Cardiac rehabilitation after acute myocardial infarction

At the time of evidence-based medicine, while the proofs of the benefits of cardiac rehabilitation to the coronary multiply, a large number of patients are still managed without any form of rehabilitation. In particular, younger patients with myocardial infarction treated by early reperfusion and older subjects. The objective of in-hospital or ambulatory cardiac rehabilitation is a global coverage of the patient and his/her risk factors, that the short duration of hospitalization in the acute phase does not allow. Several randomized studies, metaanalyses, and registers show a decrease from 20 to 30% of the mortality after cardiac rehabilitation. The benefits of physical training on risk factors modification are demonstrated by numerous works: improvement of lipid parameters and arterial pressure, prevention of diabetes, increased smoking cessation, loss of weight, better overall well-being; besides the management of risk factors, physical training improves exercise capacity, a recognised prognostic factor. The efficiency of cardiac rehabilitation may be comparable with that of the key treatments of coronary artery disease, such as beta-blockers or coronary angioplasty. All these proofs give to the cardiac rehabilitation in post-myocardial infarction a high-level recommendation, grade IA.     

A school for patients with a history of myocardial infarct and their families: a method of group psychosocial intervention and an assessment of its effectiveness

A group method of psychosocial intervention (a "school") has been developed for post-myocardial infarction patients and their families in order to build up positive attitudes to medical recommendations. The efficiency of the school as well as the social and psychologic factors involved were assessed using the multifactorial scale of psychosocial changes, and 16PF, and "polar profiles" tests, and Leary's method, in 27 post-myocardial infarction patients (mean age 49.8 years) and their 12 wives. It was demonstrated that the patients' attitudes to medical recommendations became more positive, as compared to a control group; moreover, this positive quality persisted over long-term follow-up. Certain personality features (self-image, psychological makeup) affecting the patient's observance of medical advice were demonstrated which should be considered in planning the rehabilitation strategy for myocardial infarction patients. The results indicate that patients' wives should also be enrolled in the group effort.     

The psychological perspective: a professional view

Psychological issues surrounding the care of patients with cardiovascular disease are many and diverse. This paper discusses three main areas: cognitions, emotions, and social support. The examples given relate primarily to post-myocardial infarction patients but the concepts discussed are relevant to other aspects of cardiovascular disease. Patients' cognitions can influence early help seeking for symptoms of myocardial infarction, attendance at cardiac rehabilitation, behaviour change, and return to work. Depression and anxiety are common following myocardial infarction and can be associated with increased mortality. Mood changes must therefore be addressed as part of the cardiac rehabilitation programme. Social support also plays an important part in cardiac rehabilitation.     

Importance of isometric training in the rehabilitation of myocardial infarct patients

A method of isometric exercise was developed for myocardial infarction patients, and its efficiency was evaluated in the course of rehabilitation after acute myocardial infarction in 48 patients aged 39 to 57 years. The trained patients showed significantly increased tolerance to arm and leg isometric exercise and better systemic hemodynamic response to isometric exercise, manifested in a lower cost of one isometric tension unit, and increased minute blood volume, a result of increased stroke volume. It is concluded that isometric exercise has a favorable effect on cardiovascular function and physical working capacity of postmyocardial-infarction patients.     

La réadaptation cardiaque en postinfarctus du myocarde

Although the proofs of the benefits of cardiac rehabilitation accumulate, many patients are not sent to rehabilitation units, especially younger and very elderly patients. As the length of stay in acute care units decreases, rehabilitation offers more time to fully assess the patients’ conditions and needs. Meta-analyses of randomised trials suggest that mortality can be improved by as much as 20-30%. In addition, rehabilitation helps managing risk factors, including hyperlipidemia, diabetes, smoking and sedentary behaviours. Physical training also helps improving exercise capacity. Because of all of these effects, cardiac rehabilitation for post-myocardial infarction patients has been given a class IA recommendation in current guidelines.     

Effectiveness of physical training in patients who have had a myocardial infarct

A study of the effects of exercise on cardiovascular function of myocardial infarction survivors showed their physical stress tolerance to increase as a result of improved myocardial contractility and the optimum adjustment of hemodynamic and oxygen support of exercise. Therefore, exercise should be used more extensively as part of the rehabilitation effort following myocardial infarction.     

Does post myocardial infarction rehabilitation prolong survival? A meta-analytic survey

Cardiac rehabilitation undoubtedly helps post-myocardial infarction patients to feel better; however, it is under consideration whether or not it also prolongs their survival. Since 1972 several published studies have examined the role of physical rehabilitation in relation to patient survival after myocardial infarction. Eight randomized controlled trials were reviewed in order to compare the rate of events (total death, cardiac death, recurrence of non-fatal myocardial infarction) in the trained and untrained patient population. A tendency toward a positive training effect on survival was present in almost all trials; however, in only one study was the number of cardiac deaths shown to be significantly reduced in trained patients. The aim of this study was to use a quantitative analysis based on estimates of individual trials to evaluate the effect of post-myocardial infarction rehabilitation programs on survival. The analysis of pooled data revealed a significant decrease in total mortality (relative risk 0.68 with 95% confidence limits 0.53-0.86; p = 0.002), and cardiac mortality (relative risk 0.62 with 95% confidence limits 0.48-0.82; p less than 0.001). However, there was a non-significant increase in recurrences (relative risk 1.12 with 95% confidence limits 0.84-1.49; p = 0.45). These data are very similar to those found by another meta-analytic survey performed on a different set of published studies, i.e., odds risk for total death 0.76, for cardiac mortality 0.75 and for non-fatal myocardial infarction 1.15.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sport als Therapie

Over the last 2 decades the clinical application of physical exercise as a therapeutic strategy has developed from rehabilitation to prevention and treatment of cardiovascular diseases. This shift in clinical application was accompanied by a more systematic research approach of the involved mechanisms and the objective clinical assessment of sport interventions using prospective randomized clinical trials. