12:45 PM-2:15 PM Thursday, September 8, 2011

RESEARCH COMMITTEE

Scientific Oral Presentations

Beginning Investigator Presentations

REPEAT ENROLLMENT INTO CARDIAC REHABILITATION FOLLOWING CORONARY EVENTS

Sanjay Maniar, MD; Bonnie Sanderson, RN, PhD; Vera Bittner, MD, MSPH

Primary institution where research was conducted: University of Alabama-Birmingham School of Medicine

Introduction: Cardiac rehabilitation (CR) among patients with coronary heart disease (CHD) has proven benefits for individuals completing CR programs. However, over 40% of patients enrolled in CR fail to complete their program. A fraction of individuals who fail to complete CR experience subsequent coronary events which require repeat enrollment into CR.

Purpose: The purpose of the present study is to: (1) investigate baseline clinical characteristics at index admission between single enrollees and repeat enrollees into CR programs, and (2) examine the differences between repeat enrollees who are initial completers versus those who are initial non-completers of CR.

Design: This study is a retrospective analysis of patients enrolled from January 1996 to September 2009 in a CR/secondary prevention program based in an academic medical center.

Methods: Data from patient records (n = 1558, 32% women, 36% non-white) collected between January 1996 and September 2009 were examined. Initial comparisons were made between "single enrollees" (n = 1385) and "repeat enrollees" (n = 163) for baseline demographic and clinical characteristics at index admission. Repeat enrollees were sub-categorized into "initial completers" (n = 99) and "initial non-completers" (n = 64). Sub-analyses were conducted among repeat enrollees to investigate the differences between "initial completers" and "initial non-completers."

Results: Compared to single enrollees, repeat enrollees had poorer blood pressure control, more depressive symptoms, higher hemoglobin A1C levels (when diabetes was present), and more co-morbidities (all p < 0.05) at index admission. Among repeat enrollees, initial non-completers were younger, more obese and entered CR with more co-morbidities (all p < 0.05). When initial completers entered CR for repeat enrollment, they had lower hemoglobin A1C levels (when diabetes was present, p < 0.01), better lipid profiles (lower total cholesterol, lower LDL and lower non-HDL cholesterol, all p < 0.001), and lower diastolic blood pressure (p < 0.01). In comparison, initial non-completers demonstrated no significant differences upon repeat enrollment when compared to their index enrollment. Initial completers re-entered CR 3.3 years following their initial admission, compared to 2.0 years among initial non-completers.

Conclusions: Repeat enrollees into CR demonstrate worse risk factor profiles compared to single enrollees. Initial completers re-entered CR with higher proportions achieving secondary prevention goals except for blood pressure control. Initial non-completers re-entered CR with no significant changes in proportion at secondary prevention goal. This study illustrates that sustainable benefits of CR are achieved and emphasizes the importance of patients completing CR programs.

THE SAFETY, FEASIBILITY, AND EFFECTIVENESS OF EARLY PHYSICAL THERAPY FOR CRITICALLY ILL CARDIAC PATIENTS IN CARDIAC INTENSIVE CARE UNIT

Maki Ono, MD; Naonori Tashiro, PT; Ryota Iwatsuka, MD; Yuji Hashimoto, MD

Primary institution where research was conducted: Kameda Medical Center

Introduction: Recently, early mobilization has been shown to be feasible, effective, and safe in critically ill patients at intensive care units. Critically ill cardiac patients, however, are limited of their activity because of IABP or PCPS insertion or specificity of their diseases such as myocardial infarction or heart failure with which bed rest are believed to be important.

Purpose: To assess the safety, feasibility, and effectiveness of early physical activity and mobilization in critically ill cardiac patients.

Design: Prospective quality improvement study in a tertiary medical care center in Japan that assessed the safety and effectiveness of early mobilization.

Methods: Patients stayed at cardiac intensive care unit at Kameda Medical Center, Japan, for more than 48 hours were included for this study. Patients with acute stroke, or withdrawal of treatment within 48 hours, and patients on critical pathways for acute myocardial infarction without any complications were excluded. For control group (24 patients from September to October 2010), physical therapy was ordered depending on the doctors in charge. From November 2010, every morning cardiac care team members, including doctors in charge, physical therapists, nurses, pharmacists, and nutritionists started assessment of all the patients staying at cardiac intensive care unit more than 48 hours for the early mobilization. For intervention group (33 patients from November 2010 to January 2011), physical therapy was ordered by the assessment at the meeting every morning when there were no exclusion criteria met.

Results: Baseline characteristics were similar between two groups. Control group received physical therapy at 20.0% and Intervention group at 57.9% (P = 0.02). There were no serious adverse events, such as hypotension (systolic blood pressure <70 mmHg), arrhythmia, desaturation, fall to knees, or endotracheal tube removal during physical therapy for both groups. There were no significant differences between groups of the amount of vasopressor/inotropes at initiation of therapy, the percentage of delirium or pressure ulcers, or the length of stay at cardiac intensive care unit or hospital, the percentage of decrease of ADLs, and the Barthel Index at discharge, or VO2 at anaerobic threshold or peak VO2 at discharge.

Conclusions: Early mobilization of critically ill cardiac patients can be carried out safely without serious adverse events. Assessing the patients everyday for early mobilization is necessary for increasing the percentage of physical therapy order. We must continue this study for the further evaluation of the effectiveness of early mobilization.

RELATIVE CONTRIBUTION OF DEPRESSION, ANXIETY AND HOSTILITY TO MORTALITY IN STABLE CORONARY PATIENTS FOLLOWING FORMAL CARDIAC REHABILITATION PROGRAMS

Alban De Schutter, MD; C Lavie, MD; R Milani, MD

Primary institution where research was conducted: Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine

Introduction: We and others have demonstrated the high prevalence of psychological risk factors in cohorts with coronary heart disease (CHD) and the benefits of cardiac rehabilitation (CR) on these factors and major clinical prognosis.

Purpose: We examined the relative mortality contribution of depression, anxiety and hostility after completion of cardiac rehabilitation.

Design: We examined levels of depression, anxiety and hostility in a large CHD cohort who completed cardiac rehabilitation (CR).

Methods: We studied 539 patients with CHD following major CHD events who had completed formal CR. Using validated questionnaires, a level stress was measured in one of three domains: anxiety, hostility and depression. Subjects were divided into 4 groups: stress-free (N = 502), depression alone (N = 7), depression with anxiety or hostility (N = 21), and subjects with all three (N = 8). A multivariate analysis for mortality was performed using a composite psychosocial stress score (PSS;sum of scores for anxiety, depression, and hostility.) Subjects were analyzed by total mortality over 3-year follow-up by National Death Index.

Results: Mortality was highest in the anxious-depressed-hostile group (38%; P < 0.0001 compared with all other groups.) There was no difference in mortality between the depression alone vs the depression with anxiety or hostility group, both had mortalities significantly higher than the stress free group (14% vs 3%; p < 0.0001).Correcting for age, peak oxygen consumption, and ejection fraction (all independent predictors of mortality) and gender, PSS (OR 1.89;CI 1.03-3.44) was a strong independent predictor of mortality following CR.

Conclusions: Psychosocial stress is an independent predictor of mortality in stable CHD patients following CR. Depression seems to be the most important risk factor in this cohort, regardless of whether accompanied by anxiety or hostility. Patients with persistent depression following CR may need further intervention.

IMPLEMENTATION OF A COMPUTERIZED, AUTOMATED REFERRAL SYSTEM IN IMPROVING PARTICIPATION RATES TO OUTPATIENT CARDIAC REHABILITATION

Sheryl Brown, PT, MSPT

Primary institution where research was conducted: Texas Health Presbyterian Hospital, Fitness Center

Introduction: Despite American College of Cardiology and American Heart Association performance measures which state that patients with a primary diagnosis during hospitalization of chronic stable angina, MI, CABG, valve surgery, or cardiac transplantation are to be referred to an outpatient cardiac rehabilitation program, it has been well-established that both referral and participation rates in Phase II Cardiac Rehabilitation after hospitalization are low. To enhance participation to a broader population of patients, an automated, computerized referral system was implemented in a large, multi-hospital system.

Purpose: To determine the efficacy of an automated, computerized referral system as compared to a traditional, non-automated referral strategy.

Design: Systematic review with analysis of referral data pre and post intervention via a manual tracking method.

Methods: Referral and enrollment rates to Phase II Cardiac Rehabilitation were analyzed before and after implementation of the computerized, automated referral system. Enrollment and participation data was tracked manually over an eight month period through utilization of a computerized database.

Results: Prior to implementation of the automated, computerized system, an average of 58 patients per month were referred to outpatient cardiac rehabilitation after hospitalization following an MI, CABG, heart valve surgery or PTCA procedure via a traditional referral strategy. Of these, only 12 patients per month enrolled in the outpatient cardiac rehabilitation program (20.6% participation rate). After implementation of the automated, computerized system, an average of 200 referrals per month were received (increased referral rate by 243%). When sorted to exclude inappropriate patients (i.e.: those out of town or with an inappropriate diagnosis), enrollment increased to average 20 patients per month, which was a 67% increase.

Conclusions: The implementation of a computerized, automated referral system significantly improved physician referral and patient enrollment rates. The results of this study support broad implementation of automated referral systems in providing evidence-based care to a wider population of patients.

4:45 PM-5:45 PM Friday, September 9, 2011

Scientific Oral Presentations

Pulmonary Presentations

THE RELATIONSHIP BETWEEN BASELINE DEPRESSIVE SYMPTOMS AND SIX MINUTE WALK TEST PRIOR TO PULMONARY REHABILITATION

Maria Buckley, PhD; Sidney S. Braman, MD; Justin Nash, PhD; Cerissa Blaney, MA; Jacqueline F Pierce, PT

Primary institution where research was conducted: The Miriam Hospital

Secondary institution where research was conducted: Brown University

Introduction: Pulmonary rehabilitation (PR) is a multidisciplinary program to improve the physical and psychological functioning of patients with chronic lung disease. The impact of depressive symptoms on exercise performance in pulmonary rehabilitation patients is relatively unexplored.

Purpose: The goal of this study was to determine whether baseline depressive symptoms predicted a shorter distance walked during the six minute walk test (6MWT) upon entry to a pulmonary rehabilitation program (PRP).

Design: This study was a retrospective consecutive chart review of patients enrolled in an outpatient PRP of a university-affiliated teaching hospital.

Methods: We administered the Geriatric Depression Scale (GDS) to patients who were age >55 years. We determined the diagnosis, gender, age, race and FEV1 at baseline. We conducted a univariate ANCOVA to analyze between group (depressive vs. nondepressive) differences in pre-treatment 6MWT with FEV1 as the covariate.

Results: The sample in this study included forty-four females and forty-four males. The analyses included those patients who had complete data. The most common diagnosis was COPD. 38.6% (n = 34) patients presented with positive depressive symptoms at baseline (i.e., had a score of at least 11 on the GDS). For this group (x = 16.4, sd (4.8) the mean distance walked was 798.06 (sd = 366) at baseline. The 54 patients without depressive symptoms (x = 5.2, sd (3.1) walked 819.58 feet (sd = 354) prior to rehabilitation. Baseline depressive symptoms did not appear to predict statistically significant differences in 6 MWT (F(1,58) = .014, p = .91). FEV1 was not significantly related to distance walked in 6 MWT.

