Cardiac rhythm responses. 2. Review of 22 years of nursing research

To discover what questions nurses have been asking about cardiac rhythm responses, a literature search was conducted. A total of 57 nursing studies reported from 1964 through 1987 were identified. Research studies of cardiac rhythm responses could be grouped into four broad categories: (1) those that explored the phenomenon itself; (2) those that measured cardiac rhythm responses alone or in conjunction with other dependent variables as an index of another phenomenon such as fear, stress and anxiety, biologic (circadian) rhythms, pain severity and pain coping, sensory stimulation and overstimulation, fatigue, metabolic energy expenditure, and fetal well-being-fetal oxygen reserve; (3) those that measured cardiac rhythm responses to evaluate the safety or efficacy of various nursing interventions and routines; and (4) those that measured cardiac rhythm responses to evaluate recovery from acute myocardial infarction or cardiac surgery including evaluation of the success of cardiac rehabilitation programs. Four landmark studies that contributed new knowledge or changed practice are discussed. In addition, questions suggesting areas for future research are listed.     

The role of exercise in the rehabilitation of patients with systemic lupus erythematosus and patients with primary Sjögren's syndrome

PURPOSE OF REVIEW: The purpose of this review is to present an update on the evidence-based effects of exercise in systemic lupus erythematosus and in primary Sj?gren's syndrome. RECENT FINDINGS: Physical capacity is reduced in both systemic lupus erythematosus and primary Sj?gren's syndrome and fatigue is a dominating and disabling symptom in both conditions. The documentation on the effect of exercise on the rehabilitation of patients with systemic lupus erythematosus and primary Sj?gren's syndrome is sparse; the studies are few and the sample sizes often small. The available studies indicate that patients with systemic lupus erythematosus of mild to moderate disease activity as well as patients with primary Sj?gren's syndrome benefit from exercise of moderate to high intensity. Positive effects can be expected with regard to aerobic capacity, fatigue, physical function and depression. SUMMARY: There is reason to believe that exercise should be included in the rehabilitation of patients with mild to moderate systemic lupus erythematosus and patients with primary Sj?gren's syndrome. Further research is needed and should aim to evaluate the effect of exercise on groups with varying degree of disease severity and to document the long-term impact on the disease.     

Benefits of Cardiac Rehabilitation and Exercise Training Programs in Elderly Coronary Patients

The authors review several studies from the Ochsner Heart and Vascular Institute showing the benefits of formal phase II cardiac rehabilitation and exercise training programs in elderly patients with coronary artery disease, including benefits on plasma lipids, obesity indices, exercise capacity, peak oxygen consumption, behavioral characteristics (especially depression), and quality of life. Marked benefits were noted in elderly women and all elderly patients over the age of 75 years. The authors conclude that the therapy has proved to be safe and effective for elderly coronary patients, and that these individuals should be routinely referred to, and vigorously encouraged to attend, cardiac rehabilitation programs following major coronary events.     

Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation

BACKGROUND: Recent data indicate that young patients with coronary artery disease (CAD) have a poor long-term prognosis. Although the benefits of formal cardiac rehabilitation and exercise training programs are well established, most of these data come from middle-aged and older patients. METHODS: We assessed baseline behavioral data, quality of life, and risk profiles in 635 consecutive patients with CAD before and after cardiac rehabilitation and exercise training, and specifically assessed data in 104 young patients (mean +/- SD age, 48 +/- 6 years; range, 22-54 years) compared with 260 elderly patients (mean +/- SD age, 75 +/- 3 years; range, 70-85 years). RESULTS: Compared with older patients, young patients had higher body mass indexes (12.2%, P<.001), total cholesterol-high-density lipoprotein ratio (14.6%, P<.01), and triglycerides level (27.2%, P<.01), and a lower high-density lipoprotein cholesterol level (-8.8%, P=.045). Young patients also had higher scores for anxiety and hostility (51.5% and 94.4%, respectively; P<.001 for both), a considerably higher prevalence of anxiety (27.9% vs 13.5%; P<.01) and hostility (12.5% vs 4.6%; P<.01) symptoms, and slightly more depression symptoms (23.1% vs 18.8%) compared with elderly patients. Following cardiac rehabilitation and exercise training, young patients had improvements in body mass index (-1.7%, P<.01), percentage body fat (-4.4%, P<.001), high-density lipoprotein cholesterol level (10.2%, P<.001), high-sensitivity C-reactive protein level (-33.3%, P<.01), peak oxygen consumption (11.3%, P<.001), resting heart rate (-4.5%, P=.01), and resting systolic pressure (-2.3%, P=.049), and marked improvements in scores for depression (-58.5%), anxiety (-46.0%), hostility (-45.7%), somatization (-33.8%), and quality of life (15.8%) (P<.001 for all). Young patients also had greater than 50% to greater than 80% reductions in the prevalence of anxiety (P<.001), hostility (P<.01), and depression (P<.001). CONCLUSION: These data demonstrate the adverse psychological and CAD risk profiles that are present in young patients with CAD following major CAD events, and are consistent with substantial benefit of formal cardiac rehabilitation and exercise training programs in younger adults.     

Significance of Comorbid Psychological Stress and Depression on Outcomes After Cardiac Rehabilitation

Background

Depression is associated with increased mortality in stable coronary heart disease. Cardiac rehabilitation and exercise training has been shown to decrease depression, psychological stress, and mortality after a coronary heart disease event. The presence of depression at completion of cardiac rehabilitation and exercise training is associated with increased mortality. However, it is unknown if depression with comorbid psychological risk factors such as anxiety or hostility confers an additional mortality disadvantage. We evaluated the mortality effect of anxiety and hostility on depression after cardiac rehabilitation and exercise training.

Patients and Methods

We studied 1150 patients with coronary heart disease following major coronary heart disease events who had completed formal cardiac rehabilitation and exercise training. Using Kellner questionnaires, stress levels were measured in 1 of 3 domains: anxiety, hostility, and depression (with an aggregated overall psychological stress score) and divided into 3 groups: nondepressed (n = 1072), depression alone (n = 18), and depression with anxiety or hostility (n = 60). Subjects were analyzed for all-cause mortality over 161 months of follow-up (mean 6.4 years) by National Death Index.

Results

Depression after cardiac rehabilitation was not common (6.8%; mortality 20.8%) but when present, frequently associated with either anxiety or hostility (77% of depressed patients; mortality 22.0%). After adjustment for age, sex, ejection fraction, and baseline peak oxygen consumption, depression alone (hazard ratio [HR] 1.73, P = .04), as well as depression with comorbid psychological stress, was associated with higher mortality (HR 1.98, P = .03). Furthermore, our data showed an increased mortality when both anxiety and hostility were present in addition to depression after cardiac rehabilitation (HR 2.41, P = .04).

Conclusions

After cardiac rehabilitation, depression, when present, is usually associated with other forms of psychological stress, which confers additional mortality. More measures are needed to address psychological stress after cardiac rehabilitation.     

Impact of exercise training on psychological risk factors

Although the role of psychological risk factors has been underemphasized, considerable evidence indicates the adverse effects of various psychosocial stressors in the pathogenesis and recovery from cardiovascular diseases. Substantial data, especially from cardiac rehabilitation and exercise training programs, have demonstrated the role of physical activity, exercise training, and cardiorespiratory fitness, to improve psychological risk factors, including depression, anxiety, hostility, and total psychological stress, as well as stress-related mortality.     

Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training

Numerous studies have indicated that psychological distress, including anxiety, is a significant risk factor for coronary artery disease (CAD). We studied 500 consecutive patients after recent CAD events and demonstrated a very high prevalence of generalized anxiety and moderate to severe anxiety symptoms, particularly in younger patients. In addition, our data demonstrate the abnormal CAD risk profiles in these anxious patients with CAD and the marked improvements in the overall risk profiles, levels of anxiety, and overall quality of life after cardiac rehabilitation and exercise training programs. Greater attention at detecting and treating chronic anxiety, particularly with formal cardiac rehabilitation, is needed for the secondary prevention of CAD.     

Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: a systematic review and meta-analysis

BACKGROUND: To determine the effectiveness of home-based cardiac rehabilitation programmes compared with (i) usual care and (ii) supervised centre-based cardiac rehabilitation on mortality, health related quality of life and modifiable cardiac risk factors of patients with coronary heart disease. METHODS: Systematic review and meta-analysis of randomised controlled trials. Main outcome measures: mortality, smoking cessation, exercise capacity, systolic blood pressure, total cholesterol, psychological status, and health related quality of life. RESULTS: Eighteen included trials for home versus usual rehabilitation and six trials of home versus supervised centre-based rehabilitation were identified. The home-based interventions were clinically heterogeneous, trials often small, with quality poorly reported. Compared with usual care, home-based cardiac rehabilitation had a 4 mm Hg (95% CI 6.5, 1.5) greater reduction in systolic blood pressure, and a reduced relative risk of being a smoker at follow-up (RR 0.71, 95% CI 0.51, 1.00). Differences in exercise capacity, total cholesterol, anxiety and depression were all in favour of the home-based group. In patients post-myocardial infarction exercise capacity was significantly improved in the home rehabilitation group by 1.1 METS (95% CI 0.2, 2.1) compared to usual care. The comparison of home-based with supervised centre-based cardiac rehabilitation revealed no significant differences in exercise capacity, systolic blood pressure and total cholesterol. CONCLUSIONS: Current evidence does not show home-based cardiac rehabilitation to be significantly inferior to centre-based rehabilitation for low-risk cardiac patients. However, the numbers of patients included are less than 750 and ongoing trials will contribute to the debate on the acceptability, effectiveness and cost-effectiveness of home-based cardiac rehabilitation.     

Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis.

AIMS: To establish the effects of relaxation therapy on the recovery from a cardiac ischaemic event and secondary prevention. METHODS AND RESULTS: A search was conducted for controlled trials in which patients with myocardial ischaemia were taught relaxation therapy, and outcomes were measured with respect to physiological, psychological, cardiac effects, return to work and cardiac events. A total of 27 studies were located. Six studies used abbreviated relaxation therapy (3 h or less of instruction), 13 studies used full relaxation therapy (9 h of supervised instruction and discussion), and in eight studies full relaxation therapy was expanded with cognitive therapy (11 h on average). Physiological outcomes: reduction in resting heart rate, increased heart rate variability, improved exercise tolerance and increased high-density lipoprotein cholesterol were found. No effect was found on blood pressure or cholesterol. Psychological outcome: state anxiety was reduced, trait anxiety was not, depression was reduced. Cardiac effects: the frequency of occurrence of angina pectoris was reduced, the occurrence of arrhythmia and exercise induced ischaemia were reduced. Return to work was improved. Cardiac events occurred less frequently, as well as cardiac deaths. With the exception of resting heart rate, the effects were small, absent or not measured in studies in which abbreviated relaxation therapy was given. No difference was found between the effects of full or expanded relaxation therapy. CONCLUSION: Intensive supervised relaxation practice enhances recovery from an ischaemic cardiac event and contributes to secondary prevention. It is an important ingredient of cardiac rehabilitation, in addition to exercise and psycho-education.     

Reduction in C-reactive protein through cardiac rehabilitation and exercise training

OBJECTIVES: This study was designed to assess the effects of three-month formal phase II cardiac rehabilitation and exercise training programs on high-sensitivity C-reactive protein (HSCRP) levels in patients with coronary heart disease (CHD). BACKGROUND: High-sensitivity C-reactive protein is associated with abdominal adiposity and other CHD risk factors and is a potent independent predictor of CHD events. Although weight reduction and statin therapy reduce HSCRP levels, the independent effects of cardiac rehabilitation programs on HSCRP are not well established. METHODS: We analyzed plasma levels of HSCRP in 277 patients with CHD (235 consecutive patients before and after formal phase II cardiac rehabilitation and exercise training programs and 42 "control" patients who did not attend cardiac rehabilitation). Additionally, we determined the effects of cardiac rehabilitation on HSCRP independent of statin therapy and weight loss. RESULTS: Rehabilitation patients improved significantly in body fat, obesity indices, exercise capacity, and other cardiac risk factors. Mean (5.9 +/- 7.7 to 3.8 +/- 5.8 mg/l; -36%; p < 0.0001) and median levels of HSCRP (-41%; p = 0.002) decreased significantly in the rehabilitation group but not in the control population. Similar significant reductions in HSCRP occurred in the rehabilitation patients regardless of whether they received statin therapy or lost weight. CONCLUSIONS: Therapeutic lifestyle changes effected through a three-month cardiac rehabilitation program significantly improved numerous cardiac risk factors. Through this holistic approach to secondary prevention, we observed significant reductions in HSCRP levels. These findings identify another clinical modality of reducing HSCRP beyond use of statin drugs and suggest an additional benefit of formal phase II cardiac rehabilitation and exercise training programs.     

慢性阻塞性肺疾病2种肺康复策略的疗效比较

目的:比较2种不同的肺康复干预策略对慢性阻塞性肺疾病(COPD)患者BODE指数评分、焦虑抑郁及日常生活活动能力的改善及脱落率。方法:采用随机、对照的方法将155例稳定期COPD患者分为3组,肺康复干预Ⅰ组给予康复宣教、有氧呼吸操及体能训练;肺康复干预Ⅱ组仅给予康复宣教及有氧呼吸操,对照组不给予肺康复干预,为期20周。比较康复前后3组患者BODE指数、焦虑抑郁及日常生活活动能力评分及脱落的差异。结果:经过20周的肺康复干预,肺康复干预Ⅰ、Ⅱ组较对照组在焦虑抑郁评分、6 min步行距离、呼吸困难程度评分均明显改善(P<0.01),但脱落率明显高于其他2组(P     

Cardiac rehabilitation programs and health-related quality of life. State of the art

Cardiovascular disease is the main health problem in developed countries. Prevention is presented as the most effective and efficient primary care intervention, whereas cardiac rehabilitation programs are considered the most effective of secondary prevention interventions; however, these are underused. This literature review examines the effectiveness and the levels of evidence of cardiac rehabilitation programs, their components, their development and role in developed countries, applications in different fields of research and treatment, including their psychological aspects, and their application in heart failure as a paradigm of disease care under this type of intervention. It is completed by a review of the impact of such programs on measures of health-related quality of life, describing the instruments involved in studies in recent scientific literature.     

Getting Into Light Exercise (GENTLE-HF) for Patients With Heart Failure: the Design and Methodology of a Live-Video Group Exercise Study

ObjectiveNewer therapies have increased heart failure (HF) survival rates, but these therapies are rarely curative. The consequence of increased longevity is the likelihood that patients with HF will experience higher symptom burdens over time. Exercise such as cardiac rehabilitation programs can palliate symptom burdens, but numerous barriers prevent exercise participation and adherence. Small pilot studies indicate short-term beneficial effects of gentle forms of exercise such as yoga to address symptom burdens and accommodate comorbidities. Long-term symptom benefit and adherence to yoga are currently unknown. Therefore, a novel a home-based, gentle-stretching intervention that addresses issues of exercise access and adherence is described in this article.PurposeThe purpose of this article is to describe the background, design and study methodology of the Getting Into Light Exercise for HF (GENTLE-HF) randomized controlled trial. Gentle-HF will test a gentle stretching and education intervention compared to an education control group concerning symptom burden (dyspnea, exercise, activity adherence, depression, and anxiety) and quality of life. As an exploratory aim, we also will determine whether rurality moderates the relationships between exercise participation and symptom burden as a measure of health equity.MethodsWe designed a randomized controlled trial study (n = 234) with 2 arms: a gentle stretching intervention arm with HF education and an HF education-only control. Participants will be recruited from U.S. cardiology clinics in the mid-Atlantic and the San Francisco Bay areas. This recruitment strategy will include individuals from urban, suburban and rural areas and individuals that have diverse racial and ethnic backgrounds. All participants will be provided with an iPad set up to access HF educational topics, and the intervention arm will have both educational and gentle-stretching class links. Both arms will access the HF health education icons on their iPads weekly; they correspond to the 6 months (26 weeks) of study participation. Symptom burden (dyspnea, fatigue, exercise intolerance, depression, anxiety) and quality of life will be measured at the study's start and completion. Study adherence will be measured by using attendance rates and number of class minutes attended.ResultsThe GENTLE-HF study is a randomized study that will test the effect of a home-based, video-conference-delivered gentle stretching and HF education intervention designed for patients with HF. The findings will inform whether gentle stretching can decrease symptom burden and potentially provide access to symptom palliation for a diverse population of patients with HF.     

Psychological outcomes of an outpatient pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease

STUDY/PRINCIPLES: The effects of an outpatient pulmonary rehabilitation program on psychological morbidity (anxiety and depressive symptoms) were examined in patients with chronic obstructive pulmonary disease (COPD). METHODS: The 26 rehabilitation patients with COPD were compared with 19 control patients with COPD similar in age, gender, COPD severity and other variables. Initial assessment included lung function testing, health status, exercise tolerance, dyspnea intensity and psychiatric interviews using Hamilton depression rating scale (HAM-D) and Hamilton anxiety rating scale (HAM-A). A pulmonary rehabilitation program was carried out during the following 2 months; psychiatric interviews and measurements of health status, exercise tolerance and dyspnea intensity were done again on completion of the study at 2 months. RESULTS: There was a decrease in HAM-A scores in the rehabilitation group and the decrease was statistically significant (P=0.010). On the contrary the HAM-A scores did not change in control group. The decrease in HAM-A scores in rehabilitation group was also statistically significant compared with the control group (P=0.042). There was no significant difference in HAM-D scores within the two groups and also there was no significant difference between the two groups in HAM-D scores. The health status, exercise tolerance and dyspnea intensity improved significantly in the rehabilitation group compared to the control group. CONCLUSION: This study shows that our outpatient rehabilitation program leads to a benefit in anxiety and depressive symptoms in COPD patients. The benefit was especially significant in anxiety symptoms. In addition to the improvement in psychological symptoms, the health status, exercise tolerance and dyspnea intensity were also significantly improved in COPD patients who underwent the rehabilitation program. This outpatient-based rehabilitation program was well accepted by the patients. The relatively simple design of the program makes it feasible independently of expensive equipment.     

Physiological and psychological effects of exercise interventions in HIV disease

The use of both aerobic and resistance exercise has been shown to improve physiologic parameters such as strength, endurance, time to fatigue, and body composition in the HIV-infected population. Exercise has also been used successfully to treat psychologic conditions such as depression and anxiety that are common in HIV-infected individuals. However, the effects of exercise on immune function in these individuals are uncertain because of conflicting results found among studies. Additionally, many ventures into this area have been attempted with poor research design, resulting in inconclusive evidence or poor generalizability. The focus of this paper is to review the research that has been performed using exercise as an intervention for HIV-infected persons and to determine what needs to be done next to further our understanding of how the HIV-infected body and mind respond to exercise training.     

Optimal duration of pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease - a systematic review

The purpose of this review was to determine the impact of duration of pulmonary rehabilitation on measures of health-related quality of life and exercise tolerance in individuals with chronic obstructive pulmonary disease (COPD). Randomized controlled trials (RCTs) comparing different lengths of pulmonary rehabilitation in patients with COPD were identified after searches of six electronic databases (MEDLINE, PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database [PEDro] and the Cochrane Library of clinical trials) and reference lists of pertinent articles. Two reviewers performed the searches and assessed trial quality using PEDro and Jadad scales. Five RCTs met inclusion criteria. The mean PEDro score was 6 (range 3-8) and mean Jadad was 2 (range 1-3). Three trials reported a difference in health-related quality of life in favour of the longer duration program; two trials reported a benefit in exercise capacity in favour of longer programs. A meta-analysis of results was not possible due to considerable heterogeneity in program duration and outcomes. Longer duration pulmonary rehabilitation programs appear to have a more favourable effect on health-related quality of life in individuals with COPD; results for exercise capacity are less clear. The limited literature prevents a more definitive conclusion on optimal duration of rehabilitation.     

