Modest effects of exercise training alone on coronary risk factors and body composition in coronary patients

The Treatment of Obesity in Cardiac Rehabilitation: A REVIEW AND PRACTICAL RECOMMENDATIONS

BACKGROUND

Cardiac rehabilitation (CR) programs have evolved from exercise-only programs designed to improve cardiorespiratory fitness to secondary prevention programs with a broader mandate to alter lifestyle-related behaviors that control cardiac risk factors and, thereby, reduce overall cardiovascular risk. As the obesity epidemic has evolved in the late 20th and early 21st centuries, the prevalence of type 2 diabetes mellitus and the metabolic syndrome have soared and blunted the otherwise expected downturn in deaths from coronary heart disease related to better control of risk factors. In that the causes of obesity are behavioral in origin, the most effective treatment strategy requires a comprehensive, behavioral-based approach.

PURPOSE

In this review, we outline optimal lifestyle approaches that can be delivered in the CR setting to assist cardiac patients with their long-term goals of reducing weight and improving cardiac risk factors while concurrently improving cardiorespiratory fitness. We also performed a survey of CR program throughout the United States and found that only 8% currently deliver a behavioral weight programs.

CONCLUSIONS

Cardiac rehabilitation programs need to take on an important challenge of secondary prevention, which is to develop behavioral weight loss programs to assist cardiac patients to lose weight and, thereby, improve multiple risk factors and long-term prognosis.

Effects of the senior welfare center exercise program on body shape, physical fitness level, and cardiovascular health-related factors in old man from Korean rural areas

The purpose of this study was to investigate changes in body shape, physical fitness, and cardiovascular health-related factors after a 1-year combined exercise program in rural old men. Subjects were fourteen old men with more than 65 years of age living in Korean rural areas. The combined exercise program consisted of 90-min dynamic and static exercise sessions at a frequency of 3 days per week. Body shape (body weight [BW], body fat percentage [%BF], muscle mass [MM], body mass index [BMI], waist hip ratio [WHR]) and physical fitness levels (grip strength, standing up-right, one leg standing, sit and reach, and 2-min walking) were measured before, 6 months and 1 year after the program started. Cardiovascular health-related factors, including blood glucose, systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), and triglyceride (TG) were measured. There were no significant changes in BW, BMI, %BF, and MM after the training. WHR was significantly decreased at 6 months and 1-year follow-up points compared to baseline. There was no statistically significant difference in grip strength, but there was a significant increase after 6 months and 1 year after standing up right, one leg standing, sit and reach, and 2-min walking tests. There were no significant differences in the levels of glucose, SBP, DBP, TC, LDL-c, and TG, but there was a significant increase in HDL-c after 1-year.

Older Adult Attendance in Cardiac Rehabilitation: IMPACT OF FUNCTIONAL STATUS AND POSTACUTE CARE AFTER ACUTE MYOCARDIAL INFARCTION IN 63 092 MEDICARE BENEFICIARIES

PURPOSE

Older adults who use postacute care (PAC) after hospitalization for myocardial infarction (MI) are often overlooked as cardiac rehabilitation (CR) candidates because of physical limitations. This research describes the impact of functional status and PAC, including inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or home health care (HHC), on CR initiation in Medicare beneficiaries discharged from the hospital following an index MI.

METHODS

The Chronic Condition Warehouse database of Medicare beneficiaries discharged to PAC following index MI in 2008 (n = 63 092) was used for this retrospective study. Functional status at PAC discharge was described as dependent, needed assistance, needed supervision, or independent. Logistic regression examined factors associated with CR initiation.

RESULTS

CR was initiated by 3% and 21% of beneficiaries discharged from PAC as dependent or independent, respectively. Beneficiaries who were dependent, needed assistance, or needed supervision were 78% (95% CI, 0.18-0.28), 60% (0.32-0.49), and 51% (0.41-0.57) less likely to initiate CR compared with independent beneficiaries. Those who had used IRF were 40% more likely to initiate CR compared with those who had used HHC, with no difference observed between those who had used SNF compared with HHC.

CONCLUSIONS

Functional status at PAC discharge was strongly associated with CR initiation. Beneficiary initiation of CR was at proportions corresponding to the level of independence. Beneficiaries discharged from PAC as independent initiated CR at rates slightly higher than non-PAC users, and those discharged from IRF were more likely to initiate CR. These findings are promising and more targeted recruitment from PAC may increase CR initiation and completion, resulting in continued improvement in functional status.

Outcomes in a Community-Based Intensive Cardiac Rehabilitation Program: Comparison with Hospital-Based and Academic Programs

BACKGROUND

The purpose of this study was to test the hypothesis that a community-based intensive cardiac rehabilitation program could produce positive changes in risk factor profile and outcomes in an at-risk population.

METHODS

Participants seeking either primary or secondary coronary artery disease prevention voluntarily enrolled in the 12-week intensive cardiac rehabilitation program. Data were obtained at baseline and 6-12 months after completion of the program.

RESULTS

A total of 142 individuals, mean age 69 years, completed the Heart Series between 2012 and 2016. Follow-up data were available in 105 participants (74%). Participants showed statistically significant improvements in mean weight (165 to 162 lbs, P = .0005), body mass index (26 to 25 kg/m², P = .001), systolic blood pressure (126 to 122 mm Hg, P = .01), diastolic blood pressure (73 to 70 mm Hg, P = .0005), total cholesterol (175 to 168 mg/dL, P = .03), low-density lipoprotein cholesterol (LDL-C) (100 to 93 mg/dL, P = .005), LDL-C/high-density lipoprotein cholesterol (HDL-C) ratio (1.8 to 1.6, P = .005), and cholesterol/HDL-C ratio (3.2 to 3.0, P = .003). Changes in HDL-C, triglycerides, and fasting blood glucose did not reach statistical significance, but all trended in favorable directions. Adverse cardiovascular disease outcomes were rare (one stent placement, no deaths).

CONCLUSIONS

A total of 105 participants completed our 12-week community-based intensive cardiac rehabilitation program and showed significant positive changes in several measures of cardiac risk, with only 1 adverse event. These results compare favorably with those of hospital-based and academic institutional programs.

The impact of short-term cardiac rehabilitation on changing dietary habits in patients after acute coronary syndrome

PURPOSE

The aim of this study was to determine whether short-term cardiac rehabilitation (CR), including dietary counseling, had an impact on changing eating habits in patients after acute coronary syndrome (ACS), treated with primary percutaneous coronary intervention (PCI).

METHODS

The controlled, prospective, nonrandomized study was performed on 44 patients, early following ACS/PCI, who underwent 2- to 3-week inpatient CR with dietary counseling and compared to 18 patients who did not participate in CR. An analysis of the daily diet composition was performed at baseline, at 3 months post-ACS, and at 1 year post-ACS.

RESULTS

In the CR group, comparing baseline with 3 months post-ACS, daily calorie intake was significantly reduced from a mean ± SD of 2260 ± 525 kcal to 2037 ± 514 kcal (P < .05), and daily cholesterol intake from 509 ± 237 to 394 ± 199 mg (P < .05). The daily energy intake of saturated fatty acids was also significantly reduced from 13.6% at baseline to 12.2 ± 4.5% at 3 months and further reduced at 1 year post-ACS to 10.2 ± 4.3% (P < .05). Although both groups exhibited increased body mass index, the increase was significantly greater in the nonrehabilitation group than in the CR group at 1 year post-ACS (2.61 ± 2.23 vs 0.86 ± 1.67 kg/m, respectively, P < .001).

CONCLUSIONS

The analysis suggests that a short-term CR program following ACS, which includes educational meetings on dietary prevention of atherosclerosis, may result in some favorable and lasting modifications of eating habits of post-ACS patients.

Does the effect of supervised cardiac rehabilitation programs on body fat distribution remained long time?

INTRODUCTION

An increased accumulation of fat in the intra-abdominal cavity is highly correlated with adverse coronary risk profiles. Cardiac rehabilitation (CR) produces a host of health benefits related to modifiable cardiovascular risk factors. Further research is needed to define better program for weight loss and risk improvement in coronary patients. The aim of this study was to determine the effect of supervised and unsupervised cardiac rehabilitation program on body composition and body fat distribution in a population with coronary artery disease.

METHODS

The study investigated 167 patients with coronary artery disease (73% males; mean age = 52.67±9.11 years) before and after a supervised protocol cardiac rehabilitation program, and 12-months later. Target variables included body fat distribution indices (waist and hip circumference and waist to hip ratio), weight and body mass index.

RESULTS

Weight, waist circumference, waist to hip ratio and body mass index significantly decreased with 2 month supervised program (P<0.001), but hip circumference was not significantly changed. Males improved to a greater extent than the female patients. All of measurements relatively returned to baseline at the end of program (after 12 months).

CONCLUSION

Supervised cardiac rehabilitation program results in improvements in body composition and body fat distribution. The effects of non-supervised program were minimal and the program needed to be reviewed.

Potential benefits of weight loss in coronary heart disease

The prevalence of overweight, obesity and insulin resistance in patients with coronary heart disease (CHD) exceeds that of the general population. Obesity is associated with a constellation of coronary risk factors that predispose to the development and progression of CHD. Intentional weight loss, accomplished through behavioral weight loss and exercise, improves insulin sensitivity and associated cardio-metabolic risk factors such as lipid measures, blood pressure, measures of inflammation and vascular function both in healthy individuals and patients with CHD. Additionally, physical fitness, physical function and quality of life all improve. There is evidence that intentional weight loss prevents the onset of CHD in high risk overweight individuals. While weight loss associated improvements in insulin resistance, fitness and related risk factors strongly supports favorable prognostic effects in individuals with established CHD, further study is needed to determine if long-term clinical outcomes are improved.

Body fat responses to a 1-year combined exercise training program in male coronary artery disease patients

OBJECTIVE

To analyze the body fat (BF) content and distribution modifications in coronary artery disease (CAD) patients in response to a 1-year combined aerobic and resistance exercise training (CET) program.

DESIGN AND METHODS

We followed two groups of CAD male patients for 12 months. One group consisted of 17 subjects (57 ± 12 years) who engaged in a CET program (CET group) and the other was a age-matched control group of 10 subjects (58 ± 11 years). BF content and distribution were measured through dual energy X-ray absorptiometry (DXA) at baseline and follow-up.

RESULTS

We found no differences on body mass and BMI between baseline and end of follow-up in both groups but, in CET group, we found significant reductions in all analyzed BF depots, including total BF (21.60 ± 6.00 vs. 20.32 ± 5.89 kg, P < 0.01), % total BF (27.8 ± 5.5 vs. 26.4 ± 5.4%, P < 0.05), trunk fat (12.54 ± 3.99 vs. 11.77 ± 4.01 kg, P < 0.05), % trunk fat (31.1 ± 6.9 and 29.2 ± 7.1%, P < 0.05), appendicular fat (8.22 ± 2.08 vs. 7.72 ± 2.037 kg, P < 0.01), % appendicular fat (25.7 ± 4.9 and 24.5 ± 4.9%, P < 0.05), and abdominal fat (2.95 ± 1.06 vs. 2.75 ± 1.10 kg, P < 0.05). Control group showed significant increase in appendicular fat (7.63 ± 1.92 vs. 8.10 ± 2.12 kg, P < 0.05).

CONCLUSIONS

These results confirm the positive effect of CET on body composition of CAD patients, despite no changes in body mass or BMI. In this study, we observed no alterations on BF distribution meaning similar rate of fat loss in all analyzed BF depots. These results also alert for the limitations of BMI for tracking body composition changes.

The effect of the cardiac rehabilitation program on obese and non-obese females with coronary heart disease

INTRODUCTION

Obesity is strongly associated with coronary heart disease and it is known as an independent risk factor. So, the aim of this study was to investigate the effects of phase II comprehensive cardiac rehabilitation program on obesity indexes, functional capacity, lipid profiles, and fasting blood sugar in obese and non-obese female patients with coronary heart disease and to compare changes in these groups.

MATERIALS AND METHODS

Two hundred and five women with coronary heart disease participated in our study. At the beginning of study, body mass index, functional capacity, and lipid profiles and fasting blood sugar were evaluated; then, these patients were divided into two groups, patients who had BMI≥30 were known as obese and who had BMI<30 were known as non-obese patients. All of them completed the period of cardiac rehabilitation program, and 2 months later, all risk factors were examined for the second time in each group. Data were analyzed with SPSS software version 15. For comparing the mean of outcomes, independent t-tests and paired t-tests were used.

RESULTS

Data revealed that unless in weight (P=0.00) and functional capacity (P=0.001), there were no significant differences in obese and non-obese female patients, at baseline. As a result of the cardiac rehabilitation program, both groups had significant improvement in functional capacity (P=0.00), weight reduction (P=0.00), triglyceride (P=0.01 and P=0.02, respectively), low-density lipoprotein cholesterol (P=0.01), and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (P=0.00 and P=0.003, respectively). As well, significant improvement was observed in high-density lipoprotein (P=0.01) only in obese female, and non-obese female had significant differences in total cholesterol (P=0.003). However, there were not significant changes in total cholesterol (P=0.05) and fasting blood sugar (P=0.09) in obese female. Also, non-obese females didn't have favorable differences in high-density lipoprotein cholesterol (P=0.23) and fasting blood sugar (P=0.13). In addition, comparing two groups didn't show any significant differences in each risk factors except BMI (P=0.03).

CONCLUSION

Our study revealed that comprehensive cardiac rehabilitation program results in significant improvement in cardiovascular risk factors and functional capacity at all levels of BMI in female with coronary heart disease.

A pilot study examining the initial effectiveness of a brief acceptance-based behavior therapy for modifying diet and physical activity among cardiac patients

Approximately 90% of cardiac events are attributable to a small number of modifiable behavioral risk factors that, if changed, can greatly decrease morbidity and mortality. However, few at-risk individuals make recommended behavioral changes, including those who receive formal interventions designed to facilitate healthy behavior. Given evidence for the potential of specific psychological factors inherent in acceptance-based behavior therapy (ABBT; that is, intolerance of discomfort, mindfulness, and values clarity) to impact health behavior change, the authors evaluated the feasibility and initial effectiveness of an ABBT pilot program designed to increase adherence to behavioral recommendations among cardiac patients. Participants (N = 16) were enrolled in four, 90-min group sessions focused on developing mindfulness and distress tolerance skills, and strengthening commitment to health-related behavior change. Participants reported high treatment satisfaction and comprehension and made positive changes in diet and physical activity. This was the first evaluation of an ABBT program aimed at increasing heart-healthy behaviors among cardiac patients.

The treatment of obesity in cardiac rehabilitation

Obesity is an independent risk factor for the development of coronary heart disease (CHD). At entry into cardiac rehabilitation (CR), more than 80% of patients are overweight and more than 50% have the metabolic syndrome. Yet, CR programs do not generally include weight loss programs as a programmatic component and weight loss outcomes in CR have been abysmal. A recently published study outlines a template for weight reduction based on a combination of behavioral weight loss counseling and an approach to exercise that maximized exercise-related caloric expenditure. This approach to exercise optimally includes walking as the primary exercise modality and eventually requires almost daily longer-distance exercise to maximize caloric expenditure. In addition, lifestyle activities such as stair climbing and avoidance of energy-saving devices should be incorporated into the daily routine. Risk factor benefits of weight loss and exercise training in overweight CHD patients are broad and compelling. Improvements in insulin resistance, lipid profiles, blood pressure, clotting abnormalities, endothelial-dependent vasodilatory capacity, and measures of inflammation such as C-reactive protein have all been demonstrated. Cardiac rehabilitation/secondary prevention programs can no longer ignore the challenge of obesity management in CHD patients. Individual programs need to develop clinically effective and culturally sensitive approaches to weight control. Finally, multicenter randomized clinical trials of weight loss in CHD patients with assessment of long-term clinical outcomes need to be performed.

The Impact of High-Calorie-Expenditure Exercise on Quality of Life in Older Adults With Coronary Heart Disease

The acceptability of a high-calorie-expenditure (HCE) exercise program in older coronary heart disease patients participating in a behavioral weight-control program was evaluated. Seventy-four overweight patients (median age 63 yr) were randomly assigned to a 5-mo intervention of HCE exercise (3,000–3,500 kcal/wk daily walking) or standard cardiac-rehabilitation (CR) exercise (700–800 kcal/wk). Both groups received counseling to achieve a dietary caloric deficit of 3,500 kcal/ wk. Assessments at baseline and 5 mo included self-reported measures of quality of life and psychosocial variables. The HCE group experienced significantly greater weight loss (8.2 ± 4 vs. 3.7 ± 5 kg,p< .001). Changes from baseline to 5 mo on scores of physical, emotional, and social functioning were greater for the HCE than CR group (p< .05). HCE exercise also resulted in greater positive change in exercise enjoyment (p= .05), which was mediated by weight change. Even high-risk older adults can be successful in an HCE exercise program and experience no adverse physical or emotional changes.

A population-based lifestyle intervention to promote healthy weight and physical activity in people with cardiac disease: the PANACHE (Physical Activity, Nutrition And Cardiac HEalth) study protocol

Background

Maintaining a healthy weight and undertaking regular physical activity are important for the secondary prevention of cardiovascular disease (CVD). However, many people with CVD are overweight and insufficiently active. In addition, in Australia only 20-30% of people requiring cardiac rehabilitation (CR) for CVD actually attend. To improve outcomes of and access to CR the efficacy, effectiveness and cost-effectiveness of alternative approaches to CR need to be established.

This research will determine the efficacy of a telephone-delivered lifestyle intervention, promoting healthy weight and physical activity, in people with CVD in urban and rural settings. The control group will also act as a replication study of a previously proven physical activity intervention, to establish whether those findings can be repeated in different urban and rural locations. The cost-effectiveness and acceptability of the intervention to CR staff and participants will also be determined.

Methods/Design

This study is a randomised controlled trial. People referred for CR at two urban and two rural Australian hospitals will be invited to participate. The intervention (healthy weight) group will participate in four telephone delivered behavioural coaching and goal setting sessions over eight weeks. The coaching sessions will be on weight, nutrition and physical activity and will be supported by written materials, a pedometer and two follow-up booster telephone calls. The control (physical activity) group will participate in a six week intervention previously shown to increase physical activity, consisting of two telephone delivered behavioural coaching and goal setting sessions on physical activity, supported by written materials, a pedometer and two booster phone calls. Data will be collected at baseline, eight weeks and eight months for the intervention group (baseline, six weeks and six months for the control group). The primary outcome is weight change. Secondary outcomes include physical activity, sedentary time and nutrition habits. Costs will be compared with outcomes to determine the relative cost-effectiveness of the healthy weight and physical activity interventions.

Discussion

This study addresses a significant gap in public health practice by providing evidence for the efficacy and cost-effectiveness of a low cost, low contact, high reach intervention promoting healthy weight and physical activity among people with CVD in rural and urban areas in Australia. The replication arm of the study, undertaken by the control group, will demonstrate whether the findings of the previously proven physical activity intervention can be generalised to new settings. This population-based approach could potentially improve access to and outcomes of secondary prevention programs, particularly for rural or disadvantaged communities.

Trial Registration

ACTRN12610000102077

Failure to improve cardiopulmonary fitness in cardiac rehabilitation

PURPOSE

A primary goal of cardiac rehabilitation (CR) exercise is to increase cardiopulmonary fitness. The aim of this study was to identify characteristics of CR participants who fail to improve peak oxygen uptake (peakV(O(2))).

METHODS

The study cohort included 385 consecutive patients with directly measured peakV(O(2)) prior to and upon completion of CR. Patients were classified as a "nonimprover" if exit peakV(O(2)) was less than or equal to entry peakV(O(2)).

RESULTS

Eighty-one (21%) patients failed to improve peakV(O(2)). Baseline characteristics predicting nonimprovement included the following: lower handgrip strength, lower peak exercise respiratory exchange ratio, a nonsurgical diagnosis, female status, and more medical comorbidities. The number of sessions attended and exercise duration were similar between groups. Nonimprovers, however, exercised at lower exercise intensity despite a similar rating of perceived exertion. By multivariate analysis, independent positive correlates of percentage change in peakV(O(2)) included exercise training intensity and baseline handgrip strength. Negative correlates included baseline peakV(O(2)), comorbidity score, self-reported physical function, and a diagnosis of diabetes (cumulative total r = 0.51, adjusted R = 0.26, P < .0001).

CONCLUSIONS

Twenty-one percent of CR participants failed to improve peakV(O(2)) primarily due to exercise training performed at lower relative intensity despite a similar rating of perceived exertion. For patients with baseline characteristics associated with nonimprovement, alternative training protocols should be considered.

Long-term medication adherence after myocardial infarction: experience of a community

BACKGROUND

Adherence to evidence-based medications after myocardial infarction is associated with improved outcomes. However, long-term data on factors affecting medication adherence after myocardial infarction are lacking.

METHODS

Olmsted County residents hospitalized with myocardial infarction from 1997-2006 were identified. Adherence to HMG-CoA reductase inhibitors (statins), beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers, were examined. Cox proportional hazard regression was used to determine the factors associated with medication adherence over time.

RESULTS

Among 292 subjects with incident myocardial infarction (63% men, mean age 65 years), patients were followed for an average of 52+/-31 months. Adherence to guideline-recommended medications decreased over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, beta-blockers, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, respectively. Enrollment in a cardiac rehabilitation program was associated with an improved likelihood of continuing medications, with adjusted hazard ratio (95% confidence interval) for discontinuation of statins and beta-blockers among cardiac rehabilitation participants of 0.66 (0.45-0.92) and 0.70 (0.49-0.98), respectively. Smoking at the time of myocardial infarction was associated with a decreased likelihood of continuing medications, although results did not reach statistical significance. There were no observed associations between demographic characteristics, clinical characteristics of the myocardial infarction, and medication adherence.

CONCLUSIONS

After myocardial infarction, a large proportion of patients discontinue use of medications over time. Enrollment in cardiac rehabilitation after myocardial infarction is associated with improved medication adherence.

High-calorie-expenditure exercise: a new approach to cardiac rehabilitation for overweight coronary patients

BACKGROUND

More than 80% of patients entering cardiac rehabilitation (CR) are overweight, and >50% have metabolic syndrome. Current CR exercise protocols result in little weight loss and minimal changes in cardiac risk factors. We sought to design an exercise protocol that would lead to greater weight loss and risk factor change.