Conclusions: Our hypothesis that depressive symptoms predict differences in baseline 6MWT was not supported in this investigation. However, variables such as disease severity, medication use, clinical diagnosis of depression and active behavioral treatment for depression were not examined. The literature regarding the impact of depressive symptoms on exercise performance is limited. A more comprehensive look at depression and related factors in this medically complicated population is warranted to more fully understand the relationship between depression and exercise capacity.

CHANGES IN A PULMONARY REHABILITATION PROGRAM AFTER THE NEW MEDICARE RULES

DorAnne Donesky, PhD, RN; Angela Halpin, RN; Debi Knotts, RCP; Christine Tacklind, RN; Paul Selecky, MD

Primary institution where research was conducted: UCSF

Secondary institution where research was conducted: Hoag Hospital

Introduction: Prior to 2010, the established pulmonary rehabilitation (PR) program at our community hospital was 4 weeks, the majority of patients had very severe COPD with co-morbidities, physical therapy supervised the exercise, and there was no maintenance program. As a result of Medicare changes in 2010, respiratory therapists now supervise exercise, and the duration increased to 6 weeks. In addition, a maintenance program was initiated, and referral diagnoses broadened to include less severe disease and diagnoses other than COPD.

Purpose: Compare patient baseline demographics and changes in perceived health, dyspnea, functional performance, and health care utilization as a response to PR in patients who attended PR before and after the changes of 2010.

Design: Longitudinal observational design with repeated measures.

Methods: A brief questionnaire that included demographics and perceived health, dyspnea, functional performance and health care utilization was administered prior to beginning PR and again at the end of PR and at 6 and 12 months following PR. Subjects who participated in PR prior to February, 2010, when the Medicare changes were implemented (n = 45; "early group") were compared to those who participated February to June, 2010 (n = 26; "recent group"). Baseline characteristics were compared between the 2 groups using one-way ANOVA for continuous variables and Chi square for categorical variables. Differences over time between the 2 groups were analyzed using linear mixed models.

Results: Patients were similar in demographics and baseline characteristics, except for a higher heart rate after baseline six minute walk test (97 vs. 88 beats/min, p < .05), higher FVC (84 vs. 73%, p < .05), and less health interference with chores and errands (p < .05) in the recent group. There was a trend toward younger age (72 vs. 75) and less shortness of breath (3.0 vs. 3.8 on Borg) in the recent group (p = .09). The early group improved more than the recent group in health interference with hobbies and household chores (p < .05), and in 6MW distance (199 vs. 66 ft; p < .05) after PR. Both groups improved after PR in general health, dyspnea, adherence to endurance and strengthening exercise, and health care utilization (p < .05).

Conclusions: This data confirms previously reported benefits immediately after participation in a pulmonary rehabilitation program that decline over time. Future evaluation of confounding variables such as depression or anxiety, medication adherence, comorbidities, and the effect of the maintenance program on health outcomes may explain the differences between the two groups.

PREDICTIVE EQUATIONS DO NOT ACCURATELY ESTIMATE OXYGEN CONSUMPTION DURING EXERCISE.

Francois Haas, PhD; Jonathan Whiteson, MD; Ana Mola, MA, RN, ANP-BC, CTTS; Greg Sweeney, PT; Ying Tang, MA

Primary institution where research was conducted: The Joan and Joel Smilow Cardiac Rehabilitation and Prevention Center of the Rusk Institute of Rehabilitation Medicine NYU Langone Medical Center

Introduction: Oxygen uptake-considered the primary limiting factor to exercise-is typically estimated from prediction equations relating treadmill performance to VO2 (i.e., VO2peak and METs) rather than direct VO2 measurement. Despite their consistent use there is a dearth of evidence confirming the accuracy of these equations.

Purpose: To evaluate the accuracy of commonly published prediction equations for VO2 during treadmill stress tests

Design: Comparison of measured VO2 with predicted values from commonly used equations

Methods: VO2peak derived from the: ASCM-2000, Wasserman et al, Bruce, Bruce (ACTIVE), Bruce (SEDENTARY), Inbar, and Drinkwater equations, and the ACSM recommended equation for submaximal VO2 were compared to the measured peakVO2 and VO2 attained for stage I-III of the Bruce protocol in 63 healthy subjects using Bland-Altman comparison calculations and ANOVA followed by Dunnett's multiple comparison test.

Results: Men and women were of similar age, ranging from 19 to 61 years . Average BMI was 24.7 for men, and 21.9 for women. Men and women exercised to heart rates of 187 and 180 bpm, for 15.3 and 14.1 min, respectively, which is 130% and 146%, respectively, of their age-predicted maximum. Bland-Altman calculations demonstrate a large 95% limit of agreement, indicating that the differences between actual and predicted values are unacceptably high for all equations . In addition, equations that were not gender specific, i.e., the Foster and the Bruce time-based equations, the overestimation for women VO2 (ml/kg/min) was significantly higher than for men (Foster: men: 9.34 +/- 8.4, women:13.95 +/- 7.91, t = 2.210, P = 0.03; Bruce: men: 7.22 +/- 8.44, women: 11.64 +/- 7.5, t = 2.177, P = 0.03). Two-way ANOVA indicates that, the measured METs at the 3 stages of the Bruce protocol were significantly lower than that predicted by the recommended ACSM walking equation (9) (P < 0.001), and the estimated MET values increased significantly more per stage than the directly measured values (3.0 METs/stage vs. 2.0 METs/stage, P < 0.02).

Conclusions: These data emphasize that no evaluated equation accurately estimates VO2peak or submaximal VO2, raising significant concern regarding the standard reliance on estimating VO2 or METs for treadmill performance from predictive equations. This lack of agreement partially reflects the distortions created by isolating a limited number of variables from the integrated complex of processes required to sustain exercise. Therefore, in those situations in which more precise knowledge of exercise capacity limitations is important, VO2 should be reported from direct measurements rather than derived from an estimate.

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION SLUGGISH PULMONARY O2 UPTAKE KINETICS AND SPEEDS HEART RATE KINETICS

Fernanda Priore Tomasi; Vinicius M da Silva, MD; Marianne L da Silva; Gerson C Junior, PhD; Gaspar R Chiappa, PhD

Primary institution where research was conducted: Universidade de Brasilia, UnB

Secondary institution where research was conducted: Universidade Federal do Rio Grande do Sul, UFRGS

Introduction: Previous data have suggested that ganglion applied Transcutaneal electrical stimulation (TENS) attenuates sympathoexcitatory reflex, and it influences coronary blood flow and collateral perfusion in healthy subjects. However, it is currently unknown the effects of TENS in pulmonary oxygen uptake kinetics in healthy subjects.

Purpose: This study aims to investigate the effects of ganglion TENS in Pulmonary O2 uptake (VO2p) kinetics and exercise responses in healthy subjects during heavy-intensity constant-work rate exercise.

Design: Randomized observational study.

Methods: 10 healthy subjects (21.3 +/- 2.4 years) participated in this study. All participants performed ramp-incremental exercise test (20 W/min) to determine parameters of aerobic function during exercise braked cycle ergometer at 60 rpm. The individuals performed a constant work test (CWT) in two separate days with Conventional TENS (Adhesive electrodes placed on each side of the vertebral process at C7 and T4, two separate channels, with frequency 80 Hz, pulse duration 150?s, and intensity was increased from zero until the perceived sensation, during 40 minutes) and Placebo TENS (just Adhesive electrodes placed on each side). Tlim, time constant (? (s)), heart rate (HR), time delay (TD) and oxygen uptake (VO2p) were measures during CWT. In order to contrast between-subject resting and exercise responses, non-paired t or Mann-Whitney tests were used as appropriate. One-way analysis of variance (ANOVA) was used to contrast MRT values: a post-hoc analysis was performed with Scheffe test. Pearsones product moment correlation was used to assess the level of association between continuous variables. The level of statistical significance was set at p < 0.05 for all tests.

Results: Analyses of VO2p kinetics data showed higher time constant (?) (placebo TENS, 37.61 +/- 14.85 versus conventional TENS, 45.06 +/- 14.74; p < 0.05), indicating slower kinetics during TENS condition. Baseline HR was statistically lower when TENS was applied, but its amplitude at the onset of heavy-intensity constant-work rate exercise reached greater levels. In contrast, HR value at Tlim was higher when TENS placebo was applied (TlimHR: placebo, 195 +/- 14 versus TENS, 186 +/- 10; p < 0.05). Tlim was statistically higher for TENS condition when compared to placebo condition (p = 0.045).

Conclusions: Ganglion applied TENS increased time constant of pulmonary oxygen uptake and resulted in greater amplitude of HR during heavy-intensity constant-work rate exercise. Further investigations should be considered to elucidate our results and VO2p kinetics responses to ganglion applied TENS responses.

8:00 AM-9:30 AM Friday, September 9, 2011

Scientific Oral Presentations

Cardiac Presentations

WHEN ESTIMATES OF MAXIMAL MET LEVELS ARE TOO HIGH FOR CARDIAC PATIENTS

Michael Manfre, MEd; Jorge Secchi, MD; Sue Palo, RN, MA, BC; Elizabeth Haag, RN; Simcha Pollack, PhD; Nathaniel Reichek, MD

Primary institution where research was conducted: St. Francis Hospital-The Heart Center

Secondary institution where research was conducted: St. Johns University

Introduction: Holding on to the front handrail during a treadmill test is known to increase treadmill time and subsequently inflate the METmax estimate. If this estimate exceeds the measured METmax by >2 METS, the recommended intensity of exercise training in cardiac rehabilitation (CR) exceeds safety guidelines. If the METmax is overestimated at >9, some insurance plans may unknowingly limit the number of Phase II sessions.

Purpose: In treadmill tests of CR patients with a METmax estimate >9, the difference between the measured and estimate METmax will be >2.0 METS in more than 90% of the tests. When handrail support is limited, total treadmill time will decrease enough so that the predicted METmax will not be significantly different than the measured METmax.

Design: One treadmill test with and one test without measured oxygen were administered to CR patients

Methods: Patients referred for CR with a preprogram Bruce protocol treadmill test (EST) negative for ischemia and an estimated METmax >9 were tested for this study using the same protocol, but with measured oxygen uptake and handrail support limited to the tips of 2-3 fingers of one hand (CPxLH). Descriptive statistics, Paired t-test and multiple regression analysis were employed.

Results: Twenty-four male patients (age 56.4 + 9.8 years) had an EST average estimated MET level of 10.65 + 1.1. The average CPxLH measured METmax was significantly lower (P < 0.01) at 6.75 + 1.2 METS at the same percent of predicted maximal peak heart rate (87%). No patient reached a measured METmax of > 9 and the difference between the estimated and measured METmax was > 2 METS in 91.7% of the patient group. Mean EST time was 9.0 + 1.1 minutes. The CPxLH treadmill time was significantly shorter at 7.4 + 1.4 minutes (P < 0.01). Based on the estimated METmax from the CPxLH treadmill time, the difference between the measured and the estimated METmax using the Bruce Cardiac equation was, by regression analysis, indistinguishable.

