USE OF DIETARY SUPPLEMENTS BY PATIENTS UNDERGOING CARDIOPULMONARY REHABILITATION
Jonathan H. Whiteson, MD; Jeannette Jakus, BS; Francois Haas, PhD; Ana Mola, RN, ANP; Horacio D. Pineda, MD; Mariano J. Rey, MD; John and Joan Smilow Cardiac Prevention and Rehabilitation Center, Rusk Institute of Rehabilitation Medicine, NYU School of Medicine
Rationale:
There has been a significant increase in the use of complementary modalities in patients participating in cardiac and pulmonary rehabilitation programs-particularly the use of dietary supplements-with possible adverse effects.
Objectives:
To assess the use of dietary and medicinal supplements in patients undergoing cardiopulmonary rehabilitation.
Methods:
As part of the rehabilitation program admission assessment, patients were asked to complete questionnaires detailing complementary medicine usage. Questions were divided into specific use, role of principle physician in complementary usage, and information source.
Results:
We analyzed the data from 88 patients (52 men, 36 women). 65/88 reported use of dietary supplements (73.9%) but only 24% listed them under "medications." 86% of those surveyed took some form of vitamins, either alone (62%) or with other supplements (38%). Only 23.5% of the physicians seeing these patients inquired about the use of complementary modalities and 44.6% of patients began using supplements prior to informing their physicians. 35% never discussed the use of supplements. Patients reported that they received most of their information about supplements from TV, magazines, family, friends and the Internet. Only 34% received advice from their physicians.
Conclusion:
Patients frequently do not discuss the use of dietary and medicinal supplements with their physicians and do not recognize potential dangerous interactions of supplements and prescribed medications. Patient and physician education relating to the possible benefits, and negative interactions between supplements and prescribed medication is necessary. Physicians should be encouraged to discuss these issues with patients as part of their routine evaluation. Comprehensive cardiopulmonary rehabilitation programs are ideal centers to accomplish this role.
COMPARISON OF BLOOD PRESSURE LOWERING INTERVENTIONS
Rebecca D. Shore, MS; Carl Foster, Richard Pein, Elizabeth Seebach, John Porcari University of Wisconsin-La Crosse
The stress of daily life often contributes to sustained elevations in blood pressure, a cardiovascular risk factor. In this study we compared the effect of 25 minutes of quiet sitting (control) vs meditation, yoga and aerobic exercise on reducing systolic blood pressure (SBP) following an unpleasant provocative stimulus (3*1 minute cold pressor) (CP). Healthy volunteers (n = 12) performed all four interventions in random order (see Table).
All three interventions resulted in significant reductions in SBP compared to both control and CP. Corrected for changes in the control condition, meditation (-17 mm Hg), yoga (-5 mm Hg) and exercise (-14 mm Hg) all produced significant additional decreases in SBP. We conclude that a variety of interventions designed either to downregulate the sympathetic nervous system or enhance vasodilation can contribute to blood pressure control following stressful provocations.
ANGER AND HOSTILITY AS ADDED HEART DISEASE RISK FACTORS.
Waren L. Huberman, PhD; Ezra E. Dweck, BA; Francois Haas, PhD; Adina Fisher, BA; Ayelet Mizrachi, BA; Eric Lee, BA; Jonathan H. Whiteson, MD; Ana Mola, RN, ANP; Horacio D. Pineda, MD; Mariano J. Rey, MD; Joan and Joel Smilow Cardiac Rehabilitation and Prevention Center at The Rusk Institute of Rehabilitation Medicine, NYU School of Medicine
Background:
Although the previous association between Type A personality-competitive, hard working, rigid, and hostile-and increased risk for coronary artery disease (CAD) has fallen into general disfavor, an association with hostility is still accepted. If we regard hostility as equivalent to expressed anger, the relationship between Type A personality and CAD parallels that between anger and myocardial ischemia (Cardiology Clinics; 14:289,1996).
Methods and Results:
In a sample of convenience (n = 346: 251 men, 95 women) referred to the Cardiac Stress Test Laboratory, the Event (E) group (n = 145, 117 men, 28 women) had experienced either: myocardial infarction (MI) (n = 71), coronary bypass (n = 45), or other (n = 29). All subjects completed the Jenkins Activity Survey (JAS) and the State-Trait Anger Expression Inventory, 2nd edition (STAXI-2). The E group produced a higher composite JAS score than the NE (nonevent) group (57.1 +/- 28 vs 51.28 +/- 28.73, P < .03). E also scored higher on Trait Anger (generalized angry feelings) in the STAXI-2 (41.5 +/- 34.5 and 28.53 +/- 30.07, P < .001). Within E, the MI subgroup scored higher on Angry Temperament (easily angered, with poor control) than the bypass/other subgroups (MI = 58.7 +/- 23.0; non-MI = 51.1 +/- 21.6;P < .04).
