HEART IS ASKING FOR LESS BLOOD WITH YOGA THERAPY AFTER MYOCARDIAL INFARCTION
Bhavin Dalal, MD; Dr Kamal Goplani; Dr Praveen Garg; Dr Pranav Dalal; Dr Himanshu Desai
Objectives:
To evaluate role of yoga therapy and deep-breathing exercise in patients of myocardial infarction.
Methods:
23 postmyocardial infarction patients received yoga therapy and deep-breathing exercise training along with standard pharmacotherapy during recovery period of myocardial infarction, while 16 controls received only standard pharmacotherapy. Standard pharmacotherapy was given from the very first day of admission while yoga therapy was started within 10 to 20 days of admission. All patients in study group are taught for yoga therapy and deep breathing exercise in two to three episodes and are asked to continue the same at home. Follow up was done after 2 months.
Results:
Number of anginal pain events and episodes of dyspnea were 20.2% and 18% lower in study group compared to control group. Mean pulse rate in study group was 10.5% lower than control group. Sense of well-being and exercise tolerance was better in study group. Level of stress was decreased in study group significantly.
Conclusion:
Apart from routine pharmacotherapy alternative medicine therapies are quite useful in treating lethal and chronic disorders. Yoga therapy is quiet useful in relaxing the patients. Apart from effectiveness, zero cost, and no side effects are other advantages of this therapy.
EVALUATION OF THE VAS Q ASSESSMENT AS AN OUTCOMES TOOL FOR CARDIAC REHABILITATION PROGRAMS
Wendy L. Taylor, MS; Christopher C. Manetz, MS; Shore Cardiopulmonary Wellness Services, Onley, VA
The purpose of this pilot study is to evaluate the use of the VAS Q Assessment as a tool to measure a patient's perception of change in aerobic capacity pre- to postcardiac rehabilitation. The VAS Q Assessment was designed as a tool to estimate a patient's MET level for activities of daily living. The VAS Q Assessment has also been used by some exercise testing laboratories to help determine the appropriateness of an exercise stress test protocol. Ten phase 2 cardiac rehabilitation patients were randomly selected following discharge to compare perceived improvement in aerobic capacity using the estimated MET score determined by the VAS Q Assessment. The VAS Q Assessment was administered to each patient prior to starting cardiac rehabilitation and then again following discharge from cardiac rehabilitation. The population selected included 6 men and 4 women between the ages of 54 and 76 who completed an average of 32 exercise sessions within a 12-week period. The patients demonstrated a perceived improvement in aerobic capacity with a mean increase of 3.95 METS. This pilot study may demonstrate how the VAS Q Assessment can be used as a tool to measure a significant physiologic outcome in cardiac rehabilitation programs. A future study may include using the VAS Q Assessment as a tool to measure the accuracy of a patient's report of aerobic capacity as compared to absolute METS achieved on an exercise stress test.
THE EFFECTIVENESS OF DIETARY INTERVENTIONS ON CLINICAL OUTCOME IN PATIENTS PARTICIPATING IN CARDIAC REHABILITATION
Michael Angeletti; Eva Rachkovsky; Teresa Caulin-Glaser; Yale University School of Medicine
Rationale:
Weight loss is recommended to lower blood pressure, total cholesterol, low-density lipoprotein cholesterol, triglycerides, blood glucose, and to raise low levels of high-density lipoprotein cholesterol in overweight patients. However, the independent effect of various types of dietary interventions during cardiac rehabilitation (CR) on BMI, body fat, weight, waist circumference, and exercise capacity has not been well established.
Objectives:
Nutrition lectures and an adjunctive low-fat diet with targeted caloric reduction developed by a registered dietitian are more effective as compared to nutrition lectures and counseling alone in improving clinical profile and outcome for patients participating in CR.
Methods:
A total of 158 patients with BMI > 25 (95 men, 63 women) participated in either nutrition lectures and counseling (n = 89 delivered by the CR program manager, n = 34 delivered by a register dietitian) or nutrition lectures combined with a diet plan (n = 44). Patients completed a 12-week CR program; pre- and postoutcome variables included BMI, body fat distribution, waist circumference, weight, and exercise capacity.
Results:
After adjustment for other variables, those participating in lectures with adjunctive diet plans demonstrated a significant decrease in weight (-6.6 lbs, P < .001); waist circumference (-0.54 inches, P < .02); BMI (-0.91;P < .001); and body fat distribution (-1.14%, P < .034) as compared to patients who received lectures and counseling alone. There was no significant difference in exercise capacity pre- and postcompletion of the program between the groups.
Conclusion:
Nutritional lectures and counseling, delivered by experienced CR staff or a registered dietitian, are less effective in achieving important clinical outcomes compared to a more aggressive approach consisting of lectures with an adjunctive low fat diet with targeted caloric reduction in patients participating in CR.
CHARACTERISTICS OF CAD PATIENTS WHO IMPROVE SMALL ARTERY COMPLIANCE AFTER UNDERGOING CARDIAC REHABILITATION PROGRAM
Patricia Brownstein; Mohammad A. Rafey; Jonathan P Greenblatt; Lorene Bruno; Robert A. Phillips; Mount Sinai School of Medicine/ Lenox Hill Hospital, New York, NY
Rationale:
Patients with coronary artery disease (CAD) differ in their response to cardiac rehabilitation program. Identification of factors that influence optimal improvement would help in designing programs suited to patient needs.
Objectives:
Small artery compliance (SAC) is an earlier and more reliable predictor of cardiovascular events. We looked at the characteristics of the patients with CAD who showed significant improvement in the SAC following cardiac rehabilitation.
Methods:
27 patients with known CAD and no history of systolic hypertension who were referred to the cardiac rehabilitation program were enrolled in the study. The program consisted of 8 to 12 weeks of aerobic exercise (20-30 minutes/day 3 times a week target heart rate of 70%-80% of maximum heart rate). SAC was measured noninvasively using HDI Pulsewave CR 2000 device at the beginning and upon the completion of the program.
Results:
The mean small artery elasticity index (SAEI, mL/mm Hg x 100) in those who improved was 4.02 +/- .6 and in those whom it did not improve it was 6.4 +/- 1.06 (P = .03). The patients who improved were older, were obese, and had a higher percentage of body fat at baseline (see Table).
Conclusion:
CAD patients who were obese had a more severe reduction in SAC at baseline and showed significant improvement following cardiac rehabilitation. We hypothesize that in these patients endothelial dysfunction is partially contributed by obesity and higher body fat content and thus showed improvement with exercise.
ENERGY COST AND MYOCARDIAL OXYGEN DEMAND OF VACUUMING USING DIFFERENT MODELS OF VACUUM CLEANERS
J.F. Norman; J. Kautz; H. Wengler; E.R. Lyden; University of Nebraska Medical Center, Omaha, NE
Purpose:
Vacuuming can be difficult for individuals with cardiovascular disease to perform without becoming symptomatic. The aim of this study was to compare the VO2 and myocardial oxygen demand of vacuuming using five different models of vacuum cleaners.
Methods:
Thirty-six healthy females 50 to 59 years of age (54.5 +/- 3.1 years) participated in this study. An AeroSport KB1-C portable metabolic gas analyzer and Polar heart rate monitor were used to measure VO2 and heart rate (HR). Subjects were randomized to perform vacuuming in one of six different sequences. Vacuuming consisted of using three upright models and two canister models for 6 minutes each on medium pile carpet VO2, HR, and blood pressure (BP) were recorded at rest (baseline) and during each task. The rate-pressure product (RPP) was calculated to estimate myocardial oxygen demand (MVO2). One-way repeated measures ANOVA were performed for comparison of VO2, HR, RPP, and systolic BP (SBP). Significance was set at P >= .05.
Results:
see Table.
Conclusions:
Significant differences in VO2 and MVO2 were associated with using different models of vacuum cleaners. For individuals who become symptomatic during vacuuming, selecting a less demanding model may be an appropriate recommendation. However, those individuals who are symptomatic using a self-propelled upright model may need to avoid performing this housekeeping task.
WOUTCOMES OF CARDIAC REHAB AT BROOKE ARMY MEDICAL CENTER
Stacey A. Dramiga, MA, FAACVPR; Kenneth M. Leclerc, MAJ,MC; Bernard J. Rubal, PhD; and James Bulgrin, BSEE; Brooke Army Medical Center, Fort Sam Houston, Texas
Introduction:
In a time of diminishing healthcare dollars, cardiac rehab needs to document its value in measurable terms.
Procedure:
Between October 1, 1999 and August 31, 2001, 240 patients completed our locally developed cardiac rehab program. Twenty of the 240 did not have sufficient data recorded for analysis. Parameters examined include entry and completion treadmill exercise levels, vital signs and weight, with stratification by left ventricular ejection function and method of revascularization.
Demographics:
157 (71%) were male. Average age for all patients was 65 years: 16% were post-CABG, 42% post intervention, and 14% post MI. The average number of sessions attended by patients was 20, with average number of days between entry and completion of 99. By AACVPR risk stratification criteria for ejection fraction, 12% were high risk, 12% were moderate risk, and the remaining 76% were characterized as low risk.
Results:
Average increase in treadmill time was 20 +/- 8 minutes. Average increase in speed was 1.2 +/- 2.6 mph and average increase in percent grade was 5.4 +/- 4.2%. A more meaningful measure of functional progress demonstrated an average increase in metabolic equivalents (METs) of 3.2 +/- 2.0, (135% increase). There was no statistical difference between high-, moderate-, or low-risk subgroups, or gender, with regard to MET improvements.
Conclusions:
Following our locally developed step protocol, our patients showed substantial increases in exercise capacity. This was seen in terms of treadmill speed, grade and METs, and was evident regardless of age, gender, or left ejection fraction. This is an example of potential outcome measures worth tracking.
USE OF DOUBLE PRODUCT AND SF-12 TO ASSESS OUTCOMES IN PHASE 2 CARDIAC REHABILITATION
Geralyn M. Karpiscak, RN, C, BSN, Cardiopulmonary Rehabilitation, The Medical Center at Princeton, Princeton, NJ; Mark S. Zaleskiewicz, MS, FAACVPR, Cardiopulmonary Rehabilitation, Shore Memorial Hospital, Somers Point, NJ
This is a retrospective study of all enrolled cardiac rehabilitation (CR) patients at The Medical Center of Princeton for the years 2000-2001. 236 patients records were evaluated. Inclusion criteria (completed 36-exercise session, completed pre/post evaluations, no medication changes or hospitalizations) limited the study to 65 participants. The purpose of this study was to look at statistical significance and correlation of change in double product (DP) and SF-12 mental (SFM) and SF-12 physical (SFP) indicators measured pre and post phase 2 CR. Double product (systolic blood pressure times heart rate) was measured at a workload determined by the CR staff based on patient's exercise prescription. The same workload was used for each patient at the completion of their phase 2 program. SF-12 Mental and Physical scores were assessed during the first or second session and reassessed during the last week of CR.
Overall group t tests (n = 65) revealed significant differences (P < .05) in pre/post: [a] DP (12296 +/- 2868, 9615 +/- 1634); [b] SFP (39.7 +/- 9.3; 49.0 +/- 8.6); [c] SFM (51.0 +/- 9.9, 54.6 +/- 6.8). No correlation found in [a] DP/SFP, [b] DP/SFM, and [c] SFP/SFM.
Female group t tests (n = 9) revealed significant differences (P < .05) in pre/post: [a] DP (11481 +/- 1525, 9484 +/- 1679); [b] SFP (39.0 +/- 9.2, 44.8 +/- 10.15), [c] SFM (43.4.0 +/- 11.1, 54.6 +/- 7.2). A modest correlation was found in DP/SFP (.56) No correlation was found between DP/SFM and SFP/SFM.
Male group t tests (n = 56) revealed significant differences (P < .05) in pre/post: [a] DP (12427 +/- 3019, 9636 +/- 1641) and [b] SFP (39.8 +/- 9.4, 49.9 +/- 8.2) but no significant difference (P = .08) pre/post for MFP (52.3 +/- 9.2, 54.6 +/- 6.8). No correlation was found between [a] DP/SFP, [b] DP/SFM, and [c] SFP/SFM.
In conclusion, although there was significant change in pre/post SFM and SFP for both male and females, there was only modest correlation in our very small female group. The data suggests a need for further investigation with a larger sampling.
AGE-RELATED INCREASE IN HEART RATE RECOVERY DURING CARDIAC REHABILITATION
Andrew Chai; Steven C. Hao, MD; Paul Kligfield, MD; Cardiac Health Center, The New York-Presbyterian Hospital, and Division of Cardiology, Weill Medical College of Cornell University
The magnitude of decrease in heart rate during the minute after completion of peak exercise, defined as heart rate recovery (HRR), is an independent predictor of cardiac mortality, perhaps as a correlate of parasympathetic tone. It has been shown recently that HRR can be modified by exercise training in patients with heart disease, but the relationship of age to the effect of training on HRR is not known. Accordingly, we examined HRR before and after a 12-week program of phase 2 cardiac rehabilitation in 60 patients (42 men, mean age 67 years), whose predominant diagnoses were chronic stable angina and recent coronary artery bypass surgery, with or without recent myocardial infarction. HRR was measured as the peak heart rate during symptom-limited treadmill exercise minus the heart rate after one minute of a standardized walking cool-down period. For the group as a whole, effort training resulted in an increase in effort tolerance (8.3-9.7 estimated treadmill METs, P < .001), no change in peak exercise heart rate, and a 24% increase in HRR after cardiac rehabilitation (15.2-18.9 beats/min, P < .001). There were 37 patients > 65 years and 23 patients < 65. Peak estimated MET levels and HRR values, both before and after exercise training, were lower in the older than in the younger patients. However, despite comparable peak exercise heart rates within age groups before and after cardiac rehabilitation, HRR recovery increased significantly during training in both groups, from 18.8 +/- 9.0 to 23.4 +/- 10.9 beats/min in the younger patients (24% increase, P < .025) and from 13.0 +/- 7.2 to 16.0 +/- 7.8 beats/min in the older patients (23% increase, P < .025). These findings indicate that significant increase in HRR with exercise training can occur in older as well as in younger cardiac patients.
CLINICAL EFFECTIVENESS OF A PHASE 2 CARDIAC REHABILITATION PROGRAM IN PATIENTS WITH VERSUS WITHOUT A SELF-REPORTED HISTORY OF DEPRESSION
Barry Franklin PhD; Susan Haapaniemi, MS; Richard Salmon, DDS; Brenda Mitchell, PhD; Neil Gordon, MD William Beaumont Hospital and INTERxVENT Coordinating Center
Recent studies suggest that depressed patients with cardiovascular disease (CVD) are less likely to take prescribed medications and adhere to recommended behavior and lifestyle changes intended to reduce the risk of recurrent cardiac events. In this multicenter study, we compared the effect of a contemporary phase 2 cardiac rehabilitation program on multiple CVD risk factors in patients with (n = 165) and without (n = 760) self-reported current or previous problems with depression. 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. Of the patients with a self-reported history of depression, 73 (44%) indicated that they were experiencing problems with depression at baseline. On exit from the phase 2 cardiac rehabilitation program, improvements (P < .05) in multiple CVD risk factors were observed for participants with and without a self-reported history of depression who had abnormal baseline risk factor values (based on national clinical guidelines), as follows: total cholesterol (depression -35 mg/dL, no depression -45 mg/dL); LDL cholesterol (depression -27 mg/dL, no depression -33 mg/dL); HDL cholesterol (depression 3 mg/dL, no depression 6 mg/dL); triglycerides (depression -62 mg/dL, no depression -36 mg/dL); fasting glucose (depression -33 mg/dL; no depression -33 mg/dL); systolic/diastolic BP (depression -17/-15 mm Hg, no depression -21/-18 mm Hg) and weight (depression -2.5 lbs; no depression -1.9 lbs). No statistically significant differences were observed when comparing the changes in participants with and without a self-reported history of depression. Although additional research is needed to fully clarify the influence of depression on clinical outcomes, these data suggest that participants with a self-reported history of depression and abnormal CVD risk factors derive similar improvements in CVD risk factors during participation in a contemporary phase 2 cardiac rehabilitation program as compared with participants without a self-reported history of depression.
EFFECTS OF ORLISTAT IN A 12-WEEK CARDIAC REHABILITATION PROGRAM
Linda Erickson; Ronald V. Gerardo; Dora Quan; Marilyn Baily; Kim Seibert; Scott L. Charland; Rajul Patel; Maricopa Integrated Health System
Rationale:
In 2000, 56.4% of US adults were considered overweight or obese, compared with 45% in 1991. Obesity is associated with a number of diseases including diabetes and coronary heart disease (CHD). Weight loss reduces the risk of diabetes, CHD, hypertension, and hyperlipidemia.
Objective:
To determine the effects of Orlistat in obese patients currently enrolled in a cardiac rehabilitation program (CRP).
Methods:
Patients participating in a CRP were evaluated for orlistat therapy based on a BMI > 27, compliance-history, an understanding of the program, and willingness to receive orlistat. All patients participating in the CRP exercised 3 times per week and attended classes on nutrition and CHD. Data was collected on all patients participating in the CRP (orlistat/no orlistat) with a BMI > 27 and completing > 30 sessions. Data included: weight, medications, BMI, lipids, glucose, BP, HR, max MET, and SF-36 quality of life (QoL).
Results:
Twenty-four patients (11 Orlistat, 13 control) meet criteria for evaluation. Baseline characteristics were similar except for max MET (P = .04) and SF-36 general health QoL (P = .04). At the end of the program there was a statistically significant difference from baseline between Orlistat and control in BMI (-1.4 +/- 1.5 versus 0.4 +/- 1.1;P = .003), weight (-8 lbs +/- 8.4 vs 2.5 lbs +/- 6.4;P = .003), SF-36 general-health QoL (9 +/- 14.1 versus -11.3 +/- 19.8;P = .009), and SF-36 mental-health QoL (P = .02). Other parameters were not significantly different. Orlistat was well tolerated. One patient discontinued orlistat therapy after 3 days secondary to GI effects.
Conclusion:
Patients receiving Orlistat and completing the CRP, lost weight (3.7%) compared to a weight gain in those receiving diet and exercise alone (1.3%). Orlistat may provide additional benefit to diet and exercise in patients participating in a CRP.
C-REACTIVE PROTEIN AND IL-6 ARE MODIFIED BY CARDIAC REHABILITATION
David G. Edwards; Margaret Davis; Peter H. Brubaker; Gary L. Pierce; Christiaan Leeuwenburgh; Randy W. Braith; Center for Exercise Science, University of Florida and Health & Exercise Science, Wake Forest University
It is now accepted that systemic inflammation plays a pivotal role in the development and progression of atherosclerosis. Inflammatory mediators such as C-reactive protein (CRP) and interleukin-6 (IL-6) have been used to predict future coronary events in both patients with established coronary artery disease (CAD) and apparently healthy individuals. The use of statins or aspirin has been shown to reduce the reoccurrence of coronary events in patients with high CRP levels, presumably through their anti-inflammatory actions. In contrast, the effect of cardiac rehabilitation on inflammatory markers has yet to be prospectively investigated in patients with known CAD. Purpose: The purpose of this study was to prospectively study the effects of a standard 12-week cardiac rehabilitation program on plasma IL-6 and CRP in patients with CAD.
Methods:
Plasma was collected from 13 patients (mean age = 58.5) at entry into cardiac rehabilitation and again at 12 weeks after completion of the program. ELISA was used to analyze the plasma for IL-6 (Cayman Chemical) and CRP (Alpha Diagnostic).
Results:
Average exercise program compliance among the 14 patients was 77%. Cardiac rehabilitation significantly reduced IL-6 (8.23 +/- 1.82 vs 6.23 +/- 1.50 pg/mL, P < .05) and CRP (0.31 +/- 0.07 vs 0.17 +/- 0.05 mg/dL, P < .01).
Conclusion:
These data, from a cohort of CAD patients, indicate that cardiac rehabilitation has an anti-inflammatory effect. Because cardiac rehabilitation is multi-disciplinary in nature it is unclear what aspect(s) of cardiac rehabilitation might be responsible for this anti-inflammatory effect. Regardless, the decrease in these two important inflammatory mediators may reduce the risk for future coronary events.
IS RELEVANT INFORMATION LOST BY TERMINATING GXT AT 85% APMHR IN CAD PATIENTS?
Laura J. White; Peter H. Brubaker, FAACVPR; James H. Ross; Donald B. Bergey; Henry S. Miller Jr, MD
Introduction:
Graded exercise tests (GXT) are commonly terminated at 85% of age-predicted maximal heart rate (APMHR = 220 b/min - age) due to a belief that there are diminished benefits and increased risks by exceeding it. Thus, the purpose is to: (1) determine the percentage of patients that are/are not capable of exceeding 85% of APMHR during a GXT; (2) evaluate the risk versus information gained by going beyond the 85% APMHR cutoff to a "symptom-limited" level GXT.
Methods:
We retrospectively reviewed GXTs of patients entering our outpatient cardiac rehabilitation program and excluded patients on negative chronotropic medications, who had a pacemaker/ICD, or whose GXT was terminated prematurely due to contraindications. Eighty-five percent of each patient's APMHR was calculated. In those failing to reach 85% APMHR, respiratory exchange ratio (RER) and rating of perceived exertion (RPE) were used to judge degree of effort. Those exceeding 85% APMHR had heart rate reserve based on actual peak levels versus that calculated from data at 85% APMHR compared. We evaluated the frequency of untoward events and diagnostic changes that occurred above the 85% APMHR.
Results:
Of the 70 patients not excluded, 31 (44%) were unable to achieve a HR above 85% APMHR, yet at peak effort these patients had an mean (+/- SD) RER of 1.06 +/- .07 and RPE of 16.0 +/- 1.3, suggesting adequate levels of exertion. Conversely, 39 (56%) were able to achieve HR that averaged 20 +/- 10 b/min above their 85% APMHR. The HR range for exercise training (60%-80% intensity) calculated from peak HR was significantly higher (120-143 b/m) than that of the 85% APMHR level (109-126 b/min). There were no untoward events in either group, yet ischemic changes and/or arrhythmias were noted in 5 patients above, but not below, the 85% APMHR level.
Conclusions:
These results indicate that approximately 50% of patients not excluded were capable of exceeding the 85% APMHR cutoff on a GXT and that terminating the GXT at this "arbitrary" level resulted in the loss of valuable information. Based on this study, 85% APMHR levels should not be used to terminate a GXT.
RELATIONSHIP OF LIPID PROFILES AND PLASMA CRP LEVELS IN PATIENTS ENTERING CARDIAC REHABILITATION
Maggie Davis; D. G. Edwards; P. H. Brubaker, FAACVPR; T. Phillips; C. Leeuwenburgh; R. W. Braith, FAACVPR; Wake Forest University; University of Florida
Rationale:
Lipid profiles have been a standard means to identify persons at risk for future cardiac events. It is now accepted that systemic inflammation plays a pivotal role in the development and progression of atherosclerosis. Recently, the inflammatory mediator C-reactive protein (CRP) has been used to predict future coronary events in both patients with established coronary artery disease (CAD) and apparently healthy individuals independent of lipid levels.
Objective:
We sought to determine if there was a relationship between lipid profiles and plasma levels of CRP in patients entering a phase 2 cardiac rehabilitation program.
Methods:
We studied 23 patients with documented CAD (age = 60.3 +/- 2.3). Lipids were measured after a 12-hour fast and analyzed using standardized methods. CRP was measured by ELISA (Cayman Chemical).
Results:
Mean total cholesterol (TC) was 188.7 +/- 12.6 mg/dL (range = 123 to 422), LDL was 119.2 +/- 10.6 mg/dL (range = 56 to 324), HDL was 39.1 +/- 2.3 mg/dL (range = 23-64), and TC/HDL was 5.1 +/- 0.4 (range = 2.9-11.1). Mean plasma CRP levels were 0.37 +/- 0.06 mg/dL with a range from 0.01 to 1.20. Using CRP distribution from healthy individuals, 2 patients were classified as low risk (0.01-0.07), 2 were at mild risk (0.08-0.11), 5 were at moderate risk (0.12-0.19), 6 were at high risk (0.20-0.38), and 8 were at highest risk (0.38-1.50). We found no significant correlations between plasma CRP levels and any of the lipid variables. In fact, 4 patients with desirable LDL levels (< 100 mg/dL) were classified as highest risk for future coronary events based on CRP.
Conclusion:
Because CRP is an independent predictor of future cardiac events it is important to note that CAD patients with lipids in the desirable range may still be at increased risk for future events. Therefore, evaluation of CRP levels at entrance to cardiac rehabilitation may aid in identifying CAD patients in need of more intense secondary prevention.
SYSTEMATIC REVIEW OF THE ECONOMIC EVIDENCE ON CARDIAC REHABILITATION PROGRAMS FOR PEOPLE WITH CORONARY HEART DISEASE
Allan G. Brown; Hussein Noorani (Canadian Coordinating Office for Health Technology Assessment-CCOHTA); Rod Taylor (University of Birmingham UK); James Stone (University of Calgary and the Canadian Association of Cardiac Rehabilitation); Becky Skidmore (CCOHTA) Canadian Coordinating Office for Health Technology Assessment
Rationale:
Coronary heart disease (CHD) imposes a large burden on health and healthcare resources in industrialized countries. Exercise based or comprehensive rehabilitation programs are a possible intervention used for secondary prevention in patients with CHD. Systematic reviews of their effectiveness exist, but reviews of their cost-effectiveness are rare.
Objectives:
The study reviews the existing evidence on cost-effectiveness of exercise based (including comprehensive) cardiac rehabilitation, for secondary prevention in patients with CHD.
Methods:
Evidence from RCT as well as non-RCT based economic studies are included. Evidence from full economic evaluations (examining both costs and consequences), and cost studies are examined. To be included in the review, study participants must have CHD. A standardized data extraction form was used. To reduce bias, two reviewers selected the abstracts, selected the included studies, and extracted the data. Differences of opinion were resolved by consensus.
Results:
A comprehensive literature search identified 614 potential studies. 64 full papers were retrieved for assessment. Of these 6 papers were included in the review. Three of these are full economic evaluations, and 3 are cost studies. Only one of the included studies was RCT-based. One evaluation found an incremental cost per quality adjusted life year gained of $9200. The other two evaluations found an incremental cost per life year gained of $4950, and under $15,000.
Conclusions:
The study results were consistent in that the full economic evaluations all suggest cardiac rehabilitation is highly cost effective, and the cost studies suggest cardiac rehabilitation programs reduce costs to healthcare systems.
QUALITY-OF-LIFE IMPROVEMENT IS DIFFERENT FOR PATIENTS IN CARDIAC AND PULMONARY REHABILITATION
Phillip D. Hoberty, EdD, RRT, The Ohio State University, College of Medicine and Public Health, Columbus; Marci Moreno, MS, RN, and Wendy Hilling, CRT, The Ohio Association for Cardiovascular and Pulmonary Rehabilitation, Columbus
It has been shown that many patients improve in health-related quality of life (HRQL) following cardiac or pulmonary rehabilitation. The improvement can be detected by comparing pre-program to post-program scores on the Medical Outcomes Study Health Survey Short Form (SF-36). However, rehabilitation staff members who are cross-trained to work with both types of patients need to be familiar with the relative starting points and expected improvement.
Methods:
Data were taken from the OCVPR multi-center outcomes project in Ohio that contains HRQL scores from 22 programs. Starting SF-36 scores were compared by an independent t test, and improvements were compared by a repeated measures ANOVA. Significance was set at .05. The Table lists the scores.