Conclusions: The difference between the EST estimated and CPxLH measured METmax was > 2 METS in 91.7% of the patient group. Mean EST time was 9.0 + 1.1 minutes. At the same peak heart rate this time was reduced to 7.4 + 1.4 minutes when handrail support was limited to the tips of 2-3 fingers of one hand. METmax can be predicted using limited handrail support making recommendations for activity intensity safer.

LONG-TERM EFFECTS OF LIFESTYLE INTERVENTION ON WEIGHT LOSS MAINTENANCE IN INDIVIDUALS WITH CORONARY HEART DISEASE: A RANDOMIZED STUDY

Patrick D. Savage, MS; Elizabeth F. Pope, MS; Maryann Ludlow, RD; Jean Harvey-Berino, RD, PhD; Michael J. Toth, PhD; Janice Y. Bunn, PhD; David J. Schneider, MD; David W. Brock, PhD; Philip A. Ades, MD

Primary institution where research was conducted: Fletcher Allen Health Care

Secondary institution where research was conducted: University of Vermont

Introduction: Lifestyle interventions produce short-term weight loss and improvements in cardiovascular risk factors in patients with coronary heart disease (CHD). The effects of these interventions on long-term weight loss maintenance are less well known.

Purpose: We evaluated the effects of an intensive intervention of exercise and behavioral strategies on long-term weight loss maintenance.

Design: Randomized trial.

Methods: We compared the effects of 4-months of high-caloric expenditure exercise (HCEE) (N = 30, Males = 23) or standard cardiac rehabilitation (CR) exercise (N = 30, Males = 25) on weight loss in overweight patients with CHD. Caloric expenditure goal for HCEE was 3500 vs 800 kcal/week for standard CR. Both groups received weekly behavioral weight loss counseling with a goal of achieving a caloric deficit of 3500 kcal/week. Behavioral counseling sessions were provided monthly between 4-months and 1-year and none thereafter. While no formal exercise program was provided after the 4-month intervention, participants were encouraged to maintain their training regimen. Body weight was measured at baseline, 4-months, 1-year and annually through 4-years. Statistical methods included analysis of variance for repeated measures, nonpaired t-test and Pearson correlations.

Results: Mean baseline age and BMI for the entire cohort were 65 + 9 years and 33 + 7kg/m2, respectively. Study groups were similar by demographic and physical characteristics. At 4-months, the combined study groups experienced a mean weight loss of -6.3 + 5.1 kg (P < 0.001). HCEE exercise resulted in significantly more weight loss than the standard CR (-8.4 + 4.5 vs -4.1 + 4.8kg) (P < 0.0006, between groups). For the overall study population, mean weight loss at 4-years was -1.6 + 5.7kg, P < 0.04. Mean weight loss at 4-years for the HCEE and standard CR groups, respectively, was -2.6 + 5.1kg (P < 0.01) and -0.6 + 6.4kg (P = 0.59) (P = 0.20, between groups). When groups were combined, correlates of weight loss maintenance were self-reported adherence to exercise at 4-years (r2 = 0.24), baseline score on the Physical Activity Enjoyment Scale (r2 = 0.16), change in level of physical activity (as measured by accelerometer) from baseline to 4-months (r2 = 0.07), and compliance with the exercise during the 4-month intervention (r2 = 0.06) (all, p < 0.05). Baseline score of the Physical Activity Enjoyment Scale and adherence to exercise at 4-years were the only independent predictors of weight loss maintenance at 4-years (adjusted R2 = 0.37, p < 0.0001).

Conclusions: Short-term, intensive behavioral lifestyle intervention results in modest but significant long-term weight loss. Independent predictors in weight loss maintenance were self-reported compliance to exercise training and a positive perception of physical activity. Future research is needed to determine if more comprehensive long-term follow-up will assist in decreasing recidivism.

WHY DO NORTH CENTRAL STATES HAVE THE HIGHEST, AND SOUTHERN STATES THE LOWEST RATES OF CARDIAC REHABILITATION PARTICIPATION?

Philip A. Ades, MD; Stephen T. Higgins; Patrick D. Savage; Jose A. Suaya; Donald S. Shepard

Primary institution where research was conducted: University of Vermont

Secondary institution where research was conducted: Schneider Institutes for Health Policy, Heller School, Brandeis University

Introduction: Wide geographic variations in Cardiac Rehabilitation (CR) participation in the United States have been demonstrated by analysis of 1997 Medicare data. These state by state variations have not been explained. Educational attainment as measured by high school (HS) graduation rates is a robust predictor of many health-related behaviors and outcomes including smoking, obesity, physical activity, substance abuse, cardiovascular disease and premature death.

Purpose: We analyzed the role of educational attainment and other socioeconomic and demographic health indicators on geographic variations by state in CR participation.

Design: Retrospective database analysis.

Methods: Data sources included the U.S. Census Bureau, the Centers for Disease Control and the Medicare database from 1997. Data were analyzed using linear regression analysis with CR participation rates by state as the dependant variable. Independent variables included state values for HS graduation rates (%), mean household income divided by cost of living index, smoking rates, density of CR program (programs per square mile and programs per state population) and median age.

Results: HS graduation rate ranged from 54% (Georgia) to 93% (Iowa). The relationship between HS graduation rate and CR participation by state was strong (R = 0.64, P < 0.0001). HS graduation and CR participation rates were highest in North Central states and lowest in Southern states. This relationship was unaltered by adding mean household income, smoking rates, density of CR programs (per sq miles) or median age into the analysis. Adding the density of CR programs (per population) added further predictive value with an added partial correlation of 0.07 to a cumulate R value of 0.71, P < 0.0001.

Conclusions: HS graduation attainment by state was strongly and positively associated with variations in CR participation rates. To a lesser degree, the availability of CR programs expressed as programs per population was also correlated with state by state CR participation. Educational attainment is a powerful predictor of state by state variations in CR utilization.

INFLUENCE OF PHYSICAL TRAINING IN THE HEART RATE RECOVERY IN PATIENTS WITH CORONARY ARTERY DISEASE

Hermes L Ilarraza, MS; Eleonora Montenegro, MD; Ricardo E Romo, MD; Jesus Alonso, MD; Alejandro Almaraz, MD; Jesus B Vargas, MD.

Primary institution where research was conducted: National Institute of Cardiology Ignacio Chavez

Introduction: The heart rate behavior during a stress test can be an independent predictor of mortality among patients with heart disease. Exercise therapy in this kind of patients had demonstrated that can reduce mortality, and this could be due, in part, to the improvement of the heart rate behavior.

Purpose: The aim of the study was to compare the heart rate recovery, between a deconditioning and an exercise training periods, in patients with coronary artery disease.

Design: Longitudinal, prospective, prolective, non randomized, self-controlled, and open study.

Methods: Thirty five patients with coronary artery disease, that were referred to a cardiac rehabilitation program, were included. At the beginning all of them performed a symptoms-limited stress test (baseline). Then, they were advised to not exercise, and after a 4 weeks period, a second stress test was made. This was taken as the control group (deconditioning period). After this, the same patients started to participate in a hospital-based cardiac rehabilitation program, and were included to an intensive 4 weeks program of aerobic training, 30 minutes daily, with a moderate rate of perceived exertion and prescribing the target heart rate using the Karvonen formula (70%). Finally, the 3rd stress test was performed. Heart rate recovery was defined as the difference, in beats per minute (bpm), between the heart rate at maximal exercise and at the first minute of recovery. A Student's t test for repeated measures was carried out to calculate the statistical differences of means. We established as a stochastic difference, all those p values equal or less to 0.05.

Results: Initially, after a 4 weeks of physical inactivity, the heart rate recovery decreased, without stochastically significance, from 15.4 +/- 7 bpm to 14 +/- 8 bpm (p = 0.18), but once these patients have trained during a similar lapse of time, the heart rate recovery improved significantly from 14 +/- 8 bpm to 15.8 +/- 8 bpm (p = 0.04).

Conclusions: A four weeks program of aerobic and moderate physical training can increase the heart rate recovery in patients with coronary artery disease.

OPTIMAL EXERCISE PROGRAM LENGTH FOR PATIENTS WITH CLAUDICATION: A RANDOMIZED CONTROLLED TRIAL

Andrew W. Gardner, PhD; Polly S. Montgomery, MS; Donald E. Parker, PhD

Primary institution where research was conducted: University of Oklahoma Health Sciences Center

Introduction: Supervised exercise programs are efficacious for clinical management of patients with peripheral artery disease (PAD) and claudication, as improvements for claudication onset time (COT) and peak walking time (PWT) are noted. However, the optimal program length for improving COT and PWT has received little attention.

Purpose: To determine whether an optimal exercise program length exists to efficaciously change COT and PWT in subjects with PAD and claudication undergoing a 6-month exercise rehabilitation program. We hypothesized that COT and PWT improve in a progressive fashion with increasing exercise volume during 6-months of rehabilitation.

Design: Prospective, randomized controlled clinical trial.

Methods: 142 patients were randomized to either supervised exercise (n = 106) or to usual care control (n = 36) in a 3:1 ratio, 83 completed the exercise program and 24 completed usual care control. The exercise program was six months in length, and consisted of intermittent walking to near maximal claudication pain three days per week, with progressive increases in exercise duration 15 minutes per session at the beginning of the program to 40 minutes per session by the end. COT and MWT were obtained from a treadmill exercise test at baseline and bi-monthly during the study.

Results: Mean adherence to supervised exercise was 74%. During the 6-month exercise program, patients walked on the treadmill for a duration of 24 +/- 5 min/session (mean +/- SD) at an intensity of 3.5 +/- 0.7 MET/min, yielding a total exercise volume of 4815 +/- 2705 MET-min. The change in COT (p < 0.001) and PWT (p < 0.001) following exercise were greater than the changes following usual care control. In the exercise program, PWT increased from baseline (431 +/- 243 m) to month 2 (651 +/- 267 m) (p < 0.05), further increased from month 2 to month 4 (711 +/- 286 m) (p < 0.05), and did not change from month 4 to month 6 (746 +/- 297 m) (p > 0.05). Similar changes were noted in the exercise group for COT.

Conclusions: This prospective, randomized controlled trial demonstrates that a 6-month program of exercise rehabilitation improves COT and PWT in patients with PAD and claudication. Furthermore, COT and PWT increase through the first four months of exercise rehabilitation, with minimal change occurring during the final two months. The efficacy of supervised exercise to improve COT and PWT primarily occurs during the first four months of rehabilitation.

GENDER-SPECIFIC EFFECTS OF DAILY FUNCTIONAL TRAINING COMPARED TO STANDARD CARDIAC REHABILITATION (CR) ON STRENGTH AND MAXIMAL EXERCISE CAPACITY IN VERY OLD PATIENTS EARLY AFTER BYPASS SURGERY (CABG)

John JC Busch; Janina Placke; Detlev Willemsen, MD; Birna Bjarnason-Wehrens, Professor

Primary institution where research was conducted: Schuchtermann-clinic, Bad Rothenfelde, Germany

Secondary institution where research was conducted: German Sports University, Institute of Cardiology and Sports Medicine, Cologne, Germany

Introduction: Very old patients after CABG surgery are more frequently referred to CR. There is no distinction between genders in therapy.

Purpose: To evaluate whether daily functional training compared to standard CR has got gender-specific effects on strength and maximal exercise capacity in very old patients who participated in in-patient CR early after CABG surgery.

