Quality of life and anxiety in a phase II cardiac rehabilitation program

Impact of Cardiac Rehabilitation Health Insurance Coverage on Cardiac Rehabilitation Use in Korea Using an Interrupted Time Series

BACKGROUND

Since 2017, the cardiac rehabilitation (CR) program in Korea has been included in the coverage provided by the National Health Insurance to alleviate financial burden. Our study aimed to identify changes in the CR program use according to the implementation of CR coverage.

METHODS AND RESULTS

We obtained data from the electronic medical records of a tertiary hospital in Seoul, Korea from January 2014 to February 2020. Data from 2988 patients with acute coronary syndrome who underwent percutaneous coronary intervention were included. To examine the CR use trend among patients undergoing percutaneous coronary intervention, the electronic medical records data of the patients were aggregated quarterly, resulting in a maximum of 24 repeated measures for each patient. Segmented regression is often used to estimate the effects of interventions in an interrupted time series. Policy implementation led to a prompt increase in the probability of CR use (odds ratio [OR], 3.99 [95% CI, 2.89-5.51]). After the implementation of CR coverage, no significant change in CR use (OR, 0.97 [95% CI, 0.92-1.01]) was observed. After percutaneous coronary intervention, more patients opted for CR, especially those receiving education compared with exercise (education: OR, 87.44 [95% CI, 36.79-207.83] versus exercise: OR, 1.99 [95% CI, 1.43-2.76]).

CONCLUSIONS

The implementation of CR coverage resulted in a rapid increase in the probability of CR use. Use of the educational program was higher than that of the exercise program. Given the persistently low use of CR, it is imperative to stimulate its adoption by increasing its availability.

Test-retest reliability of physiological parameters in elite junior distance runners following allometric scaling

This study aimed to quantify the intra-individual reliability of a number of physiological variables in a group of national and international young distance runners. Sixteen (8 male, 8 female) participants (16.7 ± 1.4 years) performed a submaximal incremental running assessment followed by a maximal running test, on two occasions separated by no more than seven days. Maximal oxygen uptake (V̇O_2max), speed at V̇O_2max (km h^-1), running economy and speed and heart rate (HR) at fixed blood lactate concentrations were determined. V̇O_2max and running economy were scaled for differences in body mass using a power exponent derived from a larger cohort of young runners (n = 42). Running economy was expressed as oxygen cost and energy cost at the speed associated with lactate turnpoint (LTP) and the two speeds prior to LTP. Results of analysis of variance revealed an absence of systematic bias between trials. Reliability indices showed a high level of reproducibility across all parameters (typical error [TE] ≤2%; intra-class correlation coefficient >0.8; effect size <0.6). Expressing running economy as energy cost appears to provide superior reliability than using oxygen cost (TE ∼1.5% vs. ∼2%). Blood lactate and HR were liable to daily fluctuations of 0.14-0.22 mmol L^-1 and 4-5 beats min^-1 respectively. The minimum detectable change values (95% confidence) for each parameter are also reported. Exercise physiologists can be confident that measurement of important physiological determinants of distance running performance are highly reproducible in elite junior runners.

The effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005

BACKGROUND

Physical activity is a healthful behavior that has promise for combating feelings of low energy and fatigue. Despite evidence suggesting that fatigue is a prodromal symptom of major cardiac events, improvements in feelings of energy and fatigue have largely been ignored by reviewers of cardiac rehabilitation literature who have focused on anxiety, depression and general measures of quality of life.

DESIGN

A meta-analytical review.

METHODS AND RESULTS

Computer databases were searched from January 1945 to May 2005 to identify relevant literature. A total of 36 studies consisting of 4765 subjects were included. Cardiac rehabilitation exercise programs were consistently associated with increases in energy and decreases in fatigue. The magnitude of the effect was moderately large (mean delta 0.51; 95% confidence interval 0.42-0.61) but was heterogeneous and modified by features of the research design. Comparison of effect sizes in cardiac rehabilitation studies concurrently measuring energy/fatigue, anxiety and depression suggest that exercise-based cardiac rehabilitation programs have larger effects on feelings of energy and fatigue compared with anxiety and depression.

CONCLUSION

This review quantifies the potential benefit of cardiac rehabilitation exercise programs on feelings of energy and fatigue, and suggests that cardiac rehabilitation researchers and practitioners may benefit from examining, and perhaps even focusing on, feelings of energy and fatigue as an important outcome variable. A greater understanding of the effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue will be reached when more true experiments are conducted thereby avoiding the primary limitation of the literature reviewed; that is, the frequent use of non-experimental research designs.

Improved quality of life with cardiac rehabilitation for post-myocardial infarction patients in Korea

BACKGROUND

Health-related quality of life (HRQOL) has been used as a primary health outcome in cardiac rehabilitation programs (CRP).

AIMS

This study aimed to evaluate the effects of an 8-week CRP on HRQOL and exercise capacity in myocardial infarction (MI) patients in Korea.

METHODS

After matching on gender, age, and left ventricular ejection fraction, 60 subjects with a first acute MI were allocated to either a CRP group (n=31) or a Control group (n=29). The 8-week CRP included hospital-based, supervised exercise training (three times per week, average intensity of 65% VO(2peak)) and individual education sessions. The Control group was instructed on a home-based exercise regimen without contact during the 8 weeks. At baseline and 8 weeks, HRQOL was assessed by the Quality of Life Index (QLI)-cardiac version III; exercise capacity by a treadmill test.

RESULTS

After adjusting for education level, the overall QLI, health/functioning and psycho/spiritual scores showed greater increases in the CRP group than the Control group (p=.014, p=.016, and p=.036, respectively). We observed significant improvements in VO(2peak) (p<.0001), anaerobic threshold (p<.0001), and maximal exercise duration (p<.0001) in the CRP group, compared to the Control group.

CONCLUSIONS

These findings suggest that the Korean CRP can lead to significant improvements in HRQOL outcomes and exercise capacity.

Quality of Life After Participation in a Rural Phase II Cardiac Rehabilitation Program

The purpose of this study was to explore the effectiveness of a cardiac rehabilitation program (phase II) in improving participants' quality of life (QOL). Existing data collected previously by a not-for-profit rural community hospital using the SF-36 tool were analyzed. The secondary data consisted of precardiac and post-cardiac rehabilitation SF-36 scores for 121 phase II participants. All the 8 subscale post scores of the SF-36 were higher when compared to the pre-rehabilitation scores. In this non-controlled trial, results suggest that participation in rural cardiac rehabilitation programs may improve patients' perceptions of QOL and health.

Predictors of Noncompliance to Exercise Training in Heart Failure

BACKGROUND/OBJECTIVES

Exercise training is an emerging therapy in heart failure (HF). However, factors influencing noncompliance to exercise have not been evaluated. We assessed clinical factors, functional status, and emotional predictors of noncompliance to a 12-week home walking exercise program.

METHODS

Using a correlational design, we evaluated noncompliance of 39 HF patients (aged 63.2 +/- 10.1 years, left ventricular ejection fraction 29.5% +/- 8.0%, peak oxygen consumption 14.1 +/- 3.7 mL/kg/min, HF duration 37.5 +/- 32.9 months, 74% New York Heart Association class II) to home walking exercise. Noncompliance was defined as (1) completion of the 12-week program with 60% or less of prescribed weekly walking duration (noncompliant completers); or (2) failure to complete the 12-week program (dropouts). Univariate analyses (chi-square or t test) and multivariate backward logistic regression were performed to identify clinical factors (body mass index, comorbidities, and HF duration), functional status (peak VO2), and emotional dysphoria (anxiety, hostility, depression) predictive of noncompliance to training.

RESULTS

Mean compliance was 35% +/- 30% (945/2700 minutes) for noncompliant patients (n = 13) and 99% +/- 13% (2673/2700 minutes) for compliant patients (n = 26). In the multivariate analysis, higher comorbidity (odds ratio [OR]: 2.7, confidence interval [CI]: 1.11-6.71), longer HF duration (OR: 1.1, CI: 1.01-1.13), lower hostility (OR: 0.47, CI: 0.24-0.91), and lower body mass index (OR: 0.76, CI: 0.58-0.98) were predictive of noncompliance to exercise training in patients with HF.

CONCLUSIONS

Noncompliance should be monitored carefully in HF patients with multiple comorbidities, longer HF duration, lower body mass index, and lower hostility scores. In this subgroup of HF patients, tailored exercise prescriptions may enhance compliance to an exercise program.

Effects of depressive symptoms and anxiety on hemostatic responses to acute mental stress and recovery in the elderly

Depression and anxiety are prospectively associated with cardiac morbidity and mortality. Increased clotting diathesis may mediate this link. We hypothesized that there would be an association between mood and hemostatic changes that occur during and following recovery from acute mental stress. Forty-eight community-dwelling elderly subjects underwent a laboratory speech stressor task. Plasma von Willebrand factor (vWF), thrombin/antithrombin III (TAT) complexes, D-dimer, tissue-type plasminogen activator (t-PA), and type I plasminogen activator inhibitor (PAI-1) were measured at rest, after conclusion of the speech, and 14 min afterwards (recovery). Mood was assessed with the Hamilton Rating Scales for Depression (Ham-D) and Anxiety (Ham-A). Mental stress elicited a hypercoagulable state as evidenced by increases in TAT and D-dimer, and by a decrease in t-PA. Overall, hypercoagulability had increased after recovery. Ham-D scores and Ham-A scores correlated with increases in D-dimer over the testing interval (i.e. area under the curve). Ham-A (but not Ham-D) uniquely explained 8% and 17% of the variance in resting D-dimer and D-dimer area under the curve, respectively. The independent association of anxiety symptoms with resting and stress-induced fibrin formation (D-dimer) may be a mechanism linking mood with cardiovascular disease risk in the elderly.

A review to examine the use of SF-36 in cardiac rehabilitation

The aim of this article is to review critically the current literature on a health-related quality of life (HRQL) measurement tool - the Medical Outcome Short-Form General Health Survey (SF-36) - and to examine the evidence for its use in cardiac rehabilitation. A literature review was carried out using the databases Cinahl, Psychinfo, EMBASE and Cochrane. Key terms used included 'cardiac rehabilitation' and 'SF-36' and the search was carried out for the period 1995-2002. The literature examined indicates that the SF-36 is a sensitive, valid tool that provides broad applicability and is appropriate for use with cardiac rehabilitation patients. However, it remains to be seen whether a disease-specific tool could be even more effective. More research needs to be performed to compare generic measures of HRQL directly with disease-specific measures in cardiac rehabilitation populations. Until then, the author advocates its routine use as a screening tool in cardiac rehabilitation to gain insight into areas of concern so that interventions can be planned to improve patient outcomes.

Social support as a mediator of optimism and distress in breast cancer survivors

Breast cancer patients can experience emotional distress as a result of diagnosis and treatment. Higher levels of optimism and social support are associated with less emotional distress in cancer patients. This 12-month prospective study followed 69 women who had completed treatment for Stages 0-II breast cancer. At 3-month intervals, participants completed measures of mood disturbance, optimism, and social support. As hypothesized, affective social support mediated the relationship between optimism and distress in early-stage breast cancer survivors at baseline and 6 months but not at 1 year. In contrast, confidant social support did not mediate the optimism-distress relationship at any time point. Clinical and research implications of these findings are discussed.

Self-efficacy and mood in cardiac rehabilitation: should gender be considered?

The authors proposed to (a) determine the influence of phase II cardiac rehabilitation (CR) on task and barrier efficacy and mood in men and women, (b) determine the influence of task and barrier efficacy on postphase II CR exercise adherence, and (c) examine the bidirectional relationship between self-efficacy and mood. Fifty-seven men and 24 women completed task and barrier efficacy scales and the anxiety, depression, and vigor subscales 3 to 5 weeks before phase II CR, immediately before and after phase II CR, and 6 to 10 weeks after phase II CR. They found that the women had significantly larger increases in task and barrier efficacy from pre- to postphase II CR than the men did, whereas both men and women had a significant decline at follow-up. Men and women had a similar decrease in anxiety and an increase in vigor during phase II CR. However, vigor significantly declined at follow-up. All changes in mood were significantly related to changes in task and barrier efficacy.

Behavioral medicine in the prevention and treatment of cardiovascular disease

Cardiac behavioral medicine is the application of behavioral and psychosocial principles to the prevention and treatment of heart disease. Most biomedical cardiovascular risk factors (e.g., high blood lipids, high blood pressure, diabetes) require behavioral and medical interventions. Other risks, including obesity, high-fat eating pattern, smoking, and inactivity, clearly require lifestyle change. Behavioral medicine screening and intervention have been applied to psychosocial risk factors such as depression, hostility, and social isolation. Appropriate assessment of risk factors is essential because research has demonstrated successful prevention of heart disease and reduction of morbidity and mortality in patients with existing disease. Behavioral interventions have been beneficial in improving cardiac outcomes by enhancing compliance with medication taking and dietary/exercise recommendations. Future needs include the study of psychosocial factors in women and ethnic minorities with heart disease and the integration of behavioral medicine with newer medical technologies designed to detect subclinical biomarkers of heart disease.

Exercise participation after diagnosis of breast cancer: trends and effects on mood and quality of life

Individuals treated for cancer often experience higher levels of emotional distress than the general population. Previous research has shown that exercise can have an ameliorating effect on these problems. This 12-month prospective longitudinal study investigated mood, quality of life, cancer-related symptoms, and exercise behavior of 69 women who had completed treatment for Stage 0-2 breast cancer. We studied the natural progression of exercise participation after cancer treatment. Effects on mood, quality of life, and cancer-related symptoms were assessed after controlling for demographic variables, disease variables, social support, and baseline values to test the hypothesis that women who exercised were more likely to report better mood, higher quality of life, and fewer cancer-related symptoms. Results indicated that women did not increase their exercise participation over time and that overall mean minutes of exercise participation were below recommended levels. Baseline demographic predictors of exercise participation included younger age, having a spouse or partner, increased time since diagnosis, higher social support, and higher depression. Exercise participation was associated with improved physical functioning, but not overall mood or cancer-related symptoms. We discuss implications of these findings towards the well-being of breast cancer survivors.