Results:
Pulmonary patients had significantly lower pre-program scores on all except Bodily Pain, and their post-program scores improved significantly less on 5 of 8 scales.
Conclusion:
Staff accustom to working with cardiac patients may need to conduct rehabilitation interventions differently for the pulmonary patients who generally start at a lower point and improve less in HRQL.
EXPANSION OF THE CLINICAL PRACTICE GUIDELINE DECISION TREE FOR CARDIAC REHABILITATION: A THEORETICAL APPLICATION OF THE VALSALVA MANEUVER AND EXERCISE TEST RESULTS FOR OPTIMAL EXERCISE TRAINING
L.P. Cahalin; M.J. Zema Boston University and Brookhaven Memorial Hospital Medical Center
Rationale:
The Clinical Practice Guideline Decision Tree for Cardiac Rehabilitation Services has classified patients with an ejection fraction <= 30% as high risk. Methods to rapidly identify cardiac function of patients in cardiac rehabilitation are needed. Measurement of the arterial blood pressure response during the Valsalva maneuver (VMBP) may be an important method to more readily examine cardiac function, identify patients with heart failure (CHF), and allocate optimal cardiac rehabilitation when the VMBP is combined with exercise test (ET) results.
Objectives:
The purpose of this study was to investigate the ability of the VMBP to discriminate between persons with and without CHF and to develop a hypothesis-oriented algorithm (HOA) that would direct allocation of cardiac rehabilitation based on the VMBP and ET results.
Methods:
A search for studies of the VMBP in CHF was performed via PubMed. Discriminate analyses and individual study and combined study effect sizes were calculated to examine the ability of the VMBP to differentiate domains of disablement of persons with and without CHF (level of significance =P < .05).
Results:
A total of 30 articles were found, but only 13 met inclusion criteria. Discriminate analyses revealed that the cardiovascular response during the VMBP discriminated CHF from no-CHF 100% of the time (P < .05) with individual and combined study effect sizes >= 1.55 (P < .0001). No complications were reported during the VMBP in any of the studies. A HOA was developed with VMBP and ET results as the primary and secondary key decision points, respectively.
Conclusion:
The results of this investigation suggest that the cardiovascular response to the VMBP can safely and easily differentiate between CHF and no-CHF and many domains of disablement in patients with CHF, which combined with ET results may allow for optimal allocation of cardiac rehabilitation and development of a HOA.
AVERAGED SESSION HEART RATES IN CARDIAC REHABILITATION
Kimberly W. Woeber; N. Rikard; University of South Carolina Aiken
Effective cardiovascular exercise prescription for individuals participating in outpatient cardiac rehabilitation includes the essential components of appropriate mode(s), intensity, frequency, duration, and rate of progression. Multi-modal programming is particularly encouraged for many cardiac patients "to promote total physical conditioning and maximize the carry-over of training benefits to real-life activities" (ACSM, 2000). The purpose of this study was to determine whether patients participating in multi-modal programming are able to maintain appropriate intensity levels over the period of cardiovascular conditioning to insure exercise training results. Activities, such as moving to different pieces of equipment, obtaining help in properly programming the equipment, reporting data and pausing to get a drink of water, may add 5 to 15 minutes of additional time to the cardiovascular exercise period. Twenty (20) patients from a phase 2 cardiac rehabilitation program, without pacemaker insertion or significant history of arrhythmias, wore Polar a1 heart rate monitors during the cardiovascular training portion of a daily exercise session. The watches recorded averaged heart rate (avg HR) from the beginning to the completion of their prescribed workouts of 30 to 36 minutes. When compared to their target heart rate range (THR), 18 out of the 20 patients, or 90%, had an avg HR within their THR. The participants outside of THR were 4 and 8 beats below the lower end of their THR. When compared to the midpoint of their target heart rate range (MTHR), 10 patients were found to work above their MTHR by an average of 5.4 beats (+1 to +10), 9 patients were below MTHR by an average of 6.6 beats (-.5 to -16), and one patient averaged his MTHR. This study supports the ability of patients to maintain appropriate target heart rate ranges with multi-modal exercise programming, though a few may require some prompting or feedback.