the characteristics of cardiac rehabilitation programmes which can increase patients' cardiorespiratory fitness.

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.

Individualized Preventive Care in Cardiac Rehabilitation

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.

Cardiac rehabilitation in the elderly: patient selection and outcomes

In Western countries, the aging and improving survival of patients with coronary heart disease are responsible for an increasing number of older adults (65 years of age and older) who are eligible for cardiac rehabilitation. The elderly with coronary heart disease represent a special population with changes induced by aging and lifestyle, comorbidity, cognitive dysfunction, and high risk of disability. Although the elderly account for the majority of cardiac admissions and procedures, studies on cardiac rehabilitation have traditionally focused on younger patients. In aged experimental animals, there is evidence that exercise training is able to improve hemodynamic parameters and biologic markers. Moreover, in older patients, exercise improves functional capacity and reduces myocardial work, similar to that seen in younger patients. As for younger patients, cardiac rehabilitation requires a multidisciplinary approach, including comprehensive assessment, treatment of risk factors and comorbidity, and psychosocial assessment. Cardiac rehabilitation is safe and helpful for elderly coronary patients. Physicians must be encouraged to prescribe cardiac rehabilitation programs for the elderly following major coronary events and coronary revascularization procedures.

Older Adults' Views of Cardiac Rehabilitation Programs: Is it Time to Reinvent?

In spite of the documented benefits of cardiac rehabilitation program (CRP) participation, older adults are not likely to participate. Older adults' expectations of and experiences with CRPs are not known. It is also not known whether women and men differ in their expectations and experiences. This descriptive study used a convenience sample of 40 older adults who had experienced an acute cardiac event to identify patients' views of CRPs. Focus groups revealed that older adults do not have an accurate understanding of what to expect in CRPs, and that older adults' experiences in CRPs were generally positive. Older adults suggested CRPs could be improved by including more socialization opportunities, offering varied forms of exercise, enhancing teaching about stress management, and adapting teaching strategies. In this study, "strength of physician referral" was identified as the main reason for participating or not participating in a CRP. Older men feared physical pain with exercise and older women expressed a need for emotional support. A major finding in this study was the report of adverse events (i.e., exhaustion, collapse) during exercise experienced by individuals who did not go to a CRP. Because the majority of adults participating in CRPs are older, transforming CRPs to meet the needs of these older adults is important. Future research on the effectiveness of alternative CRP models will provide evidence to ensure the delivery of quality, cost-effective care.

Re-engineering cardiac rehabilitation programmes: considering the patient's point of view

AIMS

The aim of this paper is to report a study to describe how cardiac patients experience the first 3 months following a cardiac event requiring hospitalization, identify differences between the needs expressed by patients and the support they received during their recuperation and produce a preliminary model for the development of cardiac rehabilitation programmes, taking into account the patient perspective.

BACKGROUND

Although cardiac rehabilitation should be standard care for patients with cardiovascular disease, less than 20% begin and maintain a rehabilitation programme. Cited barriers include inadequate rehabilitation services, sub-optimal referral, low participation rates of women and older adults and travel considerations. The literature suggests that programmes better adjusted to patient needs could increase attendance, but little research has considered this perspective.

METHODS

Focus groups were conducted with a purposefully selected sample of 20 men and women who had been hospitalized for myocardial infarction, angina or percutaneous angioplasty. Data were analysed using qualitative content analysis.

FINDINGS

A gap exists between what traditional rehabilitation programmes offer and patients' expressed needs during the recuperating process after hospitalization for a cardiac event. In our study, participants focused on stress management rather than on modifying health habits. Support groups were viewed as beneficial and, according to patients, accepting their condition, knowing their limits and better continuity of care would also help reduce stress. Based on the findings, we devised a model as the basis for developing cardiac rehabilitation programmes.

CONCLUSION

Cardiac rehabilitation programmes need to shift their focus of attention from promoting healthier behaviours to responding to participants' perceived needs, alongside risk factor reduction.