METHODS AND RESULTS

We performed a randomized controlled clinical trial to evaluate the effect of high-calorie-expenditure exercise (3000- to 3500-kcal/wk exercise-related energy expenditure) compared with standard CR exercise (7 to 800 kcal/wk) on weight loss and risk factors in 74 overweight patients with coronary heart disease. Both groups were counseled for weight loss and taking evidence-based preventive medications. High-calorie-expenditure exercise resulted in double the weight loss (8.2+/-4 versus 3.7+/-5 kg; P<0.001) and fat mass loss (5.9+/-4 versus 2.8+/-3 kg; P<0.001) and a greater waist reduction (-7+/-5 versus -5+/-5 cm; P=0.02) than standard CR exercise at 5 months. High-calorie-expenditure exercise reduced insulin resistance, measured with the euglycemic hyperinsulinemic clamp, along with the ratio of total to high-density lipoprotein cholesterol and components of the metabolic syndrome, more than standard CR exercise (each P<0.01). Overall, fat mass loss best predicted improved metabolic risk, and the prevalence of metabolic syndrome decreased from 59% to 31%. Changes in cardiac risk factors included decreased insulin resistance, increased high-density lipoprotein cholesterol, and decreased measures of insulin, triglycerides, blood pressure, plasminogen activator inhibitor-1, and the ratio of total to high-density lipoprotein cholesterol (each P<0.05). Significant weight loss was maintained at 1 year.

CONCLUSIONS

High-calorie-expenditure exercise promotes greater weight loss and more favorable cardiometabolic risk profiles than standard CR for overweight coronary patients.

Effects of resistance and multicomponent exercise on lipid profiles of older women

OBJECTIVE

The purpose of this study was to compare the effects of two exercise programs of 8 months duration on lipid profiles in older women.

METHODS

In 2006, 77 women from Porto, Portugal, aged 60-79 years were randomly assigned into a multicomponent exercise (ME) program or resistance exercise (RE) program. Before- and after-training, body composition, daily physical activity (DPA), aerobic endurance, plasma concentrations of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG) were assessed. Training was performed twice weekly. The protocol for the ME included aerobic exercise, muscular endurance exercises and activities targeted to improve balance and flexibility. The RE protocol included leg press, leg extensions and curls, double chest raises, lateral raises, overhead press and abdominal exercises.

RESULTS

Significant decreases in TG (-5.1%, p=0.006), and significant increases in HDL-C (9.3%, p<0.001) were observed in the ME group. Following 8 months no significant changes were observed on lipid profile in RE group, although lipid- and lipoprotein-related variables tended to alter favorably. Both regimens resulted in significant improvements on 6-min walk test (6.4%, p=0.001 for ME; and 6.0%, p=0.044 for RE). No significant changes were observed in total DPA and body fat in either group after exercise interventions. No significant correlations were found between body composition, physical activity, aerobic endurance, and lipid profile.

CONCLUSIONS

The data suggested that 8 months of ME may be more effective than RE for inducing favorable changes in plasma lipoprotein and lipid profiles.

Long-term cardiac rehabilitation and exercise training programs improve metabolic parameters in metabolic syndrome patients with and without coronary heart disease

BACKGROUND AND AIMS

The effectiveness of long-term cardiac rehabilitation and exercise training programs on metabolic parameters was evaluated in metabolic syndrome subjects with and without coronary heart disease (CHD).

METHODS AND RESULTS

Fifty-nine CHD and 81 non-coronary patients with metabolic syndrome (59+/-8 vs 56+/-9years) were identified retrospectively at entry into identical cardiac rehabilitation and exercise-training programs. Metabolic syndrome was defined using modified Adult Treatment Panel III criteria. Exercise training occurred approximately twice per week. Metabolic and exercise testing data were collected at baseline and after 12months during the course of the program. Mean duration of cardiac rehabilitation and exercise training programs was over one year in both coronary and non-coronary patients (366+/-111 vs 414+/-102days for CHD and non-coronary CHD cohorts respectively, p<0.01). Significant improvements in bodyweight, body mass index, blood lipids, triglyceride/HDL ratio and exercise tolerance were noted in both cohorts. At the end of follow-up, 31% of CHD and 20% of non-CHD subjects no longer possessed diagnostic criteria for metabolic syndrome (p<0.0001 and p<0.001 respectively).

CONCLUSIONS

A long-term cardiac rehabilitation program reduces metabolic syndrome prevalence in CHD patients and results in a similar improvement in risk factor control for metabolic syndrome patients without CHD.

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.

Risk factor outcome comparison between exercise-based cardiac rehabilitation, traditional care, and an educational workshop

BACKGROUND

This study examined risk factor outcomes among patients who attended cardiac rehabilitation sessions, those who received traditional care, and those who attended Leap for Life workshops.