Changes in the quality of life: a major goal of cardiac rehabilitation

BACKGROUND

Quality of life (QOL) is a major goal in the context of preventive and therapeutic cardiology. In this article, quality of life concepts are reviewed, factors limiting QOL in cardiac disease are identified, methods of measurement are explored, and clinically significant changes are defined. The changes effected by cardiac rehabilitation are considered, together with their physiological and psychological correlates. A final section suggests avenues for future research.

METHODS

Relevant articles were identified by computer literature searches and review of extensive personal files.

FINDINGS

In the past, there has been an excessive focus on extending the length rather than the quality of the cardiac patient's life. The overall QOL is a broad concept, influenced by personal perceptions, coping mechanisms, and environmental constraints. The ideal test instrument would be reliable, valid, and responsive to clinical change. Potential options include a Gestalt-type instrument, a disease-specific instrument, a function-specific instrument, or a detailed generic questionnaire. There have been relatively few comparisons between these potential approaches. Currently, the Standard Gamble (Gestalt-type), and Living With Heart Failure Questionnaire (disease-specific type), and the Medical Outcomes Study Short-Form 36 (SF-36) Health Survey (generic-type) are among the most popular approaches. Problems arise in distinguishing a clinically important from a statistically significant change; commonly a score change of 1 standard error of the mean is regarded as clinically important. Correlations of scores with clinical, physiological, and psychological change are sometimes weak, in part because of floor and ceiling effects. Nevertheless, potential gains in QOL provide a stronger argument for preventive and therapeutic programs than do increases in longevity.

CONCLUSIONS

The current literature supports the value of QOL measurements in the management of patients with cardiac disease. However, further research is needed to determine the optimum test instrument, and the best method of interpreting resultant scores.

Comparison of intensive outpatient cardiac rehabilitation to standard outpatient care in veterans: effects on quality of life

BACKGROUND

Examination of the effect of cardiac rehabilitation (CR) on quality of life has been relatively limited. The current study examined existing clinical data, which had been obtained during the course of program evaluation. Changes in quality of life for patients who participated in an intensive rehabilitation program and those who had received standard outpatient care only were compared.

METHODS

Quality-of-life changes in cardiac patients (n = 87) from two treatment groups were compared. Patients had either participated in an 8-week intensive CR program (n = 45) consisting of monitored exercise 3 days weekly and inter-disciplinary education sessions, or routine outpatient clinic services (n = 42).

RESULTS

Patients in the intensive CR program demonstrated significant (P < 0.05-< 0.001) improvement in all areas of quality of life assessed. In contrast, patients that received routine outpatient care did not demonstrate any areas of improvement, while Vitality was significantly (P < 0.05) poorer at posttest.

CONCLUSIONS

Our results suggest that provision of more intensive outpatient CR can improve quality of life more than standard outpatient care.

Teste de sentar-levantar: apresentação de um procedimento para avaliação em Medicina do Exercício e do Esporte

A prática regular de atividade física é associada a maior quantidade e qualidade de vida da população. É sabido ainda que a sensação de bem-estar pessoal relaciona-se com a qualidade de vida orientada para a saúde e com a autonomia para a vida. Há consenso de que uma boa aptidão física depende não somente de níveis de potência máxima aeróbica satisfatórios, mas também de padrões apropriados de força e potência muscular, de flexibilidade e de estabilidade postural. É, portanto, conveniente que, do ponto de vista clínico e de saúde pública, existam instrumentos de rastreamento simples e com alta sensibilidade que permitam a avaliação dessas variáveis no âmbito de um consultório. O propósito deste artigo é apresentar o Teste de sentar-levantar (TSL). O TSL consiste, simplesmente, em quantificar quantos apoios (mãos e/ou joelhos ou, ainda, mãos ou antebraços em joelhos), o indivíduo utiliza para sentar e levantar do chão. Atribuem-se notas independentes para cada um dos dois atos - sentar e levantar. A nota máxima é 5 para cada um dos dois atos, perdendo-se um ponto para cada apoio ou ainda meio ponto para qualquer desequilíbrio perceptível. O TSL permite, em pouco tempo e em praticamente qualquer lugar, avaliar vários itens - flexibilidade das articulações dos membros inferiores, equilíbrio, coordenação motora e relação entre potência muscular e peso corporal - de uma vez só, no que talvez possa ser caracterizado como aptidão muscular funcional mínima. Pode ser aplicado em consultórios, escolas, academias e organizações militares. Com base nos resultados do TSL, profissionais de saúde terão provavelmente melhores meios para estimular a adoção de estilos de vida mais ativos e para orientar, de forma mais científica, programas de atividade física.