Discussion:
These data suggest an association between the "traditional" type A personality and increased CAD risk. To the extent that higher JAS and STAXI-2 scores reflect the same characteristic, these results support the notion that poorly managed anger increases risk for CAD, and thus may contribute directly to subsequent MIs in this population.
Conclusion:
Overall, these data point to the need for including anger management techniques in a comprehensive cardiac rehabilitation program to reduce the risk of subsequent events.
CLINICAL EFFECTIVENESS OF A COMMUNITY-BASED CARDIOVASCULAR RISK REDUCTION PROGRAM IN PARTICIPANTS WITH VERSUS WITHOUT THE METABOLIC SYNDROME
Laurence Sperling, MD; Scott Kallish, MA; John Thiel, MA; Richard Leighton, MD; Ivan Levinrad, RPT; Richard Salmon, DDS; Barry Franklin, PhD; Neil Gordon, MD; Emory Heart Center and INTERxVENT Coordinating Center
The metabolic syndrome, a constellation of lipid and nonlipid risk factors linked to insulin resistance, is now recognized as a target of cardiovascular disease (CVD) risk reduction therapy. This study is the first, to our knowledge, to compare the clinical effectiveness of a community-based comprehensive lifestyle management and CVD risk reduction program in participants with (group A, n = 515) and without (group B, n = 1291) the metabolic syndrome. Subjects were evaluated at baseline and after approximately 1 year of participation in the program. Lifestyle interventions included exercise, correct nutrition, weight management, stress management, and smoking cessation. Participants were referred to their personal physicians for consideration of medication changes in accordance with national guidelines. For participants with abnormal baseline CVD risk factors (based on national guidelines), clinically relevant improvements were observed for multiple variables in both groups, as follows (P < .05, unless otherwise indicated): total cholesterol (group A, -24 mg/dL; group B, -30 mg/dL); LDL cholesterol (group A, -15 mg/dL; group B, -17 mg/dL); HDL cholesterol (group A, 4 mg/dL; group B, 4 mg/dL); triglycerides (group A, -38 mg/dL; group B, -29 mg/dL); fasting glucose (group A, -10 mg/dL; group B, -9 mg/dL, P = NS); systolic/diastolic BP (group A, -16/-10 mm Hg; group B, -19/-12 mm Hg), and weight (group A, -4.7 lbs; group B, -1.2 lbs). With the exception of weight (greater decrease in group A) and blood pressure (greater decrease in group B), no other statistically significant (P < .05) differences were observed for group A compared with group B. In participants without coronary heart disease, the calculated Framingham 10-year coronary heart disease risk score decreased (P < .05) by 22.3% in group A and by 22.5% in group B. These data demonstrate the similar clinical effectiveness of a comprehensive lifestyle management and cardiovascular risk reduction program in participants with and without the metabolic syndrome.
CLINICAL EFFECTIVENESS OF A PHASE 2 CARDIAC REHABILITATION PROGRAM IN PATIENTS WITH VERSUS WITHOUT DIABETES
Susan Haapaniemi, MS; Barry Franklin, PhD; Dalynn Badenhop, PhD; Laurence Sperling, MD; Richard Salmon, DDS; Neil Gordon, MD; William Beaumont Hospital and INTERxVENT Coordinating Center
Diabetes is one of the most common comorbid chronic conditions in cardiac rehabilitation program participants. However, scarce data are available on the clinical effectiveness of a contemporary phase 2 cardiac rehabilitation program in participants with diabetes compared to participants without diabetes. In this multicenter study, we compared the effect of a phase 2 cardiac rehabilitation program on multiple cardiovascular disease (CVD) risk factors in patients with (n = 241) and without (n = 575) diabetes. Risk factors were evaluated at baseline and after an average of approximately 90 days of participation in a phase 2 cardiac rehabilitation program at 12 centers in the United States. Fasting blood glucose decreased by 34 mg/dL (P < .05) in participants with diabetes and remained essentially unaltered in participants without diabetes (P < .05 for participants with versus without diabetes). On exit from the phase 2 cardiac rehabilitation program, improvements in multiple other CVD risk factors were observed for participants with and without diabetes who had abnormal baseline risk factor values (based on national clinical guidelines), as follows (P < .05 unless otherwise indicated): total cholesterol (diabetes -47 mg/dL, no diabetes -40 mg/dL); LDL cholesterol (diabetes -32 mg/dL, no diabetes -29 mg/dL); HDL cholesterol (diabetes, 3 mg/dL; no diabetes, 5 mg/dL); triglycerides (diabetes -61 mg/dL; no diabetes -33 mg/dL, P = NS); systolic/diastolic BP (diabetes -19/-16 mm Hg, no diabetes -21/-18 mm Hg) and weight (diabetes -1.7 lbs; no diabetes -2.1 lbs). No statistically significant differences were observed when comparing the changes in participants with and without diabetes. These data indicate that patients with diabetes derive similar benefits in terms of CVD risk factor modification from participation in a contemporary phase 2 cardiac rehabilitation program as compared to patients without diabetes.
