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MEDICAL SURVEILLANCE DURING CARDIAC REHABILITATION

Jason B. Thompson; Bonnie K. Sanderson; Jenny R. Breland; Carla Adams; Chris Schumann; Vera Bittner; University of Alabama at Birmingham

 

Rationale:

The benefits of cardiac rehabilitation (CR) are frequently described in terms of exercise, education, and behavioral interventions. Little is known about the medical surveillance that occurs during CR.

 

Objectives:

To determine the frequency of untoward clinical events that occur during CR and to characterize the CR patients who experience these events.

 

Methods:

We retrospectively reviewed our CR database, which includes a prospective log of events that require physician notification (uncontrolled hypertension, chest pain or ST-changes, hypoglycemia, hypotension, shortness of breath, arrhythmias, falls, etc.). Univariate associations between events and demographic and clinical characteristics of CR patients were determined with t tests and chi square tests as appropriate. Occurrence of events was then modeled with logistic regression to determine independent correlates of untoward clinical events.

 

Results:

Between 1996 and 2001, 591 patients were enrolled in our CR program (age 60 +/- 12 years, 35% women, 68% white); 195 patients experienced an event, 396 did not. Among patients who had events, event number ranged from 1 to 9 (mean +/- SD: 1.81 +/- 1.3). In univariate analyses, nonwhite race, diabetes, hypertension, low physical activity, history of heart failure, high risk by AACVPR risk stratification, and shorter distance walked on the entry 6-minute walk test were correlated with an increased risk of events. By logistic regression, only history of hypertension (OR 1.80; 95% CI 1.16, 2.78) and high-risk status by AACVPR classification (OR 1.46; 95% CI 1.02, 2.11) remained significant. When we excluded events related to abnormal glucose measurements (which occur only in diabetic patients), history of hypertension (OR 1.97; 95% CI 1.26, 3.09), history of low physical activity (OR 1.53; 95% CI 1.01, 2.31) and high-risk AACVPR status (OR 1.61; 95% CI 1.11, 2.32) were significant.

 

Conclusion:

Clinical events requiring physician notification are common in CR. Medical surveillance is an important but under-appreciated component of CR.

 

SCREENING FOR PERIPHERAL ARTERIAL DISEASE IN A PHASE II CARDIAC REHABILITATION POPULATION

Jane E. Nelson Worel, RN, MS; Mark Vitcenda, MS; Ann Ward, PhD; Jean Einerson, MS University of Wisconsin Hospital and Clinics

 

Rationale:

While reports are widely varied, incidence of peripheral arterial disease (PAD) is estimated to be 15% to 25% in individual's aged 60 or older (Criqui, 1985). Approximately 35% to 40% of patients with known coronary artery disease (CAD) have PAD (Hertzer, 1985).

 

Objectives:

To document the incidence of PAD in our phase 2 cardiac rehabilitation (CR) population.

 

Methods:

Ankle brachial indices (ABIs) were performed on all CR patients upon entry into the program using Doppler ultrasound. ABIs are an accepted screening assessment for PAD. An ABI < .90 is indicative of PAD. Patients completed the Rose/WHO and Edinburgh claudication questionnaires. Data was entered into our cardiac rehab patient database.

 

Individual ABI scores divided into groups. Age, gender, risk factors and claudication questionnaire scores define the prevalence within each group (total number in group and % of group total).

 

Results:

See Table. Individual ABI scores divided into groups. Age, gender, risk factors, and claudication questionnaire scores define the prevalence within each group (total number in group and % of group total).

  
Table. No caption av... - Click to enlarge in new windowTable. No caption available.N=92 ABIs (46 individuals; one ABI for each leg)

Conclusion:

A much smaller than expected number of ABIs performed was abnormal. Half of the patients with abnormal ABIs were symptomatic. There is a history of smoking and diabetes in all of the patients with abnormal ABIs. Screening all phase 2 CR patients for the presence of PAD is time consuming. Performing ABIs on patients with diabetes and a history of smoking may be appropriate.

 

PREDICTORS OF DEPRESSION IN AFRICAN AMERICAN AND WHITE WOMEN ELIGIBLE FOR CARDIAC REHABILITATION

Keren Ben-Or; L. Benz Scott; A. Lavis; A. Moore; D. Young; K. Stewart; J. Allen; Johns Hopkins University School of Nursing

 

A substantial number of women experience depression in the months that follow hospitalization for a cardiac event. Depression has been identified as a significant barrier to cardiac rehabilitation particularly among women. However, little is known about the factors that predict depression after a cardiac event. The purpose of this study was to determine predictors of depression in a convenience sample of 253 African-American and white women who were interviewed by telephone 1 month after hospitalization for a cardiac event. Depression, functional status, comorbidity, and angina class were measured using standardized instruments. The sample was 43% African American and had a mean age of 66 +/- 12 years. Of the 253 women, 66 (26%) had CABG, 149 (59%) had PCI, and 38 (15%) had MI or acute stable angina as admitting diagnoses. The women had a mean depression score of 11.7 +/- 10.2 (median 10) with no differences by race. Multivariate linear regression analysis was used to determine predictors of depression. After controlling for race, education, and angina class, poor physical functional status (P < .0001), younger age (P = .0001), greater comorbidity score (P = .047), and the responsibility for taking care of others (P = .056) were independent predictors of depression. These findings indicate important characteristics of African American and white women at elevated risk for depression post cardiac event. Future research should explore whether targeting screening and intervention among these women can increase cardiac rehabilitation participation.