METHODS

A non-equivalent, three-group design was used in this observational study. Baseline and 12-month measurements were collected for 217 participants. Analysis of covariance was performed to determine differences between groups on outcome variables.

RESULTS

The only significant finding was in participants with an initial high-density lipoprotein value of less than 40. High-density lipoprotein levels increased more in the cardiac rehabilitation group than in the traditional care group (30.54 to 37.48 versus 30.17 to 33.67 [F= 4.577, p = .035]).

CONCLUSIONS

Based on these findings, a strong case can be made for the transition to more individually intense and focused risk factor modification strategies for patients in cardiac rehabilitation programs.

Endothelial Progenitor Cell Mobilization and Increased Intravascular Nitric Oxide in Patients Undergoing Cardiac Rehabilitation

PURPOSE

We investigated whether cardiac rehabilitation participation increases circulating endothelial progenitor cells (EPCs) and benefits vasculature in patients already on stable therapy previously shown to augment EPCs and improve endothelial function.

METHODS

Forty-six of 50 patients with coronary artery disease completed a 36-session cardiac rehabilitation program: 45 were treated with HMG-CoA reductase inhibitor (statin) therapy > or = 1 month (average baseline low-density lipoprotein cholesterol = 81 mg/dL). Mononuclear cells isolated from blood were quantified for EPCs by flow cytometry (CD133/VEGFR-2 cells) and assayed in culture for EPC colony-forming units (CFUs). In 23 patients, EPCs were stained for annexin-V as a marker of apoptosis, and nitrite was measured in blood as an indicator of intravascular nitric oxide.

RESULTS

Endothelial progenitor cells increased from 35 +/- 5 to 63 +/- 10 cells/mL, and EPC-CFUs increased from 0.9 +/- 0.2 to 3.1 +/- 0.6 per well (both P < .01), but 11 patients had no increase in either measure. Those patients whose EPCs increased from baseline showed significant increases in nitrite and reduction in annexin-V staining (both P < .01) versus no change in patients without increase in EPCs. Over the course of the program, EPCs increased prior to increase in nitrite in the blood.

CONCLUSIONS

Cardiac rehabilitation in patients receiving stable statin therapy and with low-density lipoprotein cholesterol at goal increases EPC number, EPC survival, and endothelial differentiation potential, associated with increased nitric oxide in the blood. Although this response was observed in most patients, a significant minority showed neither EPC mobilization nor increased nitric oxide in the blood.

The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program

BACKGROUND

The relative contribution of health behaviors to coronary risk factors in multicomponent secondary coronary heart disease (CHD) prevention programs is largely unknown.

PURPOSE

Our purpose is to evaluate the additive and interactive effects of 3-month changes in health behaviors (dietary fat intake, exercise, and stress management) on 3-month changes in coronary risk and psychosocial factors among 869 nonsmoking CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac Lifestyle Intervention Program.

METHODS

Analyses of variance for repeated measures were used to analyze health behaviors, coronary risk factors, and psychosocial factors at baseline and 3 months. Multiple regression analyses evaluated changes in dietary fat intake and hours per week of exercise and stress management as predictors of changes in coronary risk and psychosocial factors.

RESULTS

Significant overall improvement in coronary risk was observed. Reductions in dietary fat intake predicted reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and interacted with increased exercise to predict reductions in perceived stress. Increases in exercise predicted improvements in total cholesterol and exercise capacity (for women). Increased stress management was related to reductions in weight, total cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin A1c (in patients with diabetes), and hostility.

CONCLUSIONS

Improvements in dietary fat intake, exercise, and stress management were individually, additively and interactively related to coronary risk and psychosocial factors, suggesting that multicomponent programs focusing on diet, exercise, and stress management may benefit patients with CHD.

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.

Effect of an aerobic exercise training program on resting metabolic rate in chronically beta-adrenergic blocked hypertensive patients

PURPOSE

There is substantial evidence that the use of beta-adrenergic receptor blockers (beta-blockers) is associated with a reduction in resting metabolic rate (RMR) and that a weight gain usually occurs in the first few months of treatment. The purpose of this study was to determine if RMR of overweight and sedentary subjects consuming beta-blockers can be increased following an aerobic exercise training program.

METHODS

Twenty-four subjects participated in the study; 11 (6 women, 5 men) were treated with beta-blockers for hypertension and 13 (9 women, 4 men) were nonmedicated (control group). Body composition, RMR, and peak oxygen uptake (VO2peak) were assessed for all subjects before and after a 12-week aerobic exercise training program. Weekly exercise energy expenditure equaled 83.68 kJ (20 kcal) per kg of body weight while exercise intensity was maintained between 60% and 70% of the VO2 reserve.