Design: It's a single centre prospective randomized controlled trial.

Methods: N = 173 patients = 75 years old (mean age 78.5+/-3.2 years) were randomly assigned to either an intervention group (IG, additional to standard CR daily strength and balance training) or a control group (CG, standard CR). N = 23 patients dropped out for reasons not referred to CR. Thus n = 150 patients have been analysed: IG (n = 73, m/f; 51/21), CG (n = 78, m/f; 54/24). All patients participated on average 20.4+/-3.2days in an in-patient CR 13.1+/-5.3days post surgery. Strength training consisted of 4 exercises, one set of 8-12 repetitions at 60% of 1 Repetition Maximum. A symptom limited cardiopulmonary exercise test and an isometric strength measurement for legs were used to evaluate VO2 peak, maximal exercise capacity and strength. Statistical analyses have been conducted using ANOVA.

Results: Women showed in VO2peak and strength significant lower results (p < 0.01) but not in Watt/kg (p>0.05). Both groups and genders improved VO2 peak significantly by the CR (p < 0.001), IG men from 11.7+/-2.2 to 14.2+/-2.8ml/min/kg; IG women from 9.0+/-2.9 to 11.9+/-2.7ml/min/kg and CG men from 12.1+/-2.7 to 14.3+/-3.1ml/min/kg; CG women from 10.4+/-2.1 to 11.6+/-2.9ml/min/kg. Similar results showed Watt/kg (p(time) < 0.001): IG men from 0.53+/-0.16 to 0.72+/-0.20Watt/kg, IG women from 0.46+/-0.14 to 0.65+/-0.33Watt/kg and CG men from 0.60+/-0.18 to 0.74+/-0.20Watt/kg, CG women from 0.49+/-0.12 to 0.60+/-0.14Watt/kg. No difference between men and women appeared (interaction VO2peak IG: p = 0.627, CG p = 0.124, interaction Watt/kg IG p = 0.967; CG p = 0.225). In strength only men improved: IG men from 367.3+/-125.0 to 435.1+/-147.6Nm; IG women from 234.8+/-88.9 to 258.2+/-98.3Nm and CG men from 335.2+/-114.2 to 403.2+/-145.5Nm; CG women from 217.3+/-82.6 to 222.0+/-83.3Nm.

Conclusions: CR is highly efficient to improve maximal exercise capacity for both genders in very old patients after CABG surgery. Strength was only improved in IG and CG men but not in CG women. These finding might be explained through intrinsic motivation in the test procedure as other results showed improvement for both genders.

Scientific Poster Presentations

Posters available for viewing:

Friday September 9, 2011

10:30 AM-4:00 PM

Saturday September 10, 2011

8:00 AM-11:30 AM

Poster #S102

DIETARY INTAKE OF SUBJECTS WITH PERIPHERAL ARTERY DISEASE

Polly Montgomery MS.; Kelly A Ort, MS, RD, LD; Brianna C. Bright, MS; Andrew W. Gardner, PhD

Primary institution where research was conducted: The University of Oklahoma HSC

Secondary institution where research was conducted: Department of Veterans Affairs Medical Center, Baltimore, MD

Classification: Cardiac

Introduction: Little is known about the dietary intake of people with peripheral artery disease (PAD).

Purpose: Therefore, we compared the dietary intakes of subjects with PAD and claudication with daily reference values and with recommendations of the American Heart Association (AHA) and the United States Department of Agriculture (USDA), and we determined whether the dietary intake of fat negatively impacts both vascular function and ambulatory function.

Design: This study used a cross-sectional design.

Methods: Forty-six subjects with PAD and claudication were characterized on dietary intake with a 7-day food record, and on demographic characteristics, cardiovascular risk factors, exercise performance, and ischemic window.

Results: Subjects consumed a macronutrient composition of 17% protein, 51% carbohydrate, and 31% fat. Compared to the AHA and USDA recommendations, all subjects exceeded the recommended values for trans-fat and sodium, 80% exceeded the value for saturated fat, 61% exceeded the recommendation for cholesterol, and only 11% attained the recommended value for fiber. After adjustment for total caloric intake, mono-unsaturated fat intake was negatively correlated with peak walking time (p < 0.05) and positively correlated with ischemic window (p < 0.01).

Conclusions: Subjects with PAD and claudication have poor nutrition, with diets particularly high in trans-fat and sodium, and low in fiber. Furthermore, dietary intake of mono-unsaturated fat was associated with impaired ambulatory and vascular function.

Poster #S103

ACCEPTANCE OF ILLNESS AND FUNCTIONAL OUTCOMES FOLLOWING CARDIAC REHABILITATION

Gregg Anazia BS; Tom P. Guck, PhD; Meg Kinney, RN, BSN; Mark A. Williams, PhD

Primary institution where research was conducted: Department of Family Medicine and Department of Medicine-Cardiology Division, Creighton University School of Medicine

Classification: Cardiac

Introduction: Acceptance is a concept found to be significantly related to improved function in the treatment of chronic pain. Factor analysis of the Chronic Pain Acceptance Questionnaire, later rewritten for Chronic Illness (CIAQ), identified 2 components of the acceptance concept, Activities Engagement (AE) and Pain Willingness (now Illness Willingness, IW). AE concerns the pursuit of activities in a normal manner even when symptoms are being experienced. It requires engagement in positive and functional everyday activities without regard to symptoms. IW concerns patient recognition that avoiding or controlling symptoms may be a strategy that is often ineffective. AE and IW have been shown to have excellent internal reliability and are highly correlated with mental and physical outcome measures. AE, but not IW, added significantly to the ability to predict each of the functional outcomes beyond information provided by demographic and clinical variables.

Purpose: This preliminary study examined the internal reliability of the AE and IW scales of the CIAQ, the relationships between AE and IW and cardiac-related functional measures, and determined the amount of variance accounted for in the functional measures by the AE and IW scales beyond demographic and clinical variables.

Design: Design is a descriptive analysis using questionnaire and demographic/clinical data.

Methods: Following IRB approval and subject consent, 38 subjects, recruited from a standard cardiac rehabilitation program, were evaluated for age, gender, education, body mass index, exercise prescription intensity, depression, emotional functioning, physical functioning, AE, and IW

Results: Results indicated modest internal consistency for the AE and IW scales. AE was significantly correlated with 2 emotional functioning measures, Beck Depression Inventory (BDI) (r = -4.94, P < .01) and SF36-Role Emotional Scale (SF36-RE) (r = .344, P < .05). AE was not significantly related to physical functioning measures. IW was not significantly correlated with any of the measures. In multiple regression analyses, AE was a significant predictor of both emotional functioning measures, BDI ([latin sharp s] = -.548, P < .005) and SF36-RE ([latin sharp s] = .490, P < .016), but not physical functioning beyond demographic and clinical variables. IW was not predictive of emotional or physical functioning.

Conclusions: Acceptance of symptoms appears related to emotional functioning, but not physical functioning, for cardiac rehabilitation patients. Differences may be explained partly in realizing that in chronic pain, patients are asked to increase physical functioning despite pain. In cardiac rehabilitation, however, increased physical functioning despite symptoms may not be appropriate, particularly when symptoms are related to cardiac function abnormalities, eg, myocardial ischemia/left ventricular dysfunction, associated with angina pectoris/fatigue/hypotension.

Poster #S104

RELIABILITY OF RUBOR OF DEPENDENCY TEST

John F Greany, PhD, PT; Lori Brunner, SPT; Lisa Lallensack, SPT

Primary institution where research was conducted: University of Wisconsin-La Crosse

Classification: Cardiac

Introduction: Numerous assessments can be used by health care professions to screen for peripheral arterial disease (PAD). Rubor of dependency is a noninvasive test for PAD in the lower extremity that is performed by examining the plantar surface of the foot and observing color return after a period of elevation of the extremity. However, no study investigating the reliability of this procedure has been published.

Purpose: The purpose of this study was to investigate the inter-rater reliability of the rubor of dependency test.

Design: This was a descriptive correlation study with blinding of results between raters.

Methods: Two Doctor of Physical Therapy students were selected as testers after successfully completing a cardiovascular and pulmonary management course. Fifty volunteers over the age of 49 (68.7 yrs +/- 9.9) with and without known cardiovascular disease were recruited from the La Crosse, WI region to participate. Each subject was positioned supine for one minute prior to data collection and color of the right foot was observed. The right leg was elevated and supported at approximately 50 degrees of hip flexion for one minute. The subject's leg was then lowered back to the table surface and the lateral portion of the forefoot was observed. The time it took for color to return was measured in seconds. This procedure was repeated with the left foot. The second examiner followed the same procedure. The order of the testers was randomly assigned. Correlations were reported as intraclass correlation coefficients (ICC3,1), Pearson product-moment correlation coefficients and split-half correlation. Inter-rater reliability analysis using the Kappa statistic was also performed to determine consistency between raters.

Results: Analysis revealed poor reliability between two novice testers (ICC3,1 = 0.35, r = 0.38). In an attempt to identify tester learning, split-half reliability was determined. There was a greater association with the last half of subjects (n = 25; ICC3,1 = 0.47) compared to the first half (n = 25; ICC3,1 = 0.32) suggesting a learning effect. Inter-rater reliability for the raters was also found to be Kappa = 0.37 (p < 0.000), for a positive test of > 25 seconds.

Conclusions: The results suggest poor reliability of the rubor of dependency test between two novice raters as indicated by low ICC values. Reliability does improve with experience using the test, however these values are still not clinically acceptable reliability measures. This test should also be evaluated for validity prior to making conclusive statements on its use as a screening instrument for peripheral arterial disease.

Poster #S105

5-POINT FUNCTIONAL ASSESSMENT GUIDES EXERCISE PRESCRIPTION AND OUTCOMES FOR CARDIAC REHABILITATION

Pedro T. Recalde, MS, MBA, MHA; Pranav Loyalka, MD

Primary institution where research was conducted: St. Luke's Episcopal Hospital

Classification: Cardiac

Introduction: The 5-point functional assessment utilizes speech evaluation (SpE) for the identification of exercise intensity provoking ventilatory threshold (VT). The VT intensity is unique to each patient and allows the exercise physiologist to create a program specific to individual needs.

Purpose: The authors wish to demonstrate how this standardized protocol further enhances the cardiac rehabilitation program by providing physiological data to be used in patient care, education, and ongoing physician communications regarding the benefits of program participation.

Design: Open-label data collection in which program participants receive pre- and post- program functional assessments.

Methods: Cardiac rehabilitation patients (N = 55) completed pre and post evaluations of functional capacity (FC) using standardized SpE protocol. FC is defined by the authors as sustainable exercise intensity designated by patient response of equivocal (+/-) during the functional assessment. The indices for SpE are elicited by having a patient read a standardized paragraph during consecutive stages of the functional assessment, followed by self evaluation of their ability to speak comfortably. The authors compared responses using the equivocal (+/-) stage of the pre assessment versus values at the same intensity during an exit functional assessment. The values for comparison at SpE (+/-) are defined by Metabolic Equivalent (METs), Rating of Perceived Exertion (RPE), Heart Rate (HR), Systolic Blood Pressure (SBP) and Rate Pressure Product (RPP). The students t-test (p < .03) was used to compare pre and post data.

