Improvement in Physiological Outcomes and Health-Related Quality of Life Following Cardiac Rehabilitation in Patients With Acute Myocardial Infarction

The Effects of Exercise Training on Exercise Capacity and Vascular Function after Transcatheter Aortic Valve Implantation-A Pilot Study

Transcatheter aortic valve implantation (TAVI) improves event-free survival in patients with severe aortic stenosis, but patients' exercise capacity remains poor after the procedure. Therefore, we sought to compare the effects of a supervised center-based exercise training program and unsupervised exercise routine on exercise capacity and vascular function in patients after TAVI. Patients were randomized to either center-based exercise training (12-24 sessions of combined aerobic and low-weight resistance training twice weekly for 8-12 weeks) or an unsupervised home-based exercise routine (initial appraisal with detailed recommendations and monthly follow-up). Exercise capacity (cardiopulmonary testing) and vascular function (ultrasonographic measurement of flow-mediated vasodilation (FMD) and arterial stiffness) were assessed at the baseline and after the study period. We included 23 patients (mean age of 81 years, 61% women), with higher-than-expected drop-out rates (41%) because of the coronavirus-19 pandemic outbreak. Exercise capacity improved over time, irrespective of the intervention group: 0.09 mL/min/kg increase in peak oxygen uptake (95% CI [0.01-0.16]; p = 0.02), 8.2 Watts increase in workload (95% CI [0.6-15.8]; p = 0.034), and 47 s increase in cumulative exercise time (95% CI [5.0-89.6]; p = 0.029). A between-group difference in change over time (treatment effect) was detected only for FMD (4.49%; 95% CI [2.35; 6.63], p < 0.001), but not for other outcome variables. Both supervised and unsupervised exercise training improve exercise capacity and vascular function in patients after TAVI, with supervised exercise training possibly yielding larger improvements in vascular function, as determined by FMD.

Physical performance and maximum tongue pressure associated with oral intake independence: a retrospective study on hospitalized patients with heart failure

Dysphagia in patients with heart failure leads to poorer outcomes during hospitalization and after discharge. Therefore, addressing dysphagia is critical for improving patient prognosis. This retrospective observational study aimed to evaluate associations between improvements in swallowing dysfunction at the time of hospital discharge and the physical function, cognitive function, nutritional status, and maximum tongue pressure (MTP). Overall, 111 patients who underwent cardiac rehabilitation and were deemed to have oral intake impairment were included. The exclusion criteria comprised the following: pre-admission diagnosis of dysphagia, in-hospital death, and missing data. Patients were categorized based on whether they did (n = 65) or did not (n = 46) exhibit improvements in oral intake impairment, which were determined from the functional oral intake scale (FOIS) score at discharge. Associations between potential explanatory variables and the FOIS score at discharge were assessed using a linear regression model. After adjusting for covariates, such as age, sex, heart failure severity, short physical performance battery score, Mini-Mental State Examination score, transthyretin level, and provision of swallowing therapy, the FOIS score at discharge was significantly associated with the MTP (P = 0.024, confidence interval: 0.006-0.046). In conclusion, the MTP was independently associated with improvements in FOIS in patients with heart failure.

Complementary and alternative medicines chosen for specific health problems: Internet survey using the I-CAM-Q in Japan: A STROBE-compliant cross-sectional study

This study investigated the different complementary and alternative medicines (CAMs) adopted by people in Japan, as well as the health problems treated with CAMs. Understanding more about this topic will facilitate the appropriate incorporation of CAMs into conventional medicine when treating health problems. Data were collected through an online survey based on the International Questionnaire to Measure Use of Complementary and Alternative Medicine (I-CAM-Q). The study examined CAM utilization among people aged 20 years or older; 164 valid responses were collected (18.9%). We adopted a cross-sectional design. We then compared the relationships between the specific health problems reported by participants, their self-help practices, and the kinds of healthcare specialists consulted. We also examined participants' reasons for using CAMs and their responses regarding the usefulness of the CAMs adopted. We found that self-help/CAM practices differed for specific health problems. Participants with musculoskeletal and heart problems were more likely to use poultices. Those with respiratory and digestive problems were more likely to practice yoga, tai chi, and qigong. Those with digestive and neurological problems were more likely to use aromatherapy. The I-CAM-Q questionnaire also revealed the purpose and usefulness of the CAMs utilized as well as the participants' attitudes regarding conventional medicine. The study showed that participants find physicians less helpful than other options for treating their health problems. Additionally, when asked whether it was helpful to consult with a specific professional for health problems, there was a higher percentage of participants who answered "Very helpful" for professionals, like massage, judo, acupuncture, and moxibustion therapists, than for physicians. The results of this study will help to inform medical providers of the most appropriate types of CAMs for dealing with various health problems.

Irisin is an Effector Molecule in Exercise Rehabilitation Following Myocardial Infarction (Review)

Background: Regular exercise is an effective non-pharmacological therapy for treatment and prevention of cardiovascular disease (CVD). The therapeutic benefits of exercise are mediated partly through improved vascular and increase in metabolic health. Release of exercise-responsive myokines, including irisin, is associated with beneficial effects of exercise in CVD patients.

Observations: The present review provides an overview of the role of exercise in cardiac rehabilitation of patients with myocardial infarction (MI). Further, the role of irisin as a motion-responsive molecule in improving vascular and metabolic health is explored. Possible mechanism of cardioprotective effect of irisin-mediated exercise on myocardial infarction are also summarized in this review.

Conclusion and significance of the review: Irisin is associated with reduced inflammation, antioxidant properties, and anti-apoptotic effect, implying that it is a potential key mediator of the beneficial effects of exercise on vascular and metabolic health. The findings show that irisin is a promising therapeutic target for treatment of patients with cardiovascular disease, particularly post-MI. Further research should be conducted to elucidate the potential mechanisms of cardioprotective effects of irisin and explored whether irisin induced by exercise exerts rehabilitation effects post-MI.

Mild cognitive impairment in patients with acute heart failure does not limit the effectiveness of early phase II cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) is commonly performed in patients with heart failure (HF) with mild cognitive impairment (MCI). However, whether MCI diminishes the benefit of early phase II CR is unclear.

AIM

This study aimed to clarify whether MCI diminishes the benefit of early phase II CR in patients hospitalized for HF.

DESIGN

The design of the work is a case-control study.

SETTING

All HF patients who underwent CR in acute care hospitals in Japan from April 2016 to March 2021.

POPULATION

Among the 574 patients who underwent CR, 204 were included in this study. Exclusion criteria were age <65 years, dependence for activities of daily living (ADLs) prior to admission, diagnosis of dementia or delirium, mini-mental state examination (MMSE) score at the commencement of CR<19, missing data, in-hospital death, and transfer to another department during hospitalization.

METHODS

Patients were divided into two groups, those with MCI (MCI group, N.=134) and those without MCI (non-MCI group, N.=70), based on MMSE score at the commencement of CR. Cognitive impairment was defined as a score of <19. MCI was defined as an MMSE score between 19 and 26, and normal cognitive function was defined as MMSE >26. The primary outcomes were the 6-minute walking distance (6MWD), Barthel Index (BI), and Short Physical Performance Battery (SPPB). All patients underwent guideline-based CR programs.

RESULTS

On admission, MCI patients had significantly lower BI (P<0.01, confidence interval [CI]: 4.9-20.4) and SPPB (P<0.01, CI: 1.1-3.1), despite being independent for ADLs before admission. In addition, 6MWD (P<0.01, CI: 31.2-97.2), BI (P=0.01, CI: 1.0-8.4), and SPPB (P<0.01, CI: 0.6-2.5) were significantly lower in the MCI group at the time of discharge. However, after propensity score matching to adjust for baseline characteristics, no significant differences in any primary outcome were found between the two groups.

CONCLUSIONS

The BI, SPPB, and 6MWD improvements due to CR were similar, regardless of MCI.

CLINICAL REHABILITATION IMPACT

Our results may inform the selection of appropriate rehabilitation interventions for patients with HF and MCI.

A Half-Century of Evidence-Based Cardiac Rehabilitation: A Historical Review

OBJECTIVE

To review the achievements of cardiac exercise rehabilitation programs retrospectively and to identify continuing challenges to their success.

METHODS

A review of files accumulated while working with the Toronto Rehabilitation Center, updated by articles identified by PUB-MED, OVID, and Google Scholar through February 2019.

RESULTS

After the early lead of Israeli physicians, cardiac rehabilitation began in Ontario during the 1960s and quickly attracted a large case load. Recurrence rates of the patients recruited were low relative to those receiving standard medical treatment, even after allowing for differences in risk factors at entry to programs. Controlled trials began but were individually of insufficient in size to show a significant reduction in recurrences or mortality. Subsequently, multiple meta-analyses demonstrated a 20% to 25% reduction of all-cause and cardiac mortality over the first few years of follow-up in patients who persisted with their rehabilitation. Compliance continued a problem at many centers, but special features of the Toronto cardiac rehabilitation program sustained a compliance of 82.8% over 3 years. Although vigorous exercise increased the immediate risks of a recurrence 5- to 10-fold, this was more than offset by the long-term benefits of enhanced physical condition, and cardiac deaths were a rarity during either supervised or home-based exercise sessions. About a half of patients developed a depression immediately after infarction, but if encouraged to persist with prescribed exercise, their quality of life progressively improved. Among the wide variety of mechanisms underlying the benefits of exercise, gains of aerobic power seemed particularly important. With sustained training, the physical condition of some younger patients progressed to the point of participating successfully in marathon events. Older patients also benefited from sustained training, but for them, optimal results were likely associated with less rigorous physical demands.

CONCLUSIONS

Research conducted in Toronto and elsewhere has established the benefits of exercise-centered cardiac rehabilitation. However, there remains a need to define the optimum timing of program onset, and the frequency, intensity, and duration of supervised training sessions. Return to blue-collar occupations also needs to be boosted, and the limited participation of eligible patients in available programs remains a continuing challenge.

Dysphagia and malnutrition limit activities of daily living improvement in phase i cardiac rehabilitation: a prospective cohort study for acute phase heart failure patients

Dysphagia and malnutrition combinations in hospitalized patients with acute heart failure (AHF) may affect activities of daily living (ADL) after hospital discharge more than dysphagia or malnutrition alone. The aim of the present study to clarify the impact of the combination of dysphagia and malnutrition on ADL in hospitalized patients with acute phase heart failure who have undergone cardiac rehabilitation (CR). Prospective cohort study. Acute care hospital. Participants were 224 AHF patients undergoing CR. Barthel index (BI), functional oral intake scale (FOIS), controlling nutritional status (CONUT), short physical performance battery (SPPB), and mini-mental state examination were evaluated at baseline. We examined primary effects of predictors (CONUT) and the moderator (FOIS) and the interaction effect of FOIS and CONUT (FOIS × CONUT) using hierarchical linear regression model and simple-slope tests. The ADL independence dropped in 29.5% of the patients on hospitalization; however, 82.6% of the patients successfully regained their independence at discharge. Based on the FOIS score and nutritional status on admission, 58.5% of the patients were classified into the non-dysphagia and non-malnutrition categories, 21.0% into non-dysphagia and malnutrition, 15.2% into dysphagia and non-malnutrition, and 5.3% into dysphagia and malnutrition. Lower FOIS and SPPB scores as well as the FOIS × CONUT interaction predicted a significantly lower BI but not CONUT. Simple slope test revealed a negative association between CONUT and BI with low-level FOIS (B =  - 2.917, P < .001) but not with high-level FOIS (B = .476, P = .512). Thus, patients with dysphagia and malnutrition in combination had a greater risk of failed recovery of ADL after cardiac rehabilitation than those without this combination. In hospitalized AHF patients, FOIS and CONUT had an interactive effect on BI at hospital discharge in cases with low-level FOIS. Early detection of dysphagia might improve the accurate identification of hospitalized AHF patients at higher risk of ADL dependence at discharge.

Effects of cardiac rehabilitation on physical function and exercise capacity in elderly cardiovascular patients with frailty

BACKGROUND

The effects of cardiac rehabilitation (CR) on long-term prognosis of cardiovascular disease (CVD) are well known. However, the effect of CR on frail CVD patients has not been fully addressed.

METHODS

This study consisted of 89 CVD patients with their age ≥65 years old (68 males, 75 ± 6 years), who participated in the outpatient CR program for 3 months. All the patients underwent cardiopulmonary exercise testing and the physical frailty was assessed using the Japanese Version of the Cardiovascular Health Study Standard before and after CR. Based on the assessment of frailty before CR, the patients were divided into the following two groups: frailty group (n = 23) and non-frailty group (n = 66: robust in 10 and pre-frail in 56 patients).

RESULTS

In the frailty group, 20 patients (87%) improved from frail status after CR, and usual walking speed, maximal grip strength, and lower extremity strength were significantly improved (1.06±0.20 vs. 1.20±0.18 m/sec, p<0.001; 21.7 ± 5.5 vs. 23.6 ± 6.3 kg, p<0.01; 0.37±0.09 vs. 0.43±0.11 kgf/kg, p = 0.001, respectively), but peak VO₂ did not change after CR (15.9 ± 3.1 vs. 16.2 ± 3.8 ml/min/kg, NS). In the non-frailty group, all these parameters were significantly improved after CR (1.24±0.19 vs. 1.29±0.23 m/sec, p<0.05, 28.7 ± 7.0 vs. 30.2 ± 7.3 kg, p<0.001, 0.50±0.18 vs. 0.54±0.13 kgf/kg, p<0.05, 17.7 ± 4.7 vs 18.5 ± 4.2 ml/min/kg, p<0.01, respectively).

CONCLUSION

Short-term CR could obtain the improvement of the physical function, providing the prerequisite step for possibly following improvement of exercise capacity in elderly CVD patients with frailty. It may be inferred that longer duration of CR would be needed to obtain the improvement of exercise capacity in these patients, being the future consideration to be determined.

Usefulness of 500-m walk electrocardiogram test on clinical outcomes in patients with ST-segment elevation myocardial infarction

The current Japanese guideline for ST-segment elevation myocardial infarction (STEMI) recommends 500-m walk electrocardiogram (ECG) test for patients with STEMI during hospitalization. However, little is known regarding the association between acute phase 500-m walk ECG test and clinical outcomes. The purpose of this study was to investigate the association between 500-m walk ECG test and mid-term clinical outcomes in patients with STEMI. A total of 313 STEMI patients who underwent primary percutaneous coronary interventions were included, and were divided into the successful 500-m group (n = 263) and the unsuccessful 500-m group (n = 50). The primary endpoint was the major adverse cardiovascular events (MACE), which were defined as the composite of all cause death, acute myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization (TVR). During the follow-up period (median 223 days), a total of 55 MACE were observed. The log-rank test revealed that MACE, all cause death, readmission for heart failure, and ischemia-driven TVR were more frequently observed in the unsuccessful 500-m group than the successful 500-m group. In the multivariate Cox proportional hazard model, the unsuccessful 500-m walk ECG test was significantly associated with MACE (OR 5.62, 95% CI 3.08-10.08, P < 0.01) after controlling confounding factors such as age, and serum creatinine levels. In conclusion, the unsuccessful 500-m walk ECG test was significantly associated with poor mid-term outcomes in patients with STEMI. Our results suggest the usefulness of 500-m walk ECG test to stratify the high-risk group from patients with STEMI.

Dysphagia worsens short-term outcomes in patients with acute exacerbation of heart failure

Dysphagia, defined as a dysfunction in any stage or process of eating, is common in patients with acute exacerbation of heart failure (HF). In some diseases, dysphagia worsens in-hospital mortality, length of hospital stay, and discharge disposition. However, it remains unclear whether dysphagia is associated with poor short-term outcomes in HF patients. The objective of the present study was to determine whether dysphagia affects short-term outcomes in patients with acute exacerbation of HF. A total of 327 patients hospitalized with acute exacerbation of HF were eligible for the study. Patients were divided into a dysphagia group (DG) or a non-dysphagia group (NDG) based on results of the functional oral intake scale (FOIS), which evaluates a patient's ability of eating and swallowing. FOIS is a 7-point scale, with a level of ≤ 5 indicating dysphagia. Following the withdrawal of 16 patients, short-term outcomes such as in-hospital mortality, length of hospital stay, and discharge disposition, of 311 patients were analyzed. All indexes of short-term outcomes were significantly worse in the DG than in the NDG. After propensity score matching, which was performed to adjust for baseline characteristics such as age, sex, height, weight, body mass index, medical history, complications, HF severity, ejection fraction, and biochemical data excluding nutritional status, all short-term outcomes remained significantly worse in the DG than in the NDG. Multivariate analysis showed that FOIS was an independent predictor of in-hospital survival, length of hospital stay, and discharge to home. The present study suggested that dysphagia affected short-term outcomes in patients with acute exacerbation of HF. Therefore, early detection and intervention of dysphagia in HF patients are important.

Dysphagia Hinders Hospitalized Patients with Heart Failure from Being Discharged to Home

Dysphagia, defined as a dysfunction in any stage or process of eating, is common among heart failure (HF) patients. In some diseases state, dysphagia hinders patients from being discharged to home. However, it remains unclear whether dysphagia affects discharge disposition of HF patients. This study aimed to identify the impact of dysphagia on discharge disposition of HF patients. A total of 323 patients, hospitalized with acute exacerbation of HF, were eligible for the study (excluding patients who lived at nursing care facilities before admission). Following the withdrawal of 37 patients, a total of 286 patients were analyzed. Dysphagia was determined using the functional oral intake scale (FOIS), which evaluates a patient's ability to swallow. The FOIS is a 7-point scale, with a level of ≤ 5 indicating dysphagia. Of the 286 patients analyzed, 231 (80.8%) were discharged to home, and 55 were discharged to nursing care facilities or rehabilitation hospitals (non-home). FOIS level was significantly lower, and dysphagia incidence was significantly higher among patients discharged to non-home than among those discharged to home. Multivariate analysis showed that FOIS level was an independent predictor of discharge disposition. Additionally, after propensity score matching, which was performed to adjust for baseline characteristics, FOIS level remained significantly lower in patients discharged to non-home than in those discharged to home. In conclusion, dysphagia hinders patients hospitalized with HF from being discharged to home. We conclude that evaluating dysphagia and its severity on admission is useful for predicting discharge disposition in patients hospitalized with HF.

Psychophysical health of elderly inpatients in cardiac rehabilitation: a retrospective cohort study

BACKGROUND

Elderlies in cardiac rehabilitation show a particular frailty due to specific aging issues, thus specific professional psychophysical care is required.

AIM

This study aimed at evaluating the effect of a cardiac rehabilitation program enhanced with psychological support on the psychophysical health of elderly subjects aged ≥75. Moreover, the association of psychophysical conditions with the long-term post-discharge course of medical events was examined.

DESIGN

This retrospective cohort study was conducted on elderly patients aged ≥75 admitted from 2015 to 2019 to a cardiac rehabilitation program including psychological support.

SETTING

The cardiac ward and the psychology unit of a post-acute clinical rehabilitation Institute.

POPULATION

A total of 523 elderly inpatients (44% females), aged ≥75 years (mean 79.7±3.46 years), admitted to a cardiac rehabilitation ward due to heart disease.

METHODS

Psychological and functional variables such as depression, quality of life, and Barthel Index were measured at hospitalization and at discharge. The medical events after discharge such as emergency department accesses and rehospitalizations were registered.

RESULTS

Cardiac rehabilitation showed significant improvements both in elderlies' psychological and physical health. Higher depression levels predicted a worse post-discharge course. Patients who received psychological intervention accessed emergency department and were re-hospitalized significantly later than the others.

CONCLUSIONS

Cardiac comprehensive rehabilitation can significantly improve the psycho-physical health of elderly subjects aged ≥75 who benefit of psychological support. Psychological support can enhance the psychophysical health of great elder inpatients in cardiac rehabilitation.

CLINICAL REHABILITATION IMPACT

Given the associations with short and long-term outcomes, health professionals should take care of the psychological conditions of elderlies (e.g., depression) by integrating psychological interventions in cardiac rehabilitation in order to promote the elderlies' psychophysical conditions, quality of life, as well as more favorable medical outcomes.

Physical activity-related quality of life in breast cancer survivors compared to healthy women

OBJECTIVE

To evaluate physical activity-related quality of life (PAQOL) in breast cancer survivors compared to healthy women.

METHODS

Physical activity level was measured as not active, somewhat active, active or very active. Intensity was reported as hours per week of light, moderate and vigorous activity. Physical activity-related quality of life was measured with the Vitality Plus Scale, a self-report instrument developed and validated to measure exercise-related health benefits.

RESULTS

Compared to healthy women (n = 23), breast cancer survivors (n = 23) were older (57.0 ± 2.3 vs. 49.0 ± 1.1 years; p < .01) and reported more light activity (4.1 ± 0.6 vs. 2.4 ± 0.5 hr/week; p < .05), but no differences in PAQOL. However, when grouped by physical activity level there were no differences in age, but inactive women (n = 30) had higher body mass index (29.3 ± 1.0 vs. 25.1 ± 1.1 kg/m² ; p < .05) and reported less moderate (1.3 ± 0.4 vs. 3.6 ± 0.8 hr/week; p < .05) and vigorous (0.2 ± 0.1 vs. 1.9 ± 0.5 hr/week; p < .01) activity than active women (n = 16). Furthermore, active women reported higher overall PAQOL, greater energy levels and quicker sleep onset than inactive women (p < .05).

CONCLUSIONS

In these women, moderate and vigorous physical activity and PAQOL were not influenced by breast cancer survivorship. Despite diagnosis, active women who engaged in greater amounts of moderate and vigorous activity reported better PAQOL than inactive women.

Early Phase II Comprehensive Cardiac Rehabilitation after Acute Myocardial Infarction

Background

Cardiac rehabilitation is beneficial for patients after ST-segment elevation myocardial infarction (STEMI). However, most institutes perform outpatient training phase (phase II) of post-MI cardiac rehabilitation after 2-4 weeks. To evaluate the possibility of performing cardiac rehabilitation with an earlier schedule after STEMI.

Methods

We conducted a series of early phase II cardiac rehabilitation starting from 5-7 days after STEMI, including the training group (n = 28) and the control group (n = 42).

Results

The results showed an improved mental component summary of the SF-36 questionnaire after 6 months in the training group. No adverse event was noticed during this early phase II training.

Conclusions

Cardiac rehabilitation after STEMI might be started earlier than previously thought for clinical use or further research.

Longitudinal Changes of Handgrip, Knee Extensor Muscle Strength, and the Disability of the Arm, Shoulder and Hand Score in Cardiac Patients During Phase II Cardiac Rehabilitation

Handgrip strength (HS) and knee extensor muscle strength (KEMS) showed a negative correlation with the Disabilities of the Arm, Shoulder, and Hand (DASH) score at one month following cardiac surgery. We performed a longitudinal study to examine changes in HS/KEMS and DASH score during phase II cardiac rehabilitation (CR) in patients after cardiac surgery. We measured and assessed HS, KEMS, and DASH score in 41 consecutive patients at one and three months following cardiac surgery and examined the relation between these factors at three months following cardiac surgery. Wilcoxon signed-rank test and Spearman correlation coefficients were used to analyze the results. Finally, 26 patients (63.2 years, 73.1% male) were analyzed. There were significant differences from one month to three months following cardiac surgery in HS (26.78 ± 8.26 to 31.35 ± 9.41 kgf, p < 0.001), KEMS (1.53 ± 0.42 to 1.72 ± 0.46 Nm/kg, p = 0.001), and DASH score (14.76 ± 12.58 to 7.62 ± 9.29, p < 0.001). DASH score correlated negatively with HS (r = −0.41, p = 0.01) but not with KEMS (r = −0.32, p = 0.09) after three months of phase II CR. Although HS, KEMS, and DASH scores changed significantly from one to three months following cardiac surgery during phase II CR, only HS correlated negatively with DASH score at three months following cardiac surgery.

Is Exercise Prescription in Cardiac Rehabilitation Influenced by Physical Capacity or Cardiac Intervention?

This study investigated the influence of cardiac intervention and physical capacity of individuals attending an Australian outpatient cardiac rehabilitation program on the initial exercise prescription. A total of 85 patients commencing outpatient cardiac rehabilitation at a major metropolitan hospital had their physical capacity assessed by an incremental shuttle walk test, and the initial aerobic exercise intensity and resistance training load prescribed were recorded. Physical capacity was lower in surgical patients than nonsurgical patients. While physical capacity was higher in younger compared with older surgical patients, there was no difference between younger and older nonsurgical patients. The initial exercise intensity did not differ between surgical and nonsurgical patients. This study highlights the importance of preprogram exercise testing to enable exercise prescription to be individualized according to actual physical capacity, rather than symptoms, comorbidities and age, in order to maximize the benefit of cardiac rehabilitation.

Relationship between Daytime Sleepiness and Health Utility in Patients after Cardiac Surgery: A Preliminary Study

Background Daytime sleepiness can be assessed by the Epworth Sleepiness Scale (ESS), which is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. Also, health utility assessed by the mean Short-Form Six-Dimension (SF-6D) score, one of several preference-based utility measures, is an important measure in health care. We aimed to examine age-related differences in daytime sleepiness and health utility and their relationship in patients 5 months after cardiac surgery. Methods; This cross-sectional study assessed 51 consecutive cardiac surgery patients who were divided into a middle-aged (<65 years, n = 29) and older-age group (≥65 years, n = 22). The mean ESS and SF-6D utility scores were measured at 5 months after cardiac surgery and compared. In addition, the relationship between ESS and SF-6D utility scores were assessed. Results; There were no significant differences between the middle-aged and older-aged groups in either the mean ESS (5.14 ± 2.96 vs. 4.05 ± 3.23, p = 0.22) or SF-6D utility (0.72 ± 0.14 vs. 0.71 ± 0.10, p = 0.76) scores. However, there was a negative correlation between both values in all of the patients after cardiac surgery (r = -0.41, p = 0.003). Conclusions; Although there were no age-related differences in the ESS and SF-6D utility values between the two groups, there was a negative correlation between these values in all patients at 5 months after cardiac surgery. This suggested that sleepiness is associated with decreased utility scores in patients at 5 months after cardiac surgery.

Age-Related Differences of Maximum Phonation Time in Patients after Cardiac Surgery

Background and aims: Maximum phonation time (MPT), which is related to respiratory function, is widely used to evaluate maximum vocal capabilities, because its use is non-invasive, quick, and inexpensive. We aimed to examine differences in MPT by age, following recovery phase II cardiac rehabilitation (CR). Methods: This longitudinal observational study assessed 50 consecutive cardiac patients who were divided into the middle-aged group (<65 years, n = 29) and older-aged group (≥65 years, n = 21). MPTs were measured at 1 and 3 months after cardiac surgery, and were compared. Results: The duration of MPT increased more significantly from month 1 to month 3 in the middle-aged group (19.2 ± 7.8 to 27.1 ± 11.6 s, p < 0.001) than in the older-aged group (12.6 ± 3.5 to 17.9 ± 6.0 s, p < 0.001). However, no statistically significant difference occurred in the % change of MPT from 1 month to 3 months after cardiac surgery between the middle-aged group and older-aged group, respectively (41.1% vs. 42.1%). In addition, there were no significant interactions of MPT in the two groups for 1 versus 3 months (F = 1.65, p = 0.20). Conclusion: Following phase II, CR improved MPT for all cardiac surgery patients.

Relation between the Disability of the Arm, Shoulder and Hand Score and Muscle Strength in Post-Cardiac Surgery Patients

Background: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a valid and reliable patient-reported outcome measure. DASH can be assessed by self-reported upper extremity disability and symptoms. We aimed to examine the relationship between the physiological outcome of muscle strength and the DASH score after cardiac surgery. Methods: This cross-sectional study assessed 50 consecutive cardiac patients that were undergoing cardiac surgery. Physiological outcomes of handgrip strength and knee extensor muscle strength and the DASH score were measured at one month after cardiac surgery and were assessed. Results were analyzed using Spearman correlation coefficients. Results: The final analysis comprised 43 patients (men: 32, women: 11; age: 62.1 ± 9.1 years; body mass index: 22.1 ± 4.7 kg/m²; left ventricular ejection fraction: 53.5 ± 13.7%). Respective handgrip strength, knee extensor muscle strength, and DASH score were 27.4 ± 8.3 kgf, 1.6 ± 0.4 Nm/kg, and 13.3 ± 12.3, respectively. The DASH score correlated negatively with handgrip strength (r = -0.38, p = 0.01) and with knee extensor muscle strength (r = -0.32, p = 0.04). Conclusion: Physiological outcomes of both handgrip strength and knee extensor muscle strength correlated negatively with the DASH score. The DASH score appears to be a valuable tool with which to assess cardiac patients with poor physiological outcomes, particularly handgrip strength as a measure of upper extremity function, which is probably easier to follow over time than lower extremity function after patients complete cardiac rehabilitation.

Implementing resistance training in the rehabilitation of coronary heart disease: A systematic review and meta-analysis

BACKGROUND

Resistance training has demonstrated efficacy in cardiac rehabilitation programs, but the optimal prescription of resistance training is unknown. This systematic review with meta-analysis compared the effectiveness of cardiac rehabilitation consisting of resistance training either alone (RT) or in combination with aerobic training (CT) with aerobic training only (AT) on outcomes of physical function. Further, resistance training intensity and intervention duration were examined to identify if these factors moderate efficacy.

METHODS

Six electronic databases were searched to identify studies investigating RT, coronary heart disease and physical function. The overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible and qualitative analysis was performed for the remaining data.

RESULTS

Improvements in peak oxygen uptake (WMD: 0.61, 95% CI: 0.20-1.10), peak work capacity (SMD: 0.38, 95% CI: 0.11-0.64) and muscular strength (SMD: 0.65, 95% CI: 0.43-0.87) significantly favoured CT over AT with moderate quality evidence. There was no evidence of a difference in effect when comparing RT and AT. Shorter duration CT was superior to shorter duration AT for improving peak oxygen uptake and muscular strength (low quality evidence) while longer duration CT was only superior to longer duration AT in improving muscular strength (moderate quality evidence).

CONCLUSIONS

CT is more beneficial than AT alone for improving physical function. Although preliminary findings are promising, more high-quality evidence is required to determine the efficacy of high intensity resistance training. Shorter duration interventions that include resistance training might allow patients to return to their normal activities of daily living earlier.

Cognitive Dysfunction and Malnutrition Are Independent Predictor of Dysphagia in Patients with Acute Exacerbation of Congestive Heart Failure

Early detection and intervention for dysphagia is important in patients with congestive heart failure (CHF). However, previous studies have focused on how many patients with dysphagia develop CHF. Studies focusing on the comorbidity of dysphagia in patients with CHF are rare. Additionally, risk factors for dysphagia in patients with CHF are unclear. Thus, the aim of this study was to clarify risk factors for dysphagia in patients with acute exacerbation of CHF. A total of 105 patients, who were admitted with acute exacerbation of CHF, were enrolled. Clinical interviews, blood chemistry analysis, electrocardiography, echocardiography, Mini-Mental State Examination (MMSE), exercise tolerance tests, phonatory function tests, and evaluation of activities of daily living (ADL) and nutrition were conducted on admission. After attending physicians permitted the drinking of water, swallowing screening tests were performed. Patients were divided into a dysphagia group (DG) or a non-dysphagia group (non-DG) based on Functional Oral Intake Scale level. Among the 105 patients, 38 had dysphagia. A greater number of patients had history of aspiration pneumonia and dementia, and there was a higher age, N-terminal pro-B-type natriuretic peptide level in the DG compared with the non-DG. MMSE scores, exercise tolerance, phonatory function, status of ADL, nutrition, albumin, and transthyretin were lower in the DG compared with the non-DG. In multivariate analysis, after adjusting for age and sex, MMSE, BI score, and transthyretin was independently associated with dysphagia. Comorbidity of dysphagia was 36.1% in patients with acute exacerbation of CHF, and cognitive dysfunction and malnutrition may be an independent predictor of dysphagia.

Interventions that improve health-related quality of life in patients with myocardial infarction

PURPOSE

Patients with myocardial infarction (MI) often report lower health-related quality of life (HRQoL) than those without MI. Interventions can affect HRQoL of these patients. The purpose of this review was to identify effective strategies for improving HRQoL among individuals with MI.

METHODS

Three electronic databases were searched and limited to articles peer-reviewed and published in English between 1995 and 2015. We screened titles and abstracts of the retrieved articles for studies that examined effectiveness of interventions to improve HRQoL in patients with MI.

RESULTS

Twenty-three studies were found that examined the effects of behavioural interventions-cardiac rehabilitation programmes (CRP), education and counselling programmes, and other psychological and cognitive interventions-to improve HRQoL in patients with MI. The studies included were mainly randomised controlled trials (14 studies) with a wide age range of participants (18-80 years) and a mean age group of 50-70 years. CRPs, including home- and hospital-based CRPs, regular weekly aerobic training programmes, and group counselling mostly resulted in improvement of HRQoL in patients with MI.

CONCLUSION

Most CRPs and other interventions were beneficial to MI patients. Therefore, patients with MI should be encouraged to participate in programmes that can help promote their HRQoL.

Health-Related Quality of Life Improves Similarly in Patients With and Without Type 2 Diabetes After Cardiac Rehabilitation

PURPOSE

Cardiovascular disease is the leading cause of death in the United States and results in substantial healthcare expenditures. Health-related quality of life (HRQoL) is an important aspect in long-term recovery for patients with cardiovascular disease. As such, improvement in HRQoL is a relevant outcome for determining cardiovascular rehabilitation (CR) program efficacy. Increasingly, diabetic patients are participating in CR and face additional challenges to HRQoL, yet there is a lack of research addressing program efficacy in this population. This study tested the hypothesis that CR would effect a favorable change in HRQoL for both diabetic (D; n = 37) and nondiabetic (N-D; n = 58) patients. Furthermore, we tested the hypothesis that the D group would demonstrate a greater overall change compared with the N-D group.

METHODS

In this retrospective study, we reviewed the charts of 95 patients who completed a CR program and collected HRQoL measures using the COOP questionnaire, where lower scores indicate higher HRQoL.

RESULTS

After CR, COOP scores for both the N-D improved (pre: 20.39 ± 0.79 vs post: 16.06 ± 0.75; P < .05) and D (pre: 20.92 ± 0.88 vs post: 15.84 ± 0.80; P < .05). HRQoL was not different between groups at the start of the program (P = .88) or at the end (P = .58), and thus, the improvement in HRQoL was not different between groups (P = .44).