RESULTS

Body composition, RMR, and VO2peak did not differ among groups at the beginning of the study. Body weight (-1.4 kg for beta-blockers, P < .05; -2.5 kg for control, P < .05) and VO2peak (+2.2 mL x kg(-1) x min(-1) for beta-blockers, P < .05; +4.1 mL x kg(-1) x min(-1) for control, P < .001) were significantly improved in both groups, whereas RMR (-272 kJ x day(-1) for beta-blockers, NS; +573 kJ x day(-1) for control, P < .05) was increased only in the control group after the aerobic exercise training program.

CONCLUSIONS

These results suggest that beta-blockers limit the increase in RMR normally observed following an aerobic exercise training program. Consequently, obtaining a negative energy balance in an attempt to lose weight may be more difficult.

Effects of exercise and cardiac rehabilitation on cardiovascular outcomes

Cardiac rehabilitation was originally conceived to counteract the deconditioning and comorbidities associated with prolonged bed rest after a myocardial infarction. Contemporary cardiac rehabilitation has taken a more comprehensive approach, with a broader range of participating patients. Relevant cardiovascular outcomes of cardiac rehabilitation can be classified as primary clinical outcomes, intermediate clinical outcomes, and quality-of-life outcomes. In this article, the effects of exercise training alone and, more importantly, the value of comprehensive cardiac rehabilitation are reviewed from the point of view of individual cardiovascular outcomes.

Cardiac rehabilitation secondary prevention programs

Contemporary cardiac rehabilitation programs are more accurately described as "secondary prevention centers." They offer comprehensive care for the patient with cardiovascular disease, resulting in decreased mortality, improvement of most cardiac risk factors, and an enhanced quality of life. Although overall participation has increased with enhanced recognition of the importance of secondary prevention, 80% of eligible patients still do not participate, in part due to lack of insurance reimbursement. This rate can be significantly increased by specific endorsement from the physician.

Effects of resistance training on physical function in older disabled women with coronary heart disease

We studied whether disabled older women with coronary heart disease can perform resistance training at an intensity sufficient to improve measured and self-reported physical function [n = 30, 70.6 +/- 4.5 (SD) yr]. Compared with the controls, the resistance-training group showed significant improvements in overall measured physical function score using the Continuous-Scale Physical Functional Performance Test (+24 vs. +3%). The Continuous-Scale Physical Functional Performance Test measures physical function for 15 practical activities, such as carrying groceries or climbing stairs. Resistance training led to improved measures for domains of upper body strength (+18 vs. +6%), lower body strength (+23 vs. +6%), endurance (+26 vs. +1%), balance and coordination (+29 vs. -2%), and 6-min walk (+15 vs. +7%). Women involved in the flexibility-control group showed essentially no improvement for physical function measures. No changes were observed for body composition, aerobic capacity, or self-reported physical function in either group. In conclusion, disabled older women with coronary heart disease who participate in strength training are able to train at an intensity sufficient to result in improvements in multiple domains of measured physical functional performance, despite no change in lean body mass.

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.

Effects of a 12-week cardiac rehabilitation exercise program on motivation and health-promoting lifestyle

OBJECTIVE

The purpose of this study was to determine the effects of a 12-week cardiac rehabilitation exercise program on the motivation and lifestyle of persons recovering from a recent heart attack or cardiac-related procedures.

DESIGN

The study design was a pretest and posttest quasi-experimental, nonrandom assignment.

SETTING

The study was conducted at 4 cardiac rehabilitation centers in Northeast Ohio.

SUBJECTS

The study included 57 participants in a cardiac rehabilitation exercise program (mean age = 64 years) and 57 comparisons (mean age = 64.6 years) who recently had a heart attack or underwent cardiac-related procedures.

OUTCOME MEASURE

Motivation and health-promoting lifestyle were measured.

INTERVENTION

A 12-week cardiac rehabilitation exercise program for small groups of participants (fewer than 12 persons) was conducted. The program provided arm and leg exercises 3 times a week for 30 to 60 minutes per session at an intensity of 60% to 90% of the maximum heart rate.

RESULTS

Analysis of covariance was used to analyze the data. After controlling for education, income, and pretest scores, the exercise group scored significantly higher than the comparison group in most motivation-related variables. Regarding lifestyle, after adjusting for the control variables both groups showed positive changes during the 12-week period, but no significant difference was found between the 2 groups in overall lifestyle.

CONCLUSION

The findings of the study confirmed that motivational variables were modifiable. Thus, when developing health promotion programs for initiating and maintaining a healthy lifestyle, the relative importance of different motivational variables should be considered.