A controlled trial of cardiac rehabilitation in the home setting using electrocardiographic and voice transtelephonic monitoring

OBJECTIVE: The goal of this study was to compare the effectiveness of home-based, transtelephonically monitored cardiac rehabilitation with standard, on-site, supervised cardiac rehabilitation. BACKGROUND: Participation in cardiac rehabilitation has been demonstrated to increase exercise capacity, decrease cardiovascular symptoms, improve psychosocial status, and decrease total and cardiovascular mortality rates in patients with coronary heart disease. Because of multiple factors, national overall participation is only at 15% of eligible patients. METHODS: Effects of a 3-month home-based, transtelephonically monitored rehabilitation program (n = 83 patients) with simultaneous voice and electrocardiographic transmission to a centrally located nurse coordinator were compared with effects of a standard on-site rehabilitation program (n = 50 patients). The study design was a multicenter, controlled trial. Primary outcome variables were peak aerobic capacity and quality of life, as measured by the Health Status Questionnaire. RESULTS: Patients in the home-based monitoring program increased peak aerobic capacity to a similar degree as patients who exercised on site (18% vs 23%). Quality of life domains of physical functioning, social functioning, physical role limitations, emotional role limitations, bodily pain, and energy/fatigue improved similarly in both groups. There were no circulatory arrests or other major exercise-related medical events in either group. A total of 3100 hours of home exercise were transtelephonically monitored. CONCLUSIONS: Patients with coronary heart disease can effectively participate in home-based, monitored cardiac rehabilitation, with exercise and quality of life improvements comparable to those demonstrated at on-site programs.     

Efficacy of cardiac rehabilitation services. With emphasis on patients after myocardial infarction

During the 1970s, emphasis increased in clinical practice on early ambulation and exercise-based rehabilitation after myocardial infarction and other cardiac illnesses or procedures. This shift was based on the belief that exercise and improved conditioning would improve prognosis. We examine the evidence supporting this assertion. Most of the reports on cardiac rehabilitation are about patients who have coronary artery disease and a history of myocardial infarction. The review, therefore, is focused primarily on the patient who has had a myocardial infarction. Effects of cardiac rehabilitation, emphasizing exercise treatment and conditioning, are reviewed with regard to patient outcomes, including changes in functional (work) capacity, psychosocial functioning and health-related knowledge, risk factor modification, morbidity and mortality, and cardiac function. The safety of cardiac exercise programs is reviewed, and the use of telemetry monitoring is considered. We also discuss the role of cardiac rehabilitation in categories of patients other than those with myocardial infarction and the application of newer approaches to rehabilitation such as programs based in the patient's home.     

Effects of an exercise intervention for older heart failure patients on caregiver burden and emotional distress.

BACKGROUND: The impact of exercise programmes for heart failure on those close to the patient is largely unknown. We examined the effect of a hospital and home-based exercise intervention on burden, anxiety and depression of informal caregivers. DESIGN: The study was a randomized, controlled trial. Heart failure patients were randomized to a seated 12-week hospital-based exercise programme. Caregiver measures were gathered at baseline, 3 months later and 6 months following baseline. METHODS: Sixty caregivers (mean age 63.4 years, 65% female) of heart failure patients (n = 82, mean age 80.5 years, 44% female) participating in a trial of an exercise intervention were recruited. Caregiver burden, anxiety and depression were assessed. RESULTS: There were no differences in caregiver burden, depression or anxiety between the two groups of caregivers at baseline (caregiver burden, patient control 33.1 versus patient exercise 34.1; anxiety 4.1 versus 5.5; depression 2.8 versus 3.8). At 3 months there were no differences between caregivers in the two groups on outcomes. At 6-month follow-up caregivers of heart failure patients in the exercise group had burden scores that were significantly worse than the control group. There were no differences between the carers of exercise and control groups in anxiety and depression. Levels of anxiety and depression in the entire carer sample were marginally higher than reference values in a healthy non-clinical sample. CONCLUSION: The present exercise interventions for frail older patients did not benefit caregivers and was associated with an increase in caregiver burden. We suggest that future exercise interventions for heart failure patients should actively incorporate informal caregivers into research designs.