CONCLUSIONS

These results suggest that D and N-D patients do not differ in their HRQoL at the start or end of CR, and that the 2 groups show similar improvements from attending the program. Larger sample studies are needed to confirm these findings.

The effect of cardiac rehabilitation on quality of life in patients with acute coronary syndrome

BACKGROUND

Acute coronary syndrome is one of the major cardiovascular diseases that leads to a significant amount of morbidity. The purpose of the present study was to investigate the effect of cardiac rehabilitation on quality of life in patients with acute coronary syndrome.

MATERIALS AND METHODS

This was a clinical trial study conducted on 50 patients with acute coronary syndrome admitted to the coronary care units of Shohada Hospital in Isfahan in 2013-2014. The participants were randomly assigned to control (n = 25) and study (n = 25) groups. The study group received cardiac rehabilitation in phase 1 and 2. Phase 1 was conducted in a hospital in Isfahan province that had no cardiac rehabilitation center but had minimal cardiac rehabilitation equipments. Phase 2 was conducted at home by follow-up through telephone and referring the patients to the hospital. The control group received usual cardiac rehabilitation. The data were collected via a demographic questionnaire and SF-36 quality of life questionnre before and 1 month after intervention by the researcher. Data were analyzed by independent samples t-test.

RESULTS

In the study group, the mean scores in all domains of quality of life increased significantly after intervention (P < 0.05). In the control group, the mean scores of quality of life were not significantly different before and after intervention (P < 0.05). A significant difference was found between the study and control groups in all domains of quality of life except for general health and social function (P < 0.05) in favor of the study group.

CONCLUSIONS

The results of this study showed that cardiac rehabilitation program could lead to improving the quality of life in the patients with acute coronary syndrome.

The effects of unsupervised exercise training on physical activity and physiological factors after supervised cardiac rehabilitation

Exercise maintenance after supervised cardiac rehabilitation is important in maintaining both physical activity and physiological factors, such as peak and muscle strength (MS), associated with reduced mortality. However, there is no evidence of the effects of unsupervised exercise training and MS training on physical activity and physiological factors after supervised cardiac rehabilitation of Japanese cardiac patients. We conducted a randomized, controlled trial to evaluate the effect of unsupervised exercise training on physical activity and selected physiological factors after supervised cardiac rehabilitation. Eighteen myocardial infarction (MI) patients (16 men, 2 women; mean age 66.3 years) were recruited following completion of a supervised recovery-phase cardiac rehabilitation program. Patients were randomly assigned to a MS training (n=10) or control group (n=8). Baseline measurements of physical activity, peak , and MS were performed at the end of supervised recovery-phase cardiac rehabilitation (6 months after the onset of MI: T1). Six months later, after going through an unsupervised exercise program (12 months after the onset of MI: T2) exercise maintenance, peak , MS, and physical activity were remeasured. The MS training group performed low-intensity MS training and walking over the second 6-month period; the control group performed walking exercise only. All patients maintained their exercise training. At T2, there were no significant differences in peak values between the MS training and control groups. There was also no significant difference in physical activity (mean number of steps per week) between the MS training and control groups. However, MS was significantly higher in the MS training group than in the control group. We concluded that unsupervised exercise training and low-level MS training performed after supervised cardiac rehabilitation may effectively maintain not only physical activity and peak but increase MS.

Health-related quality of life in relation to different levels of disease severity in patients with chronic heart failure

The purpose of the present study was to compare differences in physiological outcomes and health-related quality of life (HRQOL) in relation to degree of illness in patients with chronic heart failure (CHF) and to compare HRQOL in CHF patients with that of a normal Japanese population. One hundred and twenty-five patients with stable CHF (93 men, 32 women, mean age 63.3 ± 12.4 years) with left ventricular ejection fraction (LVEF) of less than 40% were enrolled in the present study. We used New York Heart Association (NYHA) functional class as an index of degree of illness. In 64 of the 125 patients, physiological outcome measures included peak oxygen uptake (peak O2) and E/CO2 slope. HRQOL was assessed with the medical outcome study short form-36 (SF-36) Japanese version. In addition, SF-36 scores of CHF patients were compared against Japanese standard values. Age and LVEF did not differ according to NYHA functional class. The eight SF-36 subscale scores and peak O2 decreased with increases in the NYHA functional classes, whereas E/CO2 slope increased with increases in NYHA functional class (p<0.05). Of the 8 SF-36 subscales measured in CHF patients, only the bodily pain score attained that of the normal Japanese population. These findings suggest that HRQOL decreases as NYHA functional class increases and other physiological measures worsen. In addition, HRQOL values of CHF patients were low in comparison with standard values of a normal Japanese population.

Change in positive affect during outpatient cardiac rehabilitation predicts vital exhaustion in patients with coronary heart disease

Vital exhaustion is an acknowledged psychosocial risk factor of incident coronary heart disease (CHD) and recurrent CHD events. Little is known about trajectories in vital exhaustion in patients with CHD and the factors predicting this change. We hypothesized that vital exhaustion would decrease during outpatient cardiac rehabilitation and that an increase in positive affect over time would be associated with decreased vital exhaustion at discharge from cardiac rehabilitation. We also explored the role of the patient's sex in this context. Vital exhaustion was reduced during outpatient cardiac rehabilitation, especially in patients who experienced an increase in positive affect over time (p < .001). This relationship was significant in men (p < .001) but not in women (p = .11).

Exercise as a therapeutic strategy for primary mitochondrial cytopathies

Patients with mitochondrial cytopathies often experience exercise intolerance and may have fixed muscle weakness, leading to impaired functional capacity and lower quality of life. Endurance exercise training increases Vo 2 max, respiratory chain enzyme activity, and improves quality of life. Resistance exercise training increases muscle strength and may lower mutational burden in patients with mitochondrial DNA deletions. Both modes of exercise appear to be well tolerated. Patients with mitochondrial cytopathy should consider alternating both types of exercise to derive the benefits from each (endurance = greater aerobic fitness; resistance = greater strength). Patients should start an exercise program at a low intensity and duration, gradually increasing duration and intensity. They should "listen to their body" and not exercise on days they have fever, superimposed illness, muscle pain, or cramps, and/or if they have fasted for more than 12 hours. Children often respond best to play-based exercise and tend to enjoy intermittent activity.

Effect of an IT-supported home-based exercise programme on metabolic syndrome in India

Summary

We studied the effectiveness of a home-based exercise programme with information technology (IT) support in people with metabolic syndrome in India. Ninety-four participants with metabolic syndrome (mean age 50 years) were randomized into two groups. Both groups received a 12-week home exercise programme and Group 2 received additional IT support for health education. Before and after the exercise programme, participants were measured for arterial stiffness using applanation tonometry, exercise capacity using an incremental shuttle walk test and quality of life (QoL) using the SF-36 questionnaire. Sixty-one participants completed the post intervention tests. There was a significant reduction in systolic blood pressure, mean pressure and aortic systolic pressure in both groups. Pulse wave velocity, aortic pulse pressure and aortic diastolic pressure showed significant reductions only in Group 2. There were no significant changes in QoL measures, except vitality in Group 2. There was significant improvement in fasting blood glucose in Group 2, cholesterol in Group 1 and triglycerides in both groups. The participants’ exercise capacity did not change significantly, although the mean duration of regular exercise was 7.2 weeks for Group 1 and 10.0 weeks for Group 2 ( P = 0.019). Metabolic syndrome was reversed in 16% of the participants in both groups. IT support, through mobile text messages and phone calls, may be helpful in metabolic syndrome. Longer-term studies are now required.