 

TEMPORAL TRENDS IN RISK CHARACTERISTICS AMONG PATIENTS ENROLLED IN CARDIAC REHABILITATION

Gilbert J. Zoghbi; Bonnie K. Sanderson; David T. Redden; Vera Bittner

 

Rationale:

Changes in risk characteristics among cardiac rehabilitation (CR) participants may alter approaches to exercise prescription and patient education.

 

Objectives:

To determine temporal trends of risk characteristics of patients enrolled in our university based CR program.

 

Methods:

We retrospectively reviewed data among patients enrolled in our CR program between 1996 and 2000. We stratified patients into low, intermediate, or high risk according to the AACVPR risk stratification (ARS), calculated the total number of cardiac risk factors (CRFs), and computed a comorbidity index (CMI) encompassing 11 noncardiac comorbidities. Temporal trends in risk characteristics were analyzed using ANOVA or chi square statistics as appropriate ([alpha] = 0.05).

 

Results:

Between 1996 and 2000, 472 patients (age 60 +/- 12 years, 65% males, 69% whites) were enrolled in CR. The mean number of CRFs was 3.8 +/- 1.4 (range 0-7), mean CMI was 1.8 +/- 1.7 (range 0-7), 40% were in the high ARS category. CRF number and CMI increased significantly over time; age and proportion of patients in the high ARS group remained unchanged (see Table).

  
Table. No caption av... - Click to enlarge in new windowTable. No caption available.

Conclusion:

We observed an increase in risk factor and comorbidity burden over time. When prescribing exercise and developing educational strategies in CR, health professionals need to be aware of the increasing medical complexity among CR participants.

 

INTEGRATION OF ENHANCED EXTERNAL COUNTERPULSATION (EECP) TREATMENT INTO A CARDIAC REHABILITATION SERVICE: EARLY EXPERIENCE

Christina Clair, MS; Catherine Pesek-Bird, DO; Patricia Lounsbury, RN, Med; Cardiovascular Health, Assessment, Management, and Prevention Services (CHAMPS), UI Heart Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa

 

Enhanced external counterpulsation (EECP) has been used to reduce and/or eliminate angina in patients with coronary artery disease (CAD). We sought to study other effects EECP has on this population. We obtained SF-36 Health Survey, Prime-MD Nine Symptom Checklist (Sx9), and metabolic treadmill test at commencement and completion of EECP therapy. Angina pectoris episodes since previous treatment were recorded each session. Results presented here are from the first 6 patients completing 35 sessions. Episodes of angina decreased by 66%. VO2max increased by 28.5%. Anaerobic threshold (AT) (L/min) increased by 42%. Sx9 raw scores declined 45%. SF-36 scores were as follows: physical functioning (PF) increased 54%, role physical (RP) increased 122%, bodily pain (BP) improved 31%, general health (GH) decreased 3%, vitality (V) increased 64%, social functioning (SF) improved 30%, role emotional (RE) improved 55%, and mental health (MH) improved 7%. These early data suggest that EECP decreases angina episodes as well as improves patients' functional status and quality of life. Further data need to be collected and compiled to confirm these findings.

 

RELATIONSHIP BETWEEN RATING OF PERCEIVED EXERTION AND QUALITY OF LIFE IN HEART FAILURE

Ross Arena, PhD, PT; Reed Humphrey; Mary Ann Peberdy; Virginia Commonwealth University/MCV Campus

 

Rationale:

The Borg Rating of Perceived Exertion (RPE) scale is frequently used during symptom-limited exercise testing. An underlying assumption of the RPE scale is interpretation is universal.

 

Objectives:

To test this assumption in the heart failure (HF) population, the present study examines the relationship between RPE at peak exercise and quality of life.

 

Methods:

Thirty-one subjects (21 males/10 females) diagnosed with compensated HF (21 idiopathic/10 ischemic) underwent analysis. Mean age and ejection fraction were 51.9 +/- 14.4 years and 26.9% +/- 10.7%, respectively. Subjects completed the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) and underwent symptom-limited exercise testing. Peak RPE, via the 6-20 Borg scale, was recorded during the final stage of the exercise protocol. Pearson Product Moment Correlation determined the relationship between peak RPE and: (1) MLWHFQ overall score, (2) MLWHFQ physical subscore, (3) MLWHFQ psychosocial subscore. A z test determined if r values for peak RPE-MLWHFQ physical subscore and peak RPE-MLWHFQ psychosocial subscore were significantly different;P < .05 was considered statistically significant for all tests.