CLINICAL EFFECTIVENESS OF A COMMUNITY-BASED CARDIOVASCULAR RISK REDUCTION PROGRAM IN PARTICIPANTS WITH VERSUS WITHOUT PREDIABETES
Tom Savona, MA; Richard Salmon, DDS; Carla English, MHS; Laurence Sperling, MD; Susan Pickel, BSN, MHM; Richard Leighton, MD; Barry Franklin, PhD; Neil Gordon, MD Heart Advocates and INTERxVENT Coordinating Center
Prediabetes, known previously as impaired glucose tolerance or impaired fasting glucose, is associated with a heightened risk for atherosclerotic cardiovascular disease (CVD). This study is the first, to our knowledge, to compare the clinical effectiveness of a community-based comprehensive lifestyle management and CVD risk reduction program in participants with (group A, n = 175) and without (group B, n = 2872) prediabetes. Subjects were evaluated at baseline and after approximately 12 weeks of program participation. Lifestyle interventions included exercise, correct nutrition, weight management, stress management, and smoking cessation. Participants were referred to their personal physicians for consideration of medication changes in accordance with national guidelines. Fasting blood glucose decreased by 7 mg/dL (P < .05) in group A and remained essentially unaltered in Group B (P < .05 for group A versus group B). For participants with abnormal baseline CVD risk factors (based on national guidelines), clinically relevant improvements were observed for multiple variables in both groups, as follows (P < .05): total cholesterol (group A -26 mg/dL, group B -31 mg/dL); LDL cholesterol (group A -21 mg/dL, group B -18 mg/dL); HDL cholesterol (group A 2 mg/dL, group B 3 mg/dL); triglycerides (group A -43 mg/dL, group B -39 mg/dL); systolic/diastolic BP (group A -17/-11 mm Hg, group B -17/-10 mm Hg); and weight (group A -4.9 lbs; group B -2.8 lbs). With the exception of weight (greater decrease in group A) and HDL cholesterol (greater increase in group B), no statistically significant differences were observed for group A compared with group B. In participants without coronary heart disease, the calculated Framingham 10-year coronary heart disease risk score decreased (P < .05) by 19.4% in group A and by 23.4% in group B. These data demonstrate the similar clinical effectiveness of a lifestyle management and cardiovascular risk reduction program in participants with and without prediabetes.
BARRIERS TO PSYCHOLOGICAL COUNSELING IN CARDIAC REHABILITATION
Melissa A. Dues, MS; C. McGillen, MS, RN; M. Kimball, MSW; T. Draper, MBA; M. Rubenfire, MD; University of Michigan Health System Preventive Cardiology
Rationale:
Emotional distress is a predictor of poor prognosis and increased mortality in coronary artery disease (CAD). The negative stigma associated with psychological services and cost has been identified as barriers to utilization of psychiatrist. Psychological assessment, lectures on stress management, and individual counseling are effective in CAD and have been incorporated into some cardiac rehabilitation (CRehab) programs.
Objectives:
We examined compliance and reasons for noncompliance with recommendations for individual psychological counseling in a cardiac rehabilitation program to assess whether the barriers are similar to those encountered in psychiatry.
Methods:
All patients (pts) enrolled in the cardiac rehabilitation program at the University of Michigan are assessed for psychological distress using the Symptom Checklist-90R (SCL-90R). Patients scoring high (T > 60) on the General Stress Index (GSI), Anxiety, Depression, or Hostility subscales are informed of their scores and recommended psychological counseling by our clinical social worker. All CRehab pts receive group lectures on stress management. Forty pts (men 78%, women 22%) who completed the SCL-90R were assessed for compliance and queried for reasons for non-compliance. Reasons for declining were categorized into "cost," "work conflicts," "not interested," and "other."
Results:
47.5% of the 40 patients were recommended counseling, and of these 42.1% agreed. Of the 57.9% who refused counseling the reasons were: "cost" (18.2%), "work conflicts" (9.1%), "not interested" (18.2%), and "other" (54.5%). The majority choosing "other" suggested they did not believe the SCL-90 score was accurate.
Conclusion:
While approximately 50% of cardiac rehabilitation patients could benefit from counseling based upon the SCL-90R, over half decline. The major reason for refusal appears to be the stigma of the need for psychotherapy and lack of confidence in the test result. The latter may be characteristic of denial used by CAD patients or a reflection of concern regarding the stigma.
FOLLOW-UP ATTENDANCE IN A INTENSIVE LIFESTYLE MODIFICATION PROGRAM CORRELATES WITH IMPROVED BODY COMPOSITION AND CARDIOVASCULAR FITNESS
Thomas A. Draper, MBA; K. Shoemake, MS; S. Housholder-Hughes, NP, MSN, FAHA; G. Maly, MPH; D. Smith; M. Rubenfire, MD; University of Michigan Health System Preventive Cardiology
Rationale:
Improved body composition and cardiovascular (CV) fitness are benefits of a regular exercise program. Correlation between attending on-site follow-up visits after an intense residential program and changes in body composition and CV fitness are unknown.
Objectives:
To determine the correlation between compliance with monthly follow-up visits and improvements in body composition and CV fitness after a 40-hour intense residential lifestyle modification program.
Methods:
Patients enrolled in a 1-year medically based lifestyle modification program that included a 5-day, 40-hour residential program consisting of didactic lectures and experience in stress management, nutrition, exercise, and cardiac risk factors followed by 12 monthly visits were examined. 17 patients (59 +/- 6.9 years old, 84% male, 72% with CAD, baseline VO2 18.7 +/- 5.1 mL/kg/min, BMI 35.1 +/- 8.8) underwent maximal treadmill VO2 and body composition testing at baseline and 1 year. Follow-up visits consisted of a clinic visit with nurse practitioner, meditation, exercise and group therapy. Group A attended > 75% (10-12 sessions), group B attended < 75% (5-9 sessions).
Results:
After 1 year, group A significantly decreased weight, body fat %, BMI, increased maximal treadmill VO2, and total exercise test time (ETT) from baseline. Group B demonstrated a similar but insignificant trend to improvement in each variable. Group A showed greater improvement than group B in BMI (see Table).
Conclusions:
In an intense life-style modification program consisting of a 5-day residential program and monthly follow-up, patient commitment to regular participation in follow-up appears necessary to achieve goals.
PRE- AND POSTCARDIAC REHABILITATION QUALTIY-OF-LIFE SCORES COMPARED TO AGE-MATCHED HEALTHY ADULTS SCORES ON THE SF-36 HEALTH QUESTIONAIRE
Dalynn T. Badenhop, PhD, FAACVPR; Brad Chapman, MS; Ian Smith, MS
The purpose of this observational study was to compare health-related quality of life (QOL) in cardiovascular disease patients participating in a cardiac rehabilitation (CR) program with published QOL scores for healthy adults of the same age group. Health-related QOL was assessed using the SF-36 questionnaire prior to CR in 198 patients (63.3 years +/- 10.7) and following 3 months of CR in 121 patients (63.6 years +/- 10.2). The SF-36 is comprised of eight health domains: Physical Functioning, (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (V), Social Functioning (SF), Role Emotional (RE), and Mental Health (MH). One-sample t tests were used to determine if pre-rehabilitation and post-rehabilitation QOL scores differed from published mean QOL scores. A probability level of P < .01 was considered significant. QOL scores for all age groups were significantly lower (P < .01) than published healthy adult scores prior to CR in every SF-36 domain. Prerehabilitation QOL scores on the SF-36 were significantly lower (P < .01) than healthy adult scores for the domains PF, RP, BP, GH, V, SF, in patients age 45 to 54 years; PF, RP, V, SF, and RE in patients age 55 to 64 years; PF, RP, V, SF, and RE in patients age 65 to 74 years; RP and V in patients age 75 and older. QOL scores for all age groups postrehabilitation were significantly lower (P < .01) for the domains PF, RP, and GH. Postrehabilitation QOL scores in patients age 75 and older were significantly higher (P < .01) for the domain of SF than published scores for healthy adults. Overall, patients scored lower than healthy adults on the SF-36 questionnaire prior to CR and matched healthy adult scores postrehabilitation. All age groups of patients matched or exceeded QOL scores for healthy adults in most of the domains measured by the SF-36 after treatment in a CR program. CR may improve the health-related QOL in patients with cardiovascular disease, especially in older adults.