Impact of exercise-based cardiac rehabilitation on de novo coronary lesion in patients with drug eluting stent

Objective

To compare the rate of progression of de novo lesion between the cardiac rehabilitation (CR) and control groups.

Methods

This is a retrospective observational study. Patients who received drug-eluting stent (DES) due to acute coronary syndrome were included as subjects. The CR group received eight weeks of early CR program, and sustained a self-exercise program in the homes. The control group was instructed to exercise independently. Nine months after the first insertion of DES, we implemented follow-up coronary angiography, and compared the rate of progression of de novo lesion by quantitative angiographic measurement between the two groups.

Results

A total of 81 patients were recruited as subjects to CR group (n=32) or control group (n=49). At nine months, late luminal loss was 0.04±0.23 mm in the CR group and 0.00±0.31 mm in the control group (p=0.54, observed power=0.10). Late loss was -0.90%±9.53% in the CR group and 0.80%±11.15% in the control group (p=0.58, observed power=0.05). No target lesion revascularization procedures were needed in the CR group, while two in the control group (p=0.25). In the CR group, mean VO_2max was significantly improved from 24.36±5.00 to 27.68±5.24 mL/kg/min (p<0.001).

Conclusion

We could not observe a statistically significant difference in the progression rate of de novo lesion between the CR and control groups. Thus the current amount of nine months exercise-based CR program does not seem to have a distinct impact on the retardation of de novo coronary lesion in patients who received percutaneous coronary intervention with DES.

Automatic assessment of socioeconomic impact on cardiac rehabilitation

Disability-Adjusted Life Years (DALYs) and Quality-Adjusted Life Years (QALYs), which capture life expectancy and quality of the remaining life-years, are applied in a new method to measure socioeconomic impacts related to health. A 7-step methodology estimating the impact of health interventions based on DALYs, QALYs and functioning changes is presented. It relates the latter (1) to the EQ-5D-5L questionnaire (2) to automatically calculate the health status before and after the intervention (3). This change of status is represented as a change in quality of life when calculating QALYs gained due to the intervention (4). In order to make an economic assessment, QALYs gained are converted to DALYs averted (5). Then, by inferring the cost/DALY from the cost associated to the disability in terms of DALYs lost (6) and taking into account the cost of the action, cost savings due to the intervention are calculated (7) as an objective measure of socioeconomic impact. The methodology is implemented in Java. Cases within the framework of cardiac rehabilitation processes are analyzed and the calculations are based on 200 patients who underwent different cardiac-rehabilitation processes. Results show that these interventions result, on average, in a gain in QALYs of 0.6 and a cost savings of 8,000 €.

Psychosocial outcome in cardiovascular rehabilitation of peripheral artery disease and coronary artery disease patients

We investigated patients with a primary diagnosis of peripheral artery disease (n = 69) and coronary heart disease (CAD; n = 520) at baseline and on changes in psychosocial risk factors (depression, anxiety, quality of life, negative and positive affect) during a cardiovascular rehabilitation program. Patients completed psychosocial questionnaires at the beginning and at discharge of a 12-week rehabilitation program. Depression and anxiety were measured with the Hospital Anxiety and Depression Scale (HADS), positive and negative affect with the Global Mood Scale, and health-related quality of life with the SF-36 Health Survey. Patients with PAD showed improvements in anxiety (p < 0.001), negative affect (p < 0.001) and bodily pain (p < 0.001). Patients with CAD reported significant improvements in all measured dimensions (all p-values < 0.001).

Impact of home-based exercise training with wireless monitoring on patients with acute coronary syndrome undergoing percutaneous coronary intervention

Recent studies have suggested a favorable effect of cardiac rehabilitation (CR) on patients with cardiovascular disease. This study aimed to evaluate the impact of home-based exercise training with wireless monitoring on acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). A total of 55 ACS patients undergoing PCI were randomly divided into home based exercise training with wireless monitoring cardiac rehabilitation (CR, n = 26) and usual care (UC, n = 29). Exercise capacity and quality of life (QOL) were evaluated at baseline and after 12 weeks. Change of metabolic equivalent of the tasks, maximal exercise time and QOL were significantly increased (+2.47 vs +1.43, P = 0.021; +169.68 vs +88.31 sec, P = 0.012; and +4.81 vs +0.89, P = 0.022, respectively), and the change of submaximal rate pressure product, and of submaximal rate of perceived exertion were significantly decreased (-28.24 vs -16.21, P = 0.013; and -1.92 vs -1.62, P = 0.018, respectively) in the CR group compared to the UC group after 12 weeks. CR using home-based exercise training with wireless monitoring led to improvement of exercise capacity and QOL relative to conventional care in ACS patients undergoing PCI. Our findings suggest that early scheduled CR may be considered in ACS patients undergoing PCI.

Cardiac rehabilitation may not provided a quality of life benefit in coronary artery disease patients

Background

Improvements in patient-reported health-related quality of life (HRQoL) are important goals of cardiac rehabilitation (CR). In patients undergoing coronary angiography for angina and with documented coronary artery disease (CAD), the present study compared HRQoL over 6 months in CR participants and non-participants. Clinical predictors of CR participants were also assessed.

Methods

A total of 221 consecutive patients undergoing angiography for angina with documented CAD and who were eligible for a CR program were recruited. CR participants were enrolled in a six-week Phase II outpatient CR course (31%, n = 68) within 2 months following angiography and the non-participants were included as a control. At baseline (angiography), one and six months post angiography, clinical and HRQoL data were obtained including the Short Form-36 (SF-36) and the Seattle Angina Questionnaire (SAQ). The response rate for the HRQoL assessment was 68% (n = 150). Cross sectional comparisons were age-adjusted and performed using logistic or linear regression as appropriate. Longitudinal changes in HRQoL were assessed using least squares regression. Finally, a multiple logistic regression was fitted with CR participant as the final outcome.

Results

At angiography, the CR non-participants were older, and age-adjusted analyses revealed poorer physical (angina limitation: 54 ± 25 versus 64 ± 22, p <0.05) and mental HRQoL (significant psycho-social distress: 62%, n = 95 versus 47%, n = 32, p <0.05) compared to the CR participants. In addition, the CR participants were more likely to have undergone angiography for myocardial infarction (OR = 2.8, 95% CI 1.5-5.3, p = 0.001). By six months, all patients showed an improvement in HRQoL indices, however the rate of improvement did not differ between the controls and CR participants.

Conclusion

Following angiography, CAD patients reported improvements in both generic and disease-specific HRQoL, however CR participation did not influence this outcome. This may be explained by biases in CR enrollment, whereby acute patients, who may be less limited in HRQoL compared to stable, chronic patients, are targeted for CR participation. Further investigation is required so CR programs maximize the quality of life benefits to all potential CR patients.