Results: The FC MET's (4.37 +/- 1.53 vs 5.90 +/- 1.70) was significantly higher (p < .03) post cardiac rehabilitation. The post cardiac rehabilitation RPE (13.11/20 +/- 1.44 vs 10.36/20 +/- 2.05), HR (104.71 +/- 16.52 vs. 98.33 +/- 15.51 bpm), SBP (139.13 +/- 19.03 vs. 130.80 +/- 17.72 mm/Hg), and RPP (145.89 +/- 35.98 vs. 128.80 +/- 30.63 bpm x mm/Hg x 10-3) were significantly lower (p < 0.03) when compared at pre cardiac rehabilitation SpE (+/-) intensities.

Conclusions: The 5-point functional assessment utilizing SpE provides a means to guide exercise intensity, demonstrate higher functional capacity, and reflect diminished physiological stress at submaximal exercise intensities for the cardiac rehabilitation population. The outcomes provide data for education regarding the benefits of program participation without the costs associated with expensive cardiopulmonary equipment.

Poster #S107

ASSOCIATION BETWEEN THE I/D POLYMORPHISM OF THE ANGIOTENSIN CONVERTING ENZYME AND THE BLOOD PRESSURE BEHAVIOR IN ATHLETES AND SEDENTARY INDIVIDUALS

H. Ilarraza, MS; Guadalupe P Hernandez, MS; Ivan S Serna, MD; Jesus G Fernandez, MD; Ricardo Marquez, PhD; Rafael Bojalil, PhD; Ricardo C Allende, MD; Maria Dolores S Rius, PhT; Martin R Martinez, PhD

Primary institution where research was conducted: National Institute of Cardiology Ignacio Chavez

Classification: Cardiac

Introduction: The gene that encodes the angiotensin converting enzyme (ACE) in humans can show a polymorphism (insertion or deletion), which has been associated with physical performance in several populations. On the other hand, we know that cardiovascular response during exercise depends, in part on the previous fitness level of the subject.

Purpose: The aim of this study was to determine the relationship between the ACE-polymorphism and the blood pressure response, during a stress test (ST) in sedentary and trained male.

Design: We performed a transversal, observational and open pilot study.

Methods: We recluted 10 high trained athletes and ten sedentary healthy male. A blood sample was obtained for a DNA analysis, to determine the polymorphism (I/D) of angiotensin converting enzyme (ACE). All subjects performed a symptoms-limited stress test. We calculated the blood pressure response (BPR) as the difference between blood pressure at baseline and maximal effort divided by METs. We compared the BPR according to fitness group and the ACE- polymorphism. We excluded the heterozygotic participants from the analysis. The stochastic differences between groups, were calculated using the U-Mann-Whitney test for independent samples (non parametric distribution). Further, we compared the BPR as a dichotomic variable (with a cut-point of 3.21 mmHg/MET), and we measured the degree of agreement between ACE-polymorphism groups, with a weighted-Kappa test.

Results: There were no stochastic differences on demographic characteristics between groups. During exercise test, the BPR was significantly lower (p = 0.01) in the athletes group (median 2.4 mmHg/MET; minimum 1.6 and maximum 3.8) compared with sedentary participants (median 4.5 mmHg/MET; minimum 2.5 and maximum16.5) respectively. However, among the athletes, those with an II ACE-genotype showed a strong association with a low BPR value (less than 3.21 mmHg/MET), with a weighted-Kappa value of 0.7 (p = 0.05).

Conclusions: Athletes with II ACE genotype has a lower blood pressure response, than their DD genotype counterparts. Among sedentary participants, there were no statistical difference according to ACE polymorphism

Poster #S110

SAFETY AND EFFECTIVENESS OF SEGMENTARY KINESIOTHERAPY IN PATIENTS WITH CARDIOVASCULAR DISEASE.

Maria Dolores S. Rius, PhT; Hermes L Ilarraza, MD; Maria Alicia R Viveros, PhT; Maria Esther O Franco, PhT

Primary institution where research was conducted: National Institute of Cardiology Ignacio Chavez

Classification: Cardiac

Introduction: Aerobic exercise is recommended for patients with cardiovascular disease, using several modalities such as cycling or walking. Further, all patients need a complementary general fitness program, like kinesiotherapy, to improve physical capacities like strength, flexibility, coordination and balance, nevertheless, the safety of this method in patients with heart disease, are not yet documented.

Purpose: Measure the amount of the cardiovascular response to kinesiotherapy, and the frequency of cardiovascular symptoms or complications.

Design: Pilot study (observational and descriptive)

Methods: We included 30 patients with cardiovascular disease (male, n = 22), and all performed a symptoms-limited stress test. Sixteen participants (53.3%), were stratified at high cardiovascular risk, nine (30%) at moderate and the rest (n = 5, 16.7%) at low risk. Twenty eight patients (93%) had coronary artery disease and the rest had idiopathic dilated cardiomyopathy. All participants were included in a cardiac rehabilitation program, with aerobic exercise training, lectures for secondary prevention with the nutritional and psychological advice. Afterwards, they carried out a kinesiotherapy routine, divided in 8 different segments of the body, and all patients repeated 10 times (one micro-cycle) each of the 67 different movements. So, we obtained 2010 micro-cycles of segmentary movements for the analysis. We measure heart rate (HR) and blood pressure in every micro-cycle. Also, a registry of continuous ECG was obtained. Every patient was interrogated about the presence of symptoms and the degree of perceived exertion was obtained using the 6-20 Borg Scale.

Results: No patient died or had mayor cardiovascular complication (cardiac arrest, myocardial infarction, unstable angina or stroke). After the analysis of the 2010 micro-cycles, all the patients had HR values below the 85% of the maximal theoretical heart rate (220 - age), and no one reached a HR * systolic blood pressure product above the 75% of the maximal value observed during the stress test. The highest perceived exertion value was 12 (regular). After the ECG analysis, we did not found any ventricular fibrillation or tachycardia, frequent ventricular ectopy, atrial fibrillation or flutter. No other cardiovascular complications were documented.

Conclusions: The segmentary kinesiotherapy seems to provide a low cardiovascular stimulus and could be a safe manner to bring patients a general fitness program.

Poster #S111

CONFIRMING THE ASSOCIATION OF A 4Q25 VARIANT WITH CARDIOEMBOLIC STROKE IN THE VIENNA STROKE REGISTRY

May Luke, PhD; Carmen H. Tong, MS; Joseph J. Catanese, BS; Stefan Greisenegger, MD; James J. Devlin, PhD; Christine Mannhalter, PhD

Primary institution where research was conducted: Celera

Secondary institution where research was conducted: Medical University of Vienna

Classification: Cardiac

Introduction: A single nucleotide polymorphism (SNP) on chromosome 4q25 (rs2200733) was reported to be associated with atrial fibrillation (AF) and with ischemic stroke, in particular the cardioembolic stroke (CES) subtype, in genome-wide association studies. If the association with CES is confirmed, rs2200733 could identify cardiac patients at higher risk for AF and CES and aid treatment decisions.

Purpose: We sought to confirm the reported association of rs2200733 with CES.

Design: The Vienna Stroke Registry (VSR) is a case-control study. VSR enrolled consecutive ischemic stroke patients admitted to stroke units in Vienna between October 1998 and June 2001, and healthy controls from the city of Vienna.

Methods: The ischemic stroke cases were categorized into stroke subtypes by the Trial of Org 10172 in Acute Stroke Treatment criteria. The genotype of rs2200733 was determined for 202 CES and 562 noncardioembolic stroke (nonCES) cases, and 815 healthy controls. The association between rs2200733 and CES or nonCES was assessed by regression models with and without adjusting for traditional risk factors.

Results: rs2200733 was associated with CES: T allele frequency was 14% in controls and 22% in CES cases, with an odds ratio (OR) of 2.19 (95%CI 1.43-3.36) per allele in an additive model. Compared with noncarriers, carriers of one T allele (26% of controls, 32% of cases) had an OR of 1.45 (95%CI 1.03-2.03), and carriers of two T alleles (1.5% of controls, 6% of cases) had an OR of 4.80 (95%CI 2.04-11.3) for CES. Adjusting for traditional risk factors (sex, age, smoking, diabetes, hypertension, dyslipidemia, and body mass index) did not materially change the risk estimates: the OR was 2.21 (95%CI 1.30-3.78) per allele in the additive model, and compared with noncarriers, carriers of one T allele had an OR of 1.26 (95%CI 0.80-1.99), and carriers of two T alleles had an OR of 4.72 (95%CI 1.62-13.8). In contrast, the frequency of rs2200733 T allele was the same in nonCES cases (14%) as in controls and rs2200733 was not associated with nonCES.

Conclusions: We confirmed that rs2200733 was associated with CES and found that rs2200733 was not associated with nonCES in VSR. Genotyping rs2200733 could identify cardiac patients at increased risk of CES and AF for more appropriate diagnostic or treatment decisions.

Poster #S114

BODY FAT CATEGORIES IN TERMS OF BODY MASS INDEX: HOW ACCURATE IS OUR DEFINITION OF OBESITY?

Alban De Schutter, MD; C. Lavie, MD; J. Gonzalez, MD; V. Totfalusi, MD; R Milani, MD

Primary institution where research was conducted: Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine

Classification: Cardiac

Introduction: Despite its many known shortcomings, body mass index (BMI) is the most widely used screening tool for obesity, in part because of simplicity and practicality. Percent body fat(BF) may be a more physiologic measurements of obesity.

Purpose: We examined a large cohort of coronary heart disease (CHD) patients to determine how BF categories and BMI are distributed.

Design: Re

Methods: We studied 581 patients with CHD following major CHD events, who were divided according to BMI (calculated as weight divided by height squared), based on the WHO cutoff points (18.5, 25, 30 being the cutoffs for Underweight, Normal, Overweight and Obese, respectively). The population was also divided according to BF, based on the Gallagher BF classification (BF categories adjusted for age, sex and race) into Underweight, Normal, Overweight and Obese categories).

Results: BMI and percent BF correlated significantly (r = 0.599; p < 0.0001) and classified patients in the same category (Underweight, Normal, Overweight and Obese) in about 54% of cases. When plotted based on BMI, members of the Gallagher classes found themselves normally distributed around the corresponding BMI category.

Conclusions: Even though a correlation exists between BMI and BF, they frequently classify individuals differently in our population. BMI approximates Gallagher's more physiologic obesity categories in an expected, normal distribution. Gallagher often classified patients as less obese than BMI. This supports the use of BMI as a screening tool, but not as confirmatory test for obesity in patients with CHD.

Poster #S116

9P21 RISK IS INDEPENDENT OF ADVANCED LIPOPROTEIN RISK FACTORS

H. Robert Superko, MD; Basil Margolis, MD; Thomas White, PhD; Arthur Baca, MD

Primary institution where research was conducted: Celera

Secondary where research was conducted: Saint Joseph's Research Institute-Atlanta

Classification: Cardiac

Introduction: 9p21 is an established genetic risk factor for CHD that is independent of traditional risk factors including total cholesterol, LDL-C, HDL-C, and triglycerides. The mechanism of CHD risk associated with the 9p21 polymorphism is not established.

Purpose: We investigated if there is a relationship between 9p21 genotype and advanced lipid risk factors including Apo B, Lp(a), LDL Peak Particle Diameter (PPD), LDL and HDL subclass distribution.

Design: The association between 9p21 genotype and advanced lipid risk factors was investigated in de-identified samples from 2,964 patients.

Methods: Fasting cholesterol and triglycerides were determined by enzymatic methods, HDL-C by precipitation and LDL-C by calculation. HDL and LDL subclasses were determined by polyacrylamide gradient gel electrophoresis. Lp(a) and ApoB were determined by immunoassay. 9p21 polymorphism (rs 10757278 and rs1333049) were determined by TaqMan PCR. Differences between genotypes were assessed with analysis of variance (ANOVA).

Results: Values for each 9p21 genotype (characterized as normal, heterozygous, or homozygous carriers of the risk allele) are given as mean + SE. Values did not differ according to genotype for total cholesterol (mg/dl) (191 + 1.6, 191 + 1.2, 189 + 1.7, p = 0.56), LDL-C (115 + 1.4, 114 + 1.0, 112 + 1.5, p = 0.35), HDL-C (51.1 + 0.6, 50.3 + 0.4, 50.0 + 0.6, p = 0.42), non-HDL-C (140 + 1.5, 141 + 1.1, 138 + 1.6, p = 0.33), and Apo B (87.8 + 0.8, 88.3 + 0.6, 86.9 + 0.9, p = 0.45). Other lipid measures differed modestly according to genotype: triglycerides were higher in carriers of the risk allele (122 + 2.6, 133 + 2.0, 130 + 2.8, p = 0.007); HDL2b% was lower in carriers of the risk allele (18.2 + 0.3, 17.4 + 0.2, 17.9 + 0.3, p = 0.04); LDL peak particle diameter was smaller in carriers of the risk allele (268.9 + 0.3, 268.2 + 0.2, 268.7 + 0.3, p = 0.05); and Lp(a) was lower in carriers of the risk allele (36.7 + 1.4, 33.2 + 1.0, 30.5 + 1.5, p = 0.008).

Conclusions: It is unlikely that the increased CHD risk associated with the 9p21 genotype is related to standard cholesterol risk factors. There appears to be a slight but significant relationship of some aspects of advanced lipid and lipoprotein risk factors that deserves further exploration.

Poster #S118

TRAINING EFFECT ON CARDIOVASCULAR RESPONSE DURING SUMAXIMAL STRENGTH EXERCISE

Miguel Resnik, MD; Rosa M Ruffa, MD; Dario Maggio, PE Teacher; Sergio Taurozzi, PE Teacher; Maria F Perez-Ruffa, PT; Carina Bernal, Cardiology technician; Sabrina Resnik, Medicine Student; Eda Lia Abad Monetti, MD

Primary institution where research was conducted: Julio Mendez Hospital

Secondary institution where research was conducted: Gym Athlete's School of Medicine University of Buenos Aires

Classification: Cardiac

Introduction: Previous studies have shown wide variations in blood pressure measurements during resistance exercise. We hipothesized that the increase in BP is not sigficant using light and moderate workloads and may be attenuated with training

Purpose: The purpose of this study was to evaluate the training effect on cardiovascular response during a moderate resistance exercise.

Design: We measured heart rate, systolic and diastolic blood pressure during a submaximal strength exercise (knee extension) and reevaluation after three months of training. We conducted a prospective observational study to determine if during a submaximal streng

Methods: We evaluated 30 patients (p), males, clinically stables with medical treatment, mean age 57,2 +/- 9,2 years, with documented coronary heart disease (CHD). The subjects were included after two weeks aerobic training in treadmill and/or cycle ergometer, muscular conditioning, flexibility and light dumbbells activities. All of them developed a stress testing (ST) before, determining functional capacity levels (FC). We measured one repetition maximum (1RM) for quadriceps extension (C) seated and then, a submaximal test in C (SM1) was applied (2 sets, 15 repetitions 40-60% 1RM), considering the percentage used for each p according to FC in ST. Heart rate (HR) through a Polar heart rate monitor and systolic and diastolic blood pressure (SBP and DBP respectively) by sphygmomanometer were registered at rest (rest), repetition 7 (rep.7), repetition 15 (rep 15) and immediately post exercise (pe). Training program: All subjects met two times a week for 30 minutes of resistance training, 8 exercises of upper and lower body (2 sets of 10-15 repetitions at 30-60% 1RM), 30 minutes of aerobic exercises (50-80% heart rate reserve), and additional activities. After three months of combinated training, p were reevaluated through SM2. A Wilcoxon matched pairs signed rank sum test was used considering a significant difference < 0.05.

Results: All patients completed the weightlifting exercises without symptoms. With physical training, we demonstrated significantly lower values of SBP: 119 +/- 9,23 vs. 114,33 +/- 10,23(rest); 142 +/- 14,061 vs. 133,5 +/- 9,57(rep.7); 149 +/- 12,69 vs. 140,17 +/- 11,41(rep.15); 125 +/- 11,6 vs. 120,83 +/- 9,92(pe) p < 0.05. In DBP, we observed similar changes in rep.7, rep.15 and pe: 90,67 +/- 8,07 vs. 85,33 +/- 6,56; 92,83 +/- 6,78 vs. 88,17 +/- 6,63; 77,67 +/- 7,63 vs. 75,5 +/- 5,62, respectively. < 0.05. There were no differences (p > 0.05) in DBP at rest, and HR for each period of time.

Conclusions: Resistance training has demonstrated to be safe on hemodynamic response using submaximal workloads with a considerable reduction of blood pressure with physical training.

Poster #S120

A DESCRIPTIVE STUDY OF DIABETES MELLITUS PATIENTS WITH COMORBID CARDIOVASCULAR DISEASE ENROLLED IN A COMMUNITY LIFETIME MAINTENANCE THERAPEUTIC LIFESTYLE INTERVENTION PROGRAM

Karri B. Britt, MS; Lois E. Adkins, MS; Andrew M. Kasa, BS; Kristopher F. Rake, BS; William P. Marley, PhD

Primary institution where research was conducted: Cabell Huntington Hospital

Secondary institution where research was conducted: Marshall University Medical Center

Classification: Cardiac

Introduction: Multifactorial therapeutic lifestyle intervention (MTLI) reduces signs/symptoms, fatal and nonfatal cardiac events in diabetes mellitus (DM) patients with comorbid cardiovascular disease (CVD). Better A1c levels, improved lipid profiles, and reductions in depression are among effects proposed to explain these findings. But what clinical profile can be anticipated when such patients present for a lifetime maintenance cardiac rehabilitation program (LMCRP)? Such information could prove valuable in preparing their intervention programs.

Purpose: To describe discrete gender and age engagement profiles of DM patients with comorbid CVD referred by their physicians for a MTLI/LMCRP and prepare this sample for followup outcomes research. CPGs provide detailed guidance for managing single diseases, but may fail to address the demands of complex comorbid illness.

Design: A one-group descriptive study of clinical variables categorized by age and gender in DM patients with comorbid CVD.

Methods: This study consisted of 115 patients (46% female), aged 21 to 80. They were screened with a comprehensive clinical assessment and medical record review. These admissions data were analyzed for descriptive purposes.

Results: Sample (N = 115), Male (n = 62), and Female (53) (SMF) subgroups are obese, with BMIs of 34, 33 and 36, respectively. The metabolic syndrome (MetSyn) is also established. The WHO and American Diabetes Association (ADA) recently recommended a 6.5% HbA1c cut point for DM diagnosis. SMF A1cs of 7.6, 7.5, and 7.7, respectively, confirm DM in our patients. SMF fasting blood glucose (FBG) values of 156, 153, and 161 mg/dl, respectively, (>126) also confirm DM and exceed the 130 mg/dl ADA daily glycemic control recommendation. Patients in the 45-54 age group were least effective in DM management with an A1c of 8.2% compared to a 7.3% average for the other four groups. The highest male age group A1c was 8.7% in the 45-54 year-old (YO) men and lowest in 35-44 YOs (6.7%). The highest female A1c was 8.2% in the 35-44 YO group and lowest in 21-34 YOs (7.0%). The most common risk factors were hyperlipidemia, hypertension, inactivity, obesity, stress, and family history. Lipid profiles appear to have been managed reasonably well, but LDL values exceed the recommended level of < 70 mg/dl with SMF values of 105, 101, and 109 mg/dl, respectively.

Conclusions: Unique gender and age group data were observed in this study. These analyses reveal clinical trends and profiles that can prove helpful for clinicians in managing DM patients with comorbid CVD in a MTLI/LMCRP.

Poster #S121

MEASURING HEALTH LITERACY IN CARDIAC REHABILITATION: THE MEDICAL TERM RECOGNITION TEST (METER)

Colleen Cole Mattson, BAS; Katherine Rawson, PhD; Joel W. Hughes, PhD; Donna Waechter, PhD; Jared Schprechman; James Rosneck, RN, MS

Primary institution where research was conducted: Center for Cardiopulmonary Research, Summa Health System

Secondary where research was conducted: Department of Psychology, Kent State University

Classification: Cardiac

Introduction: Health literacy is defined as ". . .the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Laramee et al., 1999). Programs such as cardiac rehabilitation involve several lifestyle changes that often require a basic understanding of health information. A simple, valid measure is needed to assess cardiac rehabilitation patients' health literacy, as they encounter medical information during participation in cardiac rehabilitation.

Purpose: The current study sought to further validate a new measure of health literacy, the Medical Term Recognition Test (METER). The METER has been used in outpatient cardiac testing, and was both reliable and related to other measures of health literacy. The METER has not been used in Cardiac Rehabilitation. It was expected that the METER would have adequate internal consistency, be correlated with other measures of health literacy (Short Test of Functional Health Literacy-Adults, sTOFHLA and the Newest Vital Sign, NVS), and be well accepted by patients in a cardiac rehabilitation setting.

Design: The sTOFHLA, NVS, and METER were administered to 165 consenting, English-speaking cardiac rehabilitation patients in exchange for a $5 gas card.

Methods: The METER consists of a list of 70 words: 40 actual medical terms and 30 non-words. Respondents placed an "X" next to terms they recognized as real medical terms.

Results: Cronbach's alpha was .94, thus the METER displayed strong reliability. Bivariate correlations showed the METER True Hits was significantly and positively related to the STOFHLA (r = .43, p > .001) and the NVS (r = .40, p > .001). Lastly, out of 165 patients, 12 did not adequately complete the sTOFHLA and 21 did not complete the NVS compared to a 100% completion rate for the METER. Cardiac rehabilitation patients were more willing to complete the METER correctly in a self-administered context.

Conclusions: The METER was further validated as a measure of health literacy. It was shown to be reliable and correlated with other measures of health literacy (NVS and sTOFHLA). Additionally, this was the first use of the METER with cardiac rehabilitation patients. It had the highest completion rate of three self-administered health literacy measures, indicating that it is well tolerated by patients in cardiac rehabilitation.

Poster #S122

VENTILATORY RESPONSE OF ACCELEROMETER ON CARDIAC RESYNCHRONIZATION THERAPY DURING EXERCISE FOR THE PATIENT WITH CHRONOTROPIC INCOMPETENCE AND CHRONIC HEART FAILURE

Maki Ono, MD; Naonori Tashiro, PT, Ryota Iwatsuka, MD, Yuji Hashimoto, MD

Primary institution where research was conducted: Kameda Medical Center

Classification: Cardiac

Introduction: Cardiac rehabilitation in patients with chronotropic incompetence (CI) and chronic heart failure has difficulty in determining the appropriate heart rate at anaerobic threshold (AT).

Purpose: To identify the effect of accelerometer rate response of cardiac resynchronized therapy (CRT) on ventilatory response to exercise.

Design: A patient with CI and heart failure on CRT underwent cardiopulmonary exercise test (CPET) with and without accelerometer rate response.

Methods: A 62 year-old Japanese male with CRT for chronic heart failure due to old myocardial infarction on ambulatory cardiac rehabilitation program underwent CPET. His CRT was set at lower rate of 70 and upper rate of 130. Three different modes were set; DDD 70/130 without rate response, DDDR 70/130 with accelerometer rate response at response setting by default, and DDDR 70/130 at response setting of the maximal response curve.

Results: Ventilatory response to exercise at three settings were as follows (without rate response/with rate response by default/with rate response of maximal response curve); Peak heart rate (81/106/130 beats per minute), AT VO2 (7.4/8.8/8.2 ml/min/kg), Peak VO2 (10.4/11.7/11.1 ml/min/kg), and VE-VCO2 slope (31.6/29.7/33.8). Time to the peak heart rate from the beginning of exercise was 5.5/4.5/1.0 minutes).

Conclusions: Exercise capacity was better with accelerometer rate response. When response curve was too steep, the heart rate reached at the upper rate drastically and the patient felt dyspnea.

Poster #S123

COMPARISON OF OUTCOMES RELATED TO QUALITY OF LIFE CHANGES IN PHASE II CARDIAC REHABILITATION

Teresa Corbisiero, RN-BC, MBA; Nathan J. Boehlke, MS; Tanis Q. Hurtt, RN, ENB; Andrea Bon-Wilson, CTRS, CAC11; Mary S. Meyers, MS, EMT-P; Cynthia A. Oster, PhD, MBA, APRN, CNS-BS, ANP

Primary institution where research was conducted: Porter Adventist Hospital/Centura Health

Classification: Cardiac

Introduction: Cardiac Rehabilitation (CR) services continue to be underutilized despite evidence these services are associated with significant benefits. Few studies have explored the relationship between stress management education and clinical outcomes. Studies indicate psychosocial intervention can positively affect stress behavior in patients with coronary artery disease.

Purpose: The aim of this study was to compare pre and post Dartmouth Quality of Life (QOL) Index scores among Phase II CR participants who attended three 1.5 hour group stress management behavioral sessions provided by a licensed professional counselor.

Design: A retrospective comparative design was used to compare 144 participants of a Phase II CR program who completed = 12 sessions between January 2008 and December 2010 at a hospital-based nationally certified CR program located in a western mountain region.

Methods: The Dartmouth Primary Care Cooperative (COOP) survey, a measure of functional status, was administered to all participants during the initial CR session and two CR sessions prior to program discharge. Scores of 4 or 5 represent unfavorable levels of health. Individual QOL scores were compared among participants attending and not attending three 1.5 hour stress management sessions. A medical record review was conducted to collect completed QOL scores, attendance of stress management sessions, gender, and age. The t-test was used to determine statistical significance.

Results: Sixty nine participants attended the stress management sessions and 75 did not. One hundred males (mean age = 64.6 years) and 44 females (mean age = 67.7 years) participated. The mean pre and post QOL score for all participants significantly improved (mean difference = ?5.56; p < 0.0001). The 69 patients attending stress management sessions did not significantly improve QOL scores. There was no significant difference in QOL scores between participants attending and not attending the three stress management sessions. Age did not differ significantly between males and females.

Conclusions: Patients attending CR are likely to significantly improve their QOL. Preliminary data suggest attending structured stress management sessions may not significantly affect QOL in this patient population. However, stress management sessions are an integral part of a CR program and identifying patients with poor QOL is a critical piece of data for a licensed professional counselor to use in order to make a specific psychosocial diagnosis. The Dartmouth QOL index scores may not accurately measure education efficacy in the stress management sessions. Further research utilizing a different measurement tool may illuminate stress management efficacy more precisely.

Poster #S124

HEALTH LITERACY IS ASSOCIATED WITH CARDIAC HEALTH KNOWLEDGE IN PHASE-II CARDIAC REHABILITATION

Joel W. Hughes, PhD; Katherine Rawson, PhD; Colleen C. Mattson, BA; Carly M. Goldstein, BA; Donna Waechter, PhD; James Rosneck, RN, MS

Primary institution where research was conducted: Summa Health System

Secondary institution where research was conducted: Kent State University

Classification: Cardiac

Introduction: Patient education is a cornerstone of cardiac rehabilitation (CR) programs. Patients' health literacy (HL) may be associated with health knowledge related to cardiac disease, but research is lacking.

Purpose: The relationship between HL and health knowledge in phase-II CR was examined. It was expected that patients with higher HL would be more informed about cardiovascular disease prior to beginning CR.

Design: Measures of HL and health knowledge were administered to 160 consenting, English-speaking CR patients in exchange for a $5 gas card.

Methods: HL measures were the Medical Term Recognition Test (METER), the Short Test of Functional Health Literacy-Adults (sTOFHLA) and the Newest Vital Sign (NVS). Patients also completed the Summa Cardiac Knowledge Assessment Tool (SCKAT) at the beginning of CR. This 31-item knowledge test was administered prior to the first rehab session. The health knowledge was taken from the educational curriculum for this AACVPR certified CR program, which consists of 36 instructional modules focusing on development and lifetime maintenance of heart healthy lifestyle practices.

Results: Participants were 160 male (69%) and female (31%) predominantly Caucasian (90%) CR patients with an average education level of 13.9 years. HL measures were all correlated with SCKAT scores at the beginning of CR: METER (n = 160, r = .36, p < .001), sTOFHLA (n = 150, r = .31, p < .001), and NVS (n = 123, r = .42, p = .001). Partial correlations controlling for education demonstrated that HL provides more information than educational level alone: METER (r = .33, p < .001), sTOFHLA (r = .26, p < .001), and NVS (r = .37, p < .001).

Conclusions: HL was related to patients' health knowledge prior to CR, even after considering differences in educational level. Fewer patients completed the NVS, suggesting that it may be less well tolerated by CR patients than the other HL measures. Additional research is necessary in less well-educated and more diverse samples. Further research examining HL in CR should examine outcomes, such as whether HL predicts improvements in fitness, adherence to medication and exercise, or knowledge gained from completing patient education in CR.

Poster #S125

CARDIAC REHABILITATION IN PATIENTS RECEIVING LVAD THERAPY: THE MAYO CLINIC EXPERIENCE

Osama O. Alsara, MD; Carmen M. Terzic, MD, PhD; Soon J. Park, MD; Ray W. Squires, PhD; Randal J. Thomas MD, MS

Primary institution where research was conducted: Mayo Clinic

Classification: Cardiac

Introduction: Cardiac rehabilitation (CR) is an integral component of the care for patients with cardiovascular diseases. However, the role of CR in patients receiving left ventricular assist device (LVAD) therapy is unclear.

Purpose: We studied the CR participation, safety and impact on mortality in patients undergoing LVAD therapy.

Design: Retrospective study.

Methods: Using the electronic medical records, we assessed CR participation, safety and mortality in 84 consecutive patients who underwent LVAD therapy at Mayo Clinic from January 2008 to June 2010. Major cardiovascular events we assessed include: death, angina, high grade ventricular arrhythmias requiring hospitalization, syncope, cardiopulmonary arrest, and a clinical condition that necessitated hospitalization. Minor events were also assessed, including: high grade arrhythmia not requiring hospitalization, abnormal blood pressure responses, and near-syncope. Data are expressed as mean +/- SD. Paired data were analyzed using Student's t test and p 0.05 was considered statistically significant.

Results: 83.3% (n = 70) of LVAD patients were referred to CR and 47.1% (n = 33) of referred patients attended at least one CR session (39.3% of all eligible LVAD patients). CR non-attendance was reported more commonly in women, patients >64 years of age, retirees, patients receiving LVAD as a bridge to transplantation, college graduates, and patients with BMI < 30. The average number of CR sessions attended per patient was 18.3 (+/-14.7), with an average of 2.9 (+/-0.9) sessions per week and a duration of 31.4 (+/-14.9) minutes per session. No major cardiovascular events were reported during a total of 316 patient-hours of exercise training. However, during exercise in CR sessions, 3 minor events occurred in the following frequency: low blood pressure in 1 patient, tachycardia in 1 patient, and near-syncope in 1 patient. The un-adjusted mortality rate in patients participating in CR was 6.1%, compared to 19.6% in non-participants. While the trend favored those who attended CR, the trend was not statistically significant.

Conclusions: We found a high level of CR referral, participation, and safety in patients receiving LVAD therapy. Mortality data showed a favorable trend for CR patients, but the trend was not statistically significant, due in part to our limited sample size. While CR appears to be a promising therapy for LVAD patients, additional studies are needed to assess the full impact of CR on clinical outcomes in patients receiving LVAD therapy.

Poster #S126

BALANCE AND FALLS RISK IN CARDIAC REHABILITATION CLIENTS

Debbie G. Scotten, RN, MS; Joseph S. Rossi, MD; Michael L. Clark, BA; Elizabeth Matteson, MA; Erin E. Toomey, BS; Angelia C. Lynch, RN; Carol A. Giuliani, PT, PhD

Primary institution where research was conducted: Chatham Hospital Cardiac Rehabilitation Program

Classification: Cardiac

Introduction: Cardiac Rehabilitation (CR) is an established intervention for improving functional capacity as measured in metabolic equivalents (METS). Our clinic has also observed improvements in balance, strength, and stability indicating that participation in CR may offer the additional benefit of fall risk reduction.

Purpose: The purpose of this project is to collect preliminary data to establish feasibility for conducting an interventional study for fall risk reduction within CR programs. We will determine feasibility of recruiting CR programs, develop testing measures with low burden, train staff and develop data collection protocols

Design: This feasibility involved a pilot study within a single CR program and a survey of 70 CR programs.

Methods: All 21 participants in this study were enrolled in a CR program. Our sample includes 15 males and 6 females (6 phase II and 15 phase IV) with an average age of 70.7+/- 8.7 yrs. We asked participants questions about their history of falling, losing balance, changing activity, and use of assistive devices. All participants also performed standardized tests for identifying fall risk: timed up and go, single leg stand, tandem stance, and repeated chair rise test. A brief survey was sent to 70 CR programs in NC to ascertain level of interest and basic program information.

Results: One hour of staff training was adequate for conducting the tests and establishing reliability. Testing time for each participant was less than 10 minutes. Half (3/6) the phase II participants reported at total of 6 falls, 5 reported balance losses, and 2 used assistive devices. None could stand on one leg for 30 sec and 4 less than 10 sec, repeated chair rise ranged 0-13 in 30 sec. These tests indicated that all 6 clients were at risk of falling. Overall the phase IV participants had fewer falls, better balance and were stronger. A preliminary survey indicated that about 26 % (18) of CR programs in NC were interested in participating in the study.

Conclusions: The test training and measurement time was efficient and identified that all Phase II participants in CR had features that increased falls risk. We are currently developing a fall intervention program that will target this at-risk population. There is significant interest in the State of North Carolina to participate in a multicenter research study to examine the effects of CR interventions to reduce fall risks in Phase II clients.

Poster #S129

SWIMMING REDUCES ARTERIOSCLEROSIS IN APOE DEFICIENT MICE BY IMPROVING MYOCARDIAL INSULIN RESISTANCE

Suixin Liu MD, PhD; Ying Cai, MD; Chuihua Sun, MD

Primary institution where research was conducted: State Key Lab of Medical Genetics of China

Classification: Cardiac

Introduction: Clinical trail and basic research demonstrate that regular exercise is an effective treatment for arteriosclerosis (AS). However, underlying mechanisms are not completely understood. Exercise improving peripheral insulin resistance may be one of it.

Purpose: The effects of swimming on peroxisome proliferator-activated receptor (PPAR-?), carnitine palmitoyl transferase-1b (CPT-1b) and medium-chain acyl-coenzyme A dehydrogenase (MCAD) expression in apolipoprotein E deficient (ApoE-/-) mice myocardium were investigated, possible mechanisms of exercise ameliorating AS were discussed.

Design: 26 male ApoE-/- mice fed a high-fat diet were randomly divided into exercise group (HFD+Ex, n = 13) and non-exercise group (HDF, n = 13). HFD+Ex group were treated with swim training for 1 hour per day and 5 days per week. A group of 10 sedentary male C57BL/6

Methods: After intervention for 12 weeks, mice were sacrificed. Serum FPG(Fasting plasma glucose), insulin, Homa-IRI, TC, TG, HDL, LDL and FFA (lfree fatty acid)evel were measured. Ascending aorta was isolated for Oil-Red O staining to identify the lipid-rich lesions. Morphology of left ventricle was observed by electron microscope imaging. PPAR-?, CPT-1b, MCAD gene expression of left ventricle was analyzed by RT-PCR. Data were analyzed using Independent Sample T-Test. The significance was less than 0.05.

Results: High fat diet caused significant increase of serum FPG, insulin, Homa-IRI, TC, LDL and FFA levels compared with normal diet control group (P < 0.01); swimming exercise significantly lowered those levels in HFD + Ex group compared with those of HFD group (P < 0.05). Oil-Red O staining of aorta showed that ApoE -/- mice had developed severe progressive atherosclerotic lesions. Exercise significantly reduced the aortic lesion area. Histochemistry study of myocardium in HFD group showed disorganized sarcomere, swollen myofilaments and enlarged mitochondria with vacuolar degeneration; while HFD+EX group maintained normal cardiac morphology. PPAR-? expression in myocardium was decreased, but CPT-1b and MCAD were increased by high fat diet fed compared with normal diet control (P < 0.01), exercise training significantly reversed these changes in HFD+Ex group (P < 0.01).

Conclusions: Swimming reduces arteriosclerosis by improving myocardial insulin resistance through upregulating PPAR-? expression, and thus down regulating CPT-1b and MCAD expression in myocardium.

Poster #S131

FUNCTIONAL CAPACITY AND QUALITY OF LIFE IN VERY OLD PATIENTS AFTER CABG SURGERY-COMPARISON OF TWO DIFFERENT EXERCISE TRAINING REGIMES

John JC Busch; Detlev Willemsen, MD; Birna Bjarnason-Wehrens, Professor

Primary institution where research was conducted: Schuchtermann-clinic, Bad Rothenfelde, Germany

Secondary institution where research was conducted: German Sports University, Institute of Cardiology and Sports Medicine, Cologne, Germany

Classification: Cardiac

Introduction: The number of very old patients after CABG is increasing. Those patients need special rehabilitation programs.

Purpose: To evaluate the effects of daily resistance and balance training compared to standard exercise training on functional capacity and quality of life (QoL) in very old patients who participated in phase II cardiac rehabilitation (CR) early after CABG surgery.

Design: It's a single centre randomized controlled trial.

Methods: N = 173 patients, = 75 years old (mean age 78.5 +/- 3.2 years) were randomly assigned to either an intervention group (IG) or a control group (CG). N = 23 patients dropped out for reasons not referred to the exercise training. Thus results are based on n = 150 patients: IG (n = 72, m/f; 51/21), CG (n = 78, m/f; 54/24). All patients participated on average 20.4 +/- 3.2days in an in-patient CR 13.1 +/- 5.3days post surgery. The CG participated in the usual exercise regime including endurance exercise training on bicycle ergometer and gymnastics. The IG participated in additional functional training including resistance training (10.8 +/- 2.4 exercise units with 4 exercises, one set of 8-12 repetitions at 60% 1RM) and special balance training (9.9 +/- 2.7 units). 6MWT was used to access functional capacity, the MacNew questionnaire to evaluate quality of life (QoL). Statistical analyses have been conducted using ANOVA, Cohen's d for effect size calculation.

Results: In both groups 6MWT was significantly improved by the CR (p < 0.001), IG from 295.8 +/- 84.1 to 363.1 +/- 80.3m, ? 67.1 +/- 49.4m and CG from 310.5 +/- 80.3 to 352.4 +/- 81.6m, ? 42.0 +/- 52.1m. There was a significant interaction (p = 0.003) and the most clinically important difference (MICD) of >54m for 6MWT was only achieved in IG, group factor was not significant (p = 0.881). Effect size was medium d = 0.5. In both groups all dimensions of QoL were significantly improved above MICD of >0.5: emotional dimension IG (5.1+/-1.0 to 5.9 +/- 0.8 p < 0.001) vs. CG (5.3 +/- 1.2 to 6.0 +/- 0.8 p < 0.001), physical dimension, IG (4.9 +/- 1.1 to 5.9 +/- 0.9 p < 0.001) vs. CG (4.9 +/- 1.2 to 5.9 +/- 1.2; p < 0.001), social dimension IG (5.2 +/- 1.1 to 6.2 +/- 0.8 p < 0.001) vs. CG (5.3 +/- 1.3 to 6.2 +/- 0.8 p < 0.001) and global IG (5.1 +/- 1.0 to 6.0 +/- 0.8 p < 0.001) vs. CG (5.1 +/- 1.2 to 6.0 +/- 0.7) p < 0.001). No significant differences were seen between the groups.

Conclusions: CR is highly efficient in very old patients after CABG surgery to improve 6MWT and QoL. An additional resistance and balance training can enhance additional benefits. The most clinically important difference of >54m for 6MWT improvement was only reached in IG.

Poster #S133

KNOWLEDGE ASSESSMENT OF CARDIOVASCULAR RISK AND DISEASE MANAGEMENT LEARNING OUTCOMES: THE SUMMA CARDIAC KNOWLEDGE ASSESSMENT TOOL (SCKAT)

James S. Rosneck, BSN, MS; Joel Hughes, PhD; John Gunstad, PhD; Donna Waechter, PhD

Primary institution where research was conducted: Summa Health System

Secondary institution where research was conducted: Kent State University

Classification: Cardiac

Introduction: Introduction: Phase II CR Patient education programs are formulated to assist patients in modifying high-risk behaviors and assuming personal responsibility for effective long-term disease management. Baseline and ongoing cardiovascular risk and disease management knowledge is fundamental for the CR educator. The Summa Cardiac Knowledge Assessment Tool (SCKAT) is a valid and reliable curriculum aligned instrument that accurately measures attainment of knowledge-based patient competencies in CR educational modules suggested by AHA/AACVPR core program components.

Purpose: The purpose of this study is to determine the effectiveness of content delivery of the cardiovascular risk and disease management curriculum as measured by patient performance on the SCKAT, pre and post treatment.

Design: This study is pre-experimental, one group pre-test post-test design which is frequently used in educational settings. In this design, there is a presentation of a pre-test, followed by a treatment, and then a post-test, where the difference betwee

Methods: The 31 item SCKAT was administered to 3,303 Cardiac Rehab patients prior to their first rehab session. The curriculum on which the test is based was presented in 36 instructional modules whose focus is development and lifetime maintenance of heart healthy lifestyle practices as part of the normal CR program. A post-test was then administered and a dependent t-test was performed.

Results: 3,303 CR patients (67.5 % men, mean age 64.73 and 32.5 % women, mean age 66.07) completed the SCKAT pretest. A comparison of mean scores of the 1,796 patients completing both, pre (17.3) and post (25.5) test, was performed using a dependent t-test and was significant at p < .001. Further analyses suggest an inverse relationship between total test score and age, for both male and female participants.

Conclusions: Patient scores improved and average of 8.2 points indicating success in teaching patients information contained in the educational modules. Results of this study are consistent with program goals and the stated purpose of this study, to improve patient knowledge of cardiovascular risk and disease management.

Poster #S134

IMPACT OF EXERCISE-BASED CARDIAC REHABILITATION ON RESTENOSIS WITH DIFFERENT GENERATIONS OF DRUG ELUTING STENT

Kim Chul, MD; Hee Eun Choi; Byung Ok Kim

Primary institution where research was conducted: Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University

Secondary institution where research was conducted: Department of Cardiology, Sanggye Paik Hospital, Inje University

Classifcation: Cardiac

Introduction: Research that compares the effects of cardiac rehabilitation (CR) on patients with different generation of drug eluting stents (DES) is very rare and has been carried out in a limited way.

Purpose: In this research, we tried to compare the rate of restenosis between CR group and control groups within three different generations of DES.

Design: Patients who received DES due to acute coronary syndrome were included as study subjects. They were divided into a CR group and a control group. We implemented use of a coronary angiography. There was a further classification of the subjects into three subgroups.

Methods: The CR group received eight weeks of early cardiac rehabilitation program in hospital setting, and sustained self exercise program for six months in community. The control group was instructed to exercise themselves after leaving the hospital. Nine months after the first occurrence of disease, we implemented follow-up coronary angiography and compared the rate of angiographic progression (late luminal loss) within the stent and the rate of restenosis by quantitative angiographic measurement between the CR and control groups. In addition, we divided the patients into three subgroups according to the generation of DES (1G = Taxus, Cypher; 2G = Endeavor sprint, Endeavor resolute; 3G = Xience, Promus) and compared the same angiographic parameters between the CR and control groups within those 3 subgroups.

Results: Total of 103 patients were recruited as study subjects after percutaneous coronary intervention with implantation of three different generations of DES (1G in 36 cases, 2G in 38 cases, 3G in 29 cases) to a 9-month CR exercise training (n = 52) or to a control group (n = 51). At 9 months, in-stent late luminal loss was smaller in the training group 0.16 +/- 0.42 mm compared to the control group 0.39 +/- 0.78 mm (p = 0.013) and late loss were much smaller in the training group 1.2 +/- 19.5% compared to the control group 13.2 +/- 25.5% (p = 0.002). There were 1 case (1.9%) of in-stent restenosis in the training group and 8 cases (15.7%) in the control group (p = 0.014). Reduction of parameters for angiographic progression in the CR group was consistent with three different generations of DES.

Conclusions: Exercise-based CR program was strongly associated with a significant reduction in late luminal loss, percent diameter stenosis, and late loss in the stented coronary segments, regardless of DES types. It means that CR can slow the progression of in-stent restenosis, very significantly.