A WOMEN'S-ONLY PHASE 2 CARDIAC REHABILITATION PROGRAM: A PILOT STUDY
Theresa Beckie; Ami Drimmer; Anthony Goldman; Rodney Randall; University of South Florida
Objectives:
The aims of this study were to: (1) estimate the feasibility of implementing a women's-only cardiac rehabilitation (CR) program with respect to compliance, completion rates, and the effectiveness of participant incentives; (2) estimate the magnitude of treatment effects, both psychosocial and physical, by comparing pretest and posttest measurements; and (3) assess participant perceptions of the strengths and weaknesses of the program.
Methods:
Using a one-group pretest/posttest design, a sample of women, with a mean age of 63 years, was drawn from women in a west central Florida hospital who were eligible to participate in a CR program. The intervention was a 12-week, 36-session program involving gender-sensitive education and counseling. The exercise training consisted of three 1-hour sessions of combined aerobic and resistance exercise/week.
Results:
All participants improved their functional capacity as measured by an exercise treadmill test. Participants demonstrated a 21% improvement in exercise capacity (METs), and a 35% improvement in treadmill exercise time. The participants showed a 10% change in HDL cholesterol levels. Treatment effects were standardized using Cohen's (1988) effect size index d for direct comparisons. Twenty-seven physiological outcomes were examined to estimate effect sizes (d range: 0.063-2.909, median 0.663). Among the 16 psychosocial outcomes, depression improved by 57% (d = 1.918). Health perceptions, measured by the SF-36 Health Survey, improved on various subscales; the role functioning-emotional subscale showed 21% improvement, d = 1.685. Other psychosocial outcomes showed notable improvements. The participants' perceptions of the strengths and weaknesses of the intervention were assessed with debriefing questionnaires. While compliance was very good, poor insurance coverage and lack of transportation were the most common barriers to participation.
Conclusion:
This pilot study demonstrated the feasibility of implementing a gender-sensitive CR program and provided information on the relative magnitude of change in physiological and psychosocial variables targeted by the program.
EFFICACY OF A STEPPED-CARE APPROACH TO SMOKING CESSATION IN PATIENTS WITH CORONARY ARTERY DISEASE
Monika E. Slovinec D'Angelo; Robert D. Reid; Andrew L. Pipe; William Dafoe; University of Ottawa Heart Institute
Rationale:
Smoking cessation is an important goal for smokers with coronary artery disease (CAD) because it reduces cardiac morbidity and mortality. Unfortunately, only one third to one half of smokers with evidence of heart disease reduce or quit smoking on their own. Effective interventions for smokers with CAD exist, but they are intensive/expensive. Stepped-care interventions have been proposed as a promising approach to allocate smoking cessation treatments in a cost-effective way. Stepped care refers to the practice of initiating treatment with low-intensity intervention and then exposing treatment failures to successively more intense interventions.
Objective:
The objective of the present study was to determine whether a stepped-care treatment would help smokers hospitalized with CAD to quit smoking over 3-month and 1-year follow-up periods.
Methods:
We gave 254 smokers with documented CAD a brief cessation treatment similar to that recommended in guidelines for hospitalized smokers. Then, some participants (n = 126) were randomly assigned to receive a more intensive stepped-care treatment, one that involved nurse counselling and nicotine replacement therapy, initiated 1-month posthospital discharge. Primary outcomes were abstinence measured at 3 months and 1 year postdischarge.
Results:
The stepped-care treatment increased smoking cessation rates from 42% to 53% at 3-month follow-up (P = .05) but had little effect at 1-year follow-up, where the cessation rate was increased from 36% to 38% (P = .89). Analysis of outcomes stratified by reason for admission showed the short-term effectiveness of the stepped-care intervention was due to its impact on patients admitted for percutaneous transluminal coronary angioplasty (PTCA)/angiogram procedures, where 3-month abstinence rates increased from 29% to 48% (P = .03).
Conclusion:
A stepped-care approach to smoking cessation, as implemented in this study, increased short-but not long-term point-prevalent abstinence in patients hospitalized with CAD. Continued refinement of the timing and content of step-up treatments is required before this form of treatment can be recommended.