 

Results:

All exercise tests were terminated secondary to volitional fatigue. There was a significant correlation between peak RPE and: (1) MLWHFQ overall score (r = 0.57, P = .002); (2) MLWHFQ physical subscore (r = 0.49, P = .008); (3) MLWHFQ psychosocial subscore (r = 0.57, P = .002). The difference between peak RPE-MLWHFQ physical subscore and peak RPE-MLWHFQ psychosocial subscore r values did not reach statistical significance (z = 0.35, P = .73).

 

Conclusions:

These results indicate subject interpretation of peak RPE was not universal in this group of patients with HF. Poorer perceived quality of life (both physical and psychosocial aspects) equated to a higher peak RPE. These findings possibly have implications for how the RPE is interpreted and used for exercise prescription in the HF population.

 

THE IMPACT OF CARDIAC REHABILITATION ON PATIENT SURVIVAL

James A. Stone, BPHE, BA, MSc, MD, PhD, FRCPC; Allan Brown; Hussein Noorani; Rod Taylor; Canadian Coordinating Office for Health Technology Assessment; University of Birmingham, UK

 

Background:

Cardiac rehabilitation (CR) programs can significantly reduce cardiac mortality. In addition, CR programs are highly cost-effective in the treatment of cardiovascular disease (CVD). Despite these scientifically validated outcomes and economic advantages, many clinicians remain reluctant to refer patients for CR.

 

Methods:

Using population information from the United States and Canada and CVD information from the Centers for Disease Control and Prevention (CDC), it is possible to estimate the potential number of patients in North America who could benefit from CR. Data on the effects of CR on mortality was obtained from the current scientific literature.

 

Results:

The prevalence of CVD in North America is currently estimated by CDC at 25% of the overall population or more than 75,000,000 people. Expert opinion suggests that only 50% of CR eligible patients will attend CR programs if referred. Thus, almost 38,000,000 of North Americans could benefit from CR. The most recent estimates on the mortality benefits of CR indicate a 25% to 31% reduction in low-risk CVD populations enrolled in CR programs. Consequently, incorporation of CR programs as truly standard care for CVD patients could save 1,900,000 to 2,356,000 lives per year in low-risk populations throughout North America.

 

Conclusion:

The provision of CR as standard care significantly reduces the number of untimely cardiac deaths in North America. Presently, the life prolonging impact of CR has been broadly researched in only relatively low-risk CVD populations. Pre-program risk stratification and the preferential enrollment of high and very high-risk patient populations in CR programs should further enhance the mortality benefits of CR. Thus, the incorporation of CR in higher risk populations should further improve the already highly cost-effective value of CR. Similarly, the inclusion of higher risk populations in CR should further reduce the number of patients needed to treat to realize significant clinical and economic benefits.

 

AN INVESTIGATION OF DEPRESSION SCREENING AND TREATMENT IN THE CARDIAC REHABILITATION SETTING

Charles Stimler; Steven W. Lichtman; Scott D. Crespy; NYSAC&PR Helen Hayes Hospital

 

Rationale:

Patients with heart disease often have depressive disorders. Depression after MI increases risk of a subsequent MI and cardiac mortality. However, limited data are available concerning the diagnosis of depression in cardiac rehabilitation and its subsequent treatment.

 

Objectives:

The purpose of the present study is to: determine the proportion of patients who receive an adequate method of depression screening during cardiac rehabilitation; increase the number of depressed cardiac patients who are successfully identified; and establish effective referral networks and/or develop on-site treatment strategies.

 

Methods:

The study will have 2 phases. In phase 1, an abstraction will be performed on 25 cardiac rehabilitation charts to determine: if a depression screening was performed, and if so, was the screening tool valid; the proportion of patients with a positive screening who received referral or treatment. Phase 2 will consist of the distribution of a depression tool kit to include validated screening tools, scoring thresholds and patient/staff educational materials. A chart abstraction 1 year later will determine the increase in use of proper depression screening tools and adequate referral for treatment. Seventy-three cardiac rehabilitation programs in New York State are participating.

 

Results:

Phase 1 results of the first 40 centers, totaling 840 charts, are presented: 19% of the facilities asked at least one intake question or observed for depression, 43% used an un-validated measure, 28% used an instrument that is considered "weakly" validated, 11% used a fully validated depression screener, 3% used DSM-IV interviews, 15% (126/840) of patients received a valid screening for depression. The proportion of patients with a positive valid screening for depression that received appropriate referral or treatment was 15% (29/193).

 

Conclusion:

Few patients receive valid screening for depression and subsequent referral for treatment. Phase 2 will determine if implementation of a depression education program for cardiac rehabilitation facilities can improve detection and treatment of depression in these patients.