Psychometric properties of the German version of the MacNew heart disease health-related quality of life questionnaire

Background

There is a lack of German-language, disease-specific health related quality of life instruments applicable in cardiac rehabilitation. The purpose of this project was to investigate the psychometric properties of the German version of the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients undergoing cardiac rehabilitation.

Methods

The MacNew was filled out by 5692 inpatients. We analysed acceptance (number of missing values), ceiling and floor effects, reliability (Cronbach’s α), factor structure (confirmatory factor analysis), construct validity (correlation with a generic health-related quality of life instrument), and sensitivity to change.

Results

Two items had more than 7% missing data. We observed neither floor nor ceiling effects. Cronbach’s α of the scales ranged from 0.78 (physical scale) to 0.95 (global scale). Confirmatory factor analysis failed to reproduce the proposed factor structure (CFI = 0.882; TLI = 0.871; RMSEA = 0.074). We therefore drafted our own model (CFI = 0.932; TLI = 0.921; RMSEA = 0.064), and observed a correlation pattern largely conforming to the hypotheses with a generic health-related quality of life instrument. The effect sizes we noted between the start and end of rehabilitation fell between 0.66 and 0.74; at the 6-month follow-up they ranged from 0.69 to 0.92.

Conclusions

The German version of the MacNew Heart Disease Health-related Quality of Life Questionnaire is a suitable instrument with which to measure the impairment experienced by individuals with heart disease during inpatient cardiologic rehabilitation. The social and the global scale must be interpreted cautiously.

Impact of Exercise-based Cardiac Rehabilitation on In-stent Restenosis with Different Generations of Drug Eluting Stent

Objective

To compare the rate of restenosis between a cardiac rehabilitation (CR) group and a control group within three different generations of drug eluting stents (DES).

Method

Patients who received DES due to an acute coronary syndrome were included. They were divided into a CR group and a control group. The CR group received six to eight weeks of early cardiac rehabilitation program in a hospital setting, and sustained a self-exercise program for six months in a community. The control group was instructed to exercise by themselves after leaving the hospital. Nine months after the first onset of disease, we implemented a coronary angiography and compared the two groups. In addition, we divided the patients into three subgroups according to the generation of DES, and compared the rate of restenosis between the CR group and control group within these three subgroups.

Results

At 9 months, in-stent restenosis, measured as an in-segment late luminal loss (LLL) of the stented coronary area, was smaller in the CR group (n=52) 0.16±0.42 mm compared to the control group (n=51) 0.39±0.78 mm (p<0.05). A reduction of LLL in the CR group compared to the control group was consistent among the three different generations of DES.

Conclusion

The CR program is strongly associated with a significant reduction in LLL in the stented coronary segments, regardless of the generation of DES.

Resistance exercise in cardiac rehabilitation

Cardiovascular disease is the leading cause of death in developed nations, and there is a clear link with physical inactivity. The benefits of resistance training in patients with coronary heart disease are well documented and can contribute to secondary prevention of heart disease with corresponding improvements in patient survival. This review describes the benefits of resistance exercise for cardiac patients, details of its prescription in this group, and considers safety and contraindications.

The effect of a self exercise program in cardiac rehabilitation for patients with coronary artery disease

OBJECTIVE

To investigate the effect of self exercise in cardiac rehabilitation on cardiopulmonary exercise capacity for selected patients with coronary artery disease.

METHOD

The subjects of this study were patients who received percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery and who participated in a cardiac rehabilitation program. The supervised exercise group participated in 6-8 weeks of aerobic exercise training with telemetry ECG monitoring in hospital. The self exercise group, whose exercise risk was low, was instructed to participiate in self exercise training in a community exercise environment according to the exercise tolerance test (ETT) using a modified Bruce protocol. Both groups underwent ETTs before and 6 months after initiation of the cardiac rehabilitation program. We compared the supervised group with the self exercise groups on exercise capacity.

RESULTS

After 6 months, the supervised exercise group showed significant changes in maximum oxygen consumption, maximal heart rate, resting heart rate, and submaximal rate pressure product. The self exercise group also showed significant improvement of maximum oxygen consumption and submaximal rate pressure product. However, the changing rate of maximum oxygen consumption was significantly higher in the supervised exercise group than the self exercise group.

CONCLUSION

Both the supervised and self exercise groups showed similar improvement of cardiopulmonary exercise capacity after 6 months' participation in the cardiac rehabilitation program. However, the changing rate of maximum oxygen consumption, maximal heart rate, and resting heart rate were significantly higher in the supervised exercise group than the self exercise group.

Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease

BACKGROUND

Cardiac rehabilitation (CR) has numerous benefits, including reduction of mortality and cardiovascular events, in patients with coronary artery disease (CAD). However, the long-term effect of phase III CR in elderly patients with stable CAD is still unknown.

METHODS AND RESULTS

The 111 elderly male CAD patients (>or=65 years), including 37 subjects participating in supervised CR for 6 months and 74 age-matched controls, were analyzed. The patients were followed for up to 3,500 days, until the occurrence of death or 1 of the following major adverse cardiovascular events (MACE): cardiovascular death, acute coronary syndrome, refractory angina requiring revascularization, admission for congestive heart failure, or stroke. All-cause mortality tended to be lower in the CR group than in the Control group (14% vs 28%, P=0.081). The MACE incidence was significantly lower in the CR group than in the Control group (30% vs 62%, P=0.001). Multivariate Cox proportional hazard analysis showed that the MACE incidence was significantly lower in the CR group than in the Control group [adjusted hazard ratio 0.43 (95% confidence interval 0.20-0.91), P=0.027].

CONCLUSIONS

Phase III CR has the beneficial effect of reducing cardiovascular events even in elderly patients with stable CAD.

Health-related quality of life in patients with coronary heart disease after residential vs ambulatory cardiac rehabilitation

BACKGROUND

The aim of this study was to evaluate the influence of residential (RCR) vs ambulatory (ACR) cardiac rehabilitation (CR) on health-related quality of life (QOL) connected with changes in exercise capacity of patients with coronary heart disease (CHD).

METHODS AND RESULTS

The 562 patients with CHD were studied: 313 participants in RCR and 249 participants in ACR. The examination was performed at the beginning of CR and after 8 weeks. QOL was assessed using the EuroQuol 5D (EQ-5D) and SF36 questionnaires. Exercise testing was performed with evaluation of workload during the last stage of the test and rate of perceived exertion intensity. In the first examination, patients from both groups did not differ significantly. After 8 weeks, a similar improvement in QOL was observed in both settings of CR according to EQ-5D and SF36 results. Health status was improved by 11.1% in the RCR group and by 10.4% in the ACR group. Last workload's intensity increased significantly by 32.1% in the RCR group and by 38.1% in the ACR group. The rate of perceived exertion intensity did not change despite the bigger workloads during the exercise test.

CONCLUSIONS

Comprehensive CR improves health-related QOL and exercise capacity without differences between residential and ambulatory models.