Effects of cardiac rehabilitation on the recovery outcomes of older adults after coronary artery bypass surgery

PURPOSE

This study aimed to examine differences in lower extremity function as well as perception of physical and mental function between adults 70 years of age or older who participated in a phase 2 cardiac rehabilitation program (CRP) (n = 32) and those who did not participate in a CRP (n = 33) after coronary artery bypass surgery (CABS).

METHODS

In this two-group longitudinal comparative study, recovery outcomes measured at baseline (6 weeks) and 6 months after CABS were compared between older adults who participated and those who did not participate in a CRP.

RESULTS

In study groups that were equivalent before the CRP, analysis of covariance (controlling for baseline scores) showed that 6 months after hospital discharge, those who participated in a CRP had greater lower extremity strength (F = 3.9; P =.04), greater ankle range of motion (F = 4.2; P =.02), better dynamic balance (F = 8.2; P =.003), better static balance (F = 3.3; P =.04), better gait (F = 4.7; P =.02), and perceptions of better physical function (F = 14.8; P =.00). The results remained the same when control was used for the effects of social support, self-efficacy, depression, comorbidity, cardiac functional status, and gender for all the variables except static balance. No difference related to perception of mental function was found between the study groups (F =.10; P =. 74).

CONCLUSIONS

Participation in a CRP by older individuals improves lower extremity function (an important dimension in preventing disability) and perception of physical function. Cardiac rehabilitation programs can be used to optimize the recovery outcomes of older individuals after CABS.

Barriers to Physical Activity Maintenance After Cardiac Rehabilitation

PURPOSE

Little is known about the contextual determinants for the maintenance of physical activity after cardiac rehabilitation. This study aimed to examine perceived social, psychological, and health-related barriers to the maintenance of physical activity among phase 2 cardiac rehabilitation graduates.

METHODS

Researchers using an open-ended format asked 160 participants (121 men and 39 women) 6 months after rehabilitation to identify perceived barriers to physical activity maintenance. The content of the participant responses was analyzed through categorization and coding of data, with independent review used to assess accuracy and reliability of decision rules. A social ecologic perspective was used for secondary coding and categorization. A chi analysis of categories was conducted to explore differences by gender, ethnicity, education, and employment.

RESULTS

Four categories were developed from the coded responses: intrapersonal, interpersonal, environmental, and organizational. In their responses, 93% of the participants reported intrapersonal barriers, with 24% reporting interpersonal barriers, 18% reporting environmental barriers, and 11% reporting organizational barriers. Years of education contributed significantly to acceptance of an inactive lifestyle among those less educated (chi = 32.489; P = .028). Employment status showed significant differences for work as a barrier among those employed full-time (chi = 13.570, P = .004). Barriers to physical activity by gender showed significant differences for interpersonal barriers as a whole (chi = 6.804; P = .009).

CONCLUSIONS

The open-ended format provided rich narrative data regarding barriers to the maintenance of physical activity. The acknowledgment of barriers, particularly from a social ecologic perspective, is needed to guide innovative, multilevel interventions for promoting physical activity maintenance among those with diagnosed coronary heart disease.

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial

BACKGROUND

Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL).

METHODS AND RESULTS

Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR.

CONCLUSIONS

Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.

Health-related interactions and the self in marriage

This study investigated the association between self processes and married partners' (N = 59 couples) perspectives of their health-related social interactions. Findings revealed that wives' self processes were associated with their social behavior from the perspective of each partner. The wives' self processes differentially predicted wives' and husbands' perspectives of their interactions, however. These findings demonstrate that wives' future expectations for the health of their husband, as well as for their role in maintaining his future health, motivate their current social behavior to promote the positive health lifestyle behaviors of their husband.

Barriers to participation in and adherence to cardiac rehabilitation programs: a critical literature review

Despite the documented evidence of the benefits of cardiac rehabilitation (CR) in enhancing recovery and reducing mortality following a myocardial infarction, only about one third of patients participate in such programs. Adherence to these programs is an even bigger problem, with only about one third maintaining attendance in these programs after 6 months. This review summarizes research that has investigated barriers to participation and adherence to CR programs. Some consistent factors found to be associated with participation in CR programs include lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, self-efficacy, perceived benefits of CR, distance and transportation, self-concept, self-motivation, family composition, social support, self-esteem, and occupation. Factors associated with non-adherence include being older, female gender, having fewer years of formal education, perceiving the benefits of CR, having angina, and being less physically active during leisure time. However, many of the studies have methodologic flaws, with very few controlled, randomized studies, making the findings tentative. Problems in objectively measuring adherence to unstructured, non-hospital-based programs, which are an increasingly popular alternative to traditional programs, are discussed. Suggestions for reducing barriers to participation and adherence to CR programs, as well as for future research aimed at clearly identifying these barriers, are discussed.

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.

Exercise rehabilitation of older patients with cardiovascular disease

As the population of elderly patients with cardiovascular disease continues to increase, much research needs to be done with the goal of maintaining physical functioning and personal independence in this population. It is of particular importance to determine whether training programs can improve physical functioning in the most severely disabled older coronary patients. Effects of cardiac rehabilitation programs on other outcome measures, including psychosocial outcomes, lipid levels, insulin levels, and body composition require better study. Finally, the economic benefits of cardiac rehabilitation in the older coronary patients has received little attention, although early reports are promising. In summary, the older population with coronary disease is characterized by high rates of disability. Exercise training has been demonstrated to be safe and to improve strength, aerobic fitness capacity, endurance and physical function. It remains to be seen whether exercise training can reverse or prevent disability in a broad population of older patients with cardiovascular disease. If successful, cardiac rehabilitation programs will pay great medical, social, and economic dividends in this population.

Psychosocial components of cardiac recovery and rehabilitation attendance

OBJECTIVE

To examine the relations between demographic factors, specific psychosocial factors, and cardiac rehabilitation attendance.

DESIGN

Cohort, repeated measures design.

SETTING

A large tertiary care centre in western Canada

PATIENTS

304 consecutive consenting patients discharged following acute myocardial infarction and/or coronary artery bypass graft surgery.

MAIN OUTCOME MEASURES

The Jenkins self-efficacy expectation scales and activity checklists of behaviour performance for maintaining health and role resumption, modified version of the self-motivation inventory, and the shortened social support scale.

RESULTS

Those who had higher role resumption behaviour performance scores at two weeks after discharge were significantly less likely to attend cardiac rehabilitation programmes. At six months after discharge, those who attended cardiac rehabilitation demonstrated higher health maintenance self-efficacy expectation and behaviour performance scores. Health maintenance self-efficacy expectation and behaviour performance improved over time. Women reported less social support but showed greater improvement in health maintenance self-efficacy expectation. Changes in self-efficacy scores were unrelated to-but changes in health maintenance behaviour performance scores were strongly associated with-cardiac rehabilitation attendance.

CONCLUSIONS

Cardiac patients and practitioners may have misconceptions about the mandate and potential benefits of rehabilitation programmes. Patients who resumed role related activities early and more completely apparently did not see the need to "rehabilitate" while those who attended cardiac rehabilitation programmes enhanced their secondary prevention behaviours.

Cardiac rehabilitation: a comprehensive review

Cardiac rehabilitation (CR) is a commonly used treatment for men and women with cardiovascular disease. To date, no single study has conclusively demonstrated a comprehensive benefit of CR. Numerous individual studies, however, have demonstrated beneficial effects such as improved risk-factor profile, slower disease progression, decreased morbidity, and decreased mortality. This paper will review the evidence for the use of CR and discuss the implications and limitations of these studies. The safety, relevance to special populations, challenges, and future directions of CR will also be reviewed.

Gender differences in referral to cardiac rehabilitation programs after revascularization

BACKGROUND

This study examines the influence of gender on the healthcare provider's secondary prevention instruction and cardiac rehabilitation (CR) referral after coronary revascularization procedures such as balloon angioplasty/coronary stenting and coronary bypass surgery (CABG). Cardiac rehabilitation decreases mortality and morbidity, yet only a small percentage of women and men are referred to these programs. The patient population of our university-affiliated CR program consisted of 88% men and 12% women.

METHODS

In a matched case observational study, 80 patients (40 men, 40 women) who had undergone coronary revascularization procedures between 1997 and 1998 completed a questionnaire on secondary prevention instruction and written referral to CR programs. Patients were matched for age and coronary revascularization procedure.

RESULTS

Women were less likely to be instructed on secondary prevention strategies and CR or referred to CR as compared to men despite being matched for age and undergoing the same procedure. The data demonstrate a gender difference in hospital teaching and referral information for CR after revascularization (P < 0.001). Being a woman was associated with a decreased likelihood of receiving a physician referral to CR after revascularization (P < 0.001).

CONCLUSION

The instruction of patients concerning secondary prevention and CR postrevascularization procedures is poor. Within that group, women were far less likely to have CR discussed or referrals made by healthcare professionals. This study demonstrates the need for education initiatives of all healthcare providers on the comprehensive nature and benefits of CR in the secondary prevention of cardiovascular disease, with a particular emphasis on women.

Physical activity for the chronically ill and disabled

Exercise prescription principles for persons without chronic disease and/or disability are based on well developed scientific information. While there are varied objectives for being physically active, including enhancing physical fitness, promoting health by reducing the risk for chronic disease and ensuring safety during exercise participation, the essence of the exercise prescription is based on individual interests, health needs and clinical status, and therefore the aforementioned goals do not always carry equal weight. In the same manner, the principles of exercise prescription for persons with chronic disease and/or disability should place more emphasis on the patient's clinical status and, as a result, the exercise mode, intensity, frequency and duration are usually modified according to their clinical condition. Presently, these exercise prescription principles have been scientifically defined for clients with coronary heart disease. However, other diseases and/or disabilities have been studied less (e.g. renal failure, cancer, chronic fatigue syndrome, cerebral palsy). This article reviews these issues with specific reference to persons with chronic diseases and disabilities.

Cardiac rehabilitation and secondary prevention programs for elderly cardiac patients

The utility of cardiac rehabilitation for elderly cardiac patients is controversial, and cost, logistic barriers, and encumbering comorbidities often seem disproportionate. Many clinicians view the emphasis of cardiac rehabilitation on behavior modification and risk-factor reduction as irrelevant for very old adults and consider pure exercise programs as appropriate alternatives. The strong rationale for cardiac rehabilitation and secondary prevention is elucidated, and available corroborating data are presented. The benefits of exercise prescription in cardiac rehabilitation and synchronized risk-factor reduction are pertinent to aging and age-related heart disease, including coronary heart disease and heart failure.

Determinants of exercise tolerance after acute myocardial infarction in older persons

OBJECTIVES

Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age-related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI.

DESIGN, SETTING, AND PARTICIPANTS

Data is from baseline assessment of 265 post-MI patients (age range 45-85 years) enrolled in the Cardiac Rehabilitation in Advanced Age randomized, controlled trial. Patients with major comorbidities or severe MI complications were excluded from the trial. Exercise tolerance was determined from symptom-limited exercise testing and expressed as total work capacity (TWC, kg.m) or peak oxygen consumption (VO2peak, mL/kg/min). The associations between both TWC and VO2peak and baseline demographic, social, clinical, and neuropsychological variables and an index of health-related quality of life were determined with univariate and multivariate analysis.

RESULTS

With univariate analysis, TWC decreased by 1285 kg.m per decade of increasing age between 45 and 85 years of age. With multivariate analysis, TWC decreased by 922 kg.m per decade. Increasing age (P < .001), female gender (P < .001), a small body surface area (P < .001), a low level of usual physical exercise before MI (P < .002), and the presence of post-MI depressive symptoms (P < .024) were independently associated with a lower TWC. The same factors, in addition to a small arm muscle area (P < .002), were also independently associated with a lower VO2peak.

CONCLUSIONS

Age per se accounts for approximately 70% of the age-related decay in TWC or VO2peak. However, the inclusion of modifiable factors such as physical exercise and depression in the prediction model reinforces the importance of a multidimensional approach to the evaluation and treatment of older patients with a recent MI.

Effect of myocardial ischaemia on left ventricular function and adaptability to exercise training

PURPOSE

We evaluated the possible interaction between exercise-induced myocardial ischemia and abnormalities in left ventricular function in 72 patients with coronary artery disease at entry and upon discharge from a 6-month exercise training program.

METHODS

Twenty-two patients with myocardial ischemia (MIS) defined by electrocardiographic and radionuclide imaging criteria constituted our experimental group (EG). Fifty patients without MIS were assigned to the control group for exercise training (CG-ET) and 31 healthy subjects to the control group for measures of left ventricular function (CG-LV).

RESULTS

Both groups EG and CG-ET showed significant and comparable increases in peak oxygen uptake (EG: 25.2 +/- 5.1 to 26.9 +/- 5.4 mL x kg(-1) x min(-1), P < 0.02; CG-ET: 25.1 +/- 0.6 to 27.4 +/- 0.7 mL x kg(-1) x min(-1), P < 0.001) after exercise training, but only CG-ET showed significant reductions in heart rate, systolic blood pressure, and rate-pressure product during submaximal exercise. A significant increase in end-diastolic volume contributed to the increase in cardiac output during exercise in patients with MIS. Heart rate or treadmill time at onset of ST segment depression failed to increase as a result of training, and stroke counts and the product of stroke counts and heart rate showed a trend toward a decrease in response to exercise, suggesting progression of disease.

CONCLUSIONS

Patients with myocardial ischemia showed improvements in maximal exercise capacity but failed to elicit physiologic adaptations during submaximal exercise or to increase the threshold for ischemia after exercise training. It is possible that the main emphasis in the management of this type of patient in a cardiac rehabilitation setting should be placed more on coronary risk factor modification to slow progression of disease than on improving cardiovascular efficiency.

Coronary heart disease. Stable and unstable syndromes

CHD in the elderly population will continue to be a source of major concern because of the increasing costs entailed and uncertainties about how the widespread array of diagnostic and therapeutic interventions, often expensive and sometimes hazardous, should be applied. Financial, political, and health policy decisions will continue to occupy much attention, but it is likely that philosophic considerations about aging and death, both from the individual and the societal perspective, will be of paramount importance of deciding how the substantial resources available to the elderly will be used. Randomized, controlled trials are unlikely to play a major role in resolution of management dilemmas in the elderly because of the extraordinary heterogeneity in this population. Registries (databases) involving carefully prospectively collected key variables are likely to be a more effective approach. Critical characterization of complications of procedures, adverse drug reactions, and collection of follow-up data on functional status are among the critical questions, and these can be answered by registry studies. Algorithms and clinical rules developed in younger cohorts are not directly transferable to the elderly cardiovascular patients, further emphasizing the need for prospectively collected, syndrome-specific data. Treatments convincingly demonstrated to reduce mortality in absolute terms more in the elderly than in the young are underused. The heterogeneity of aging emphasizes the wide variability in patients' ability to withstand the stress of procedures and complications of disease and makes clear the need to consider physiologic reserve and biologic age rather than chronology. With better characterization of biologic age and physiologic reserve, more precise estimates of outcomes of therapies and interventions can be made, and patients can be given better information and with their families have more realistic expectations. Better-informed decisions will result. Biologic age will be multifactorial, involving cognitive, emotional, physical, and nutritional attributes as well as specific organ function (lung, kidney, liver) because no single feature can characterize the total elderly patient. The concept of competing risks among the cardiovascular disease being treated, comorbidity, risks of study, and life expectancy will evolve because even the most successful therapy will have limited effect on longevity in the very old. Although important research at the cellular and molecular level will characterize and provide better understanding of the aging process, it is not likely that this basic information will be immediately useful in the management of the large number of elderly patients with major cardiovascular disease. Preventive measures, including physical exercise, mental stimulation, avoidance of depression, good nutrition, and abstinence from tobacco use, are useful approaches to postpone or ameliorate the consequences of aging and allow patients to tolerate cardiovascular diseases better when they become manifest.

Cardiac rehabilitation in older coronary patients

The majority of patients presenting with acute coronary disease or undergoing coronary revascularization procedures are older than age 65. Disability rates are very high in these patient populations, particularly in women, the older-old, and patients with clinical manifestations of angina pectoris or chronic heart failure. The presence of mental depression is also an important determinant of poor physical functioning. Cardiac rehabilitation has been demonstrated to safely increase aerobic capacity, muscular strength, and endurance in older coronary populations.

Aims, design and enrollment rate of the Cardiac Rehabilitation in Advanced Age (CR-AGE) randomized, controlled trial

Data regarding the efficacy of cardiac rehabilitation after acute myocardial infarction in advanced age are limited, and are derived from either controlled but non randomized trials, or observational studies. Several aspects of cardiac rehabilitation after myocardial infarction in advanced age, including its effectiveness on exercise tolerance and health-related quality of life, as well as the feasibility of rehabilitation programs, need clarification. The objectives of this randomized, controlled trial, Cardiac Rehabilitation in Advanced Age (CR-AGE), are to examine the effects of an 8-week comprehensive cardiac rehabilitation intervention, comparing 1) supervised outpatient, hospital-based cardiac rehabilitation, 2) home-based cardiac rehabilitation, and 3) usual care in each of three groups of post-myocardial infarction patients, 45-65, 66-75, and 76-85 years of age. The primary objective of the trial is to evaluate the change in physical fitness in each age group assessed by total work capacity at the end of the intervention, and during follow-up over both the medium- (6 months) and the long-term (1 and 2 years). Secondary objectives of the trial include an examination of the feasibility of cardiac rehabilitation in older patients, as well as the determination of the following: exercise complication rates; changes in peak oxygen consumption; changes in other outcome measures, such as health-related quality of life, prevalence of anxiety and depressive symptoms, fluid intelligence, body composition and mass index; incidence of new cardiac and non-cardiac events; and utilization rates of health care services. Enrollment in the CR-AGE trial is expected to be completed within the first half of 1998.

Cardiac rehabilitation referral and attendance: not one and the same

Despite empirical evidence that cardiac rehabilitation programs can play a significant role in enhancing recovery following a primary cardiac event and in enacting secondary prevention measures, attendance rates remain remarkably low. Referral and attendance at cardiac rehabilitation programs are not one and the same. Recognizing this, issues related to the referral of eligible patients to cardiac rehabilitation and factors that affect patients' decisions regarding attendance must be identified and addressed. This article presents an overview of the potential benefits of cardiac rehabilitation programs, describes salient issues related to referral and attendance, and identifies directions for future research.

Cardiac rehabilitation in the elderly

Rehabilitation for patients with heart disease consists of exercise training, behavioral interventions, counseling, and education with the goal of improving physiologic and psychosocial status. The Cardiac Rehabilitation Clinical Practice Guidelines, recently published in the United States, list the most substantial benefits of cardiac rehabilitation as an improvement in exercise tolerance, symptoms, blood lipid levels, and psychosocial well-being, and a reduction in cigarette smoking, stress, and mortality. With the evidence-base on the elderly in the Guidelines derived from 1 non-randomized controlled trial and 7 observational studies, the efficacy and effectiveness of cardiac rehabilitation is based almost exclusively on data generated on young and middle-aged males. We have located an additional 10 randomized and 2 non-randomized controlled trials published since the Guidelines, but only one provided age-specific data. The elderly are the fastest growing segment of the population, and may be more responsive to the effects of cardiac rehabilitation as they often have greater initial disability and less independence than younger patients. While referral of elderly persons to cardiac rehabilitation services appears safe and warranted in the secondary prevention of heart disease, the lack of rigorous scientific evidence has created an important clinical research and clinical policy vacuum which urgently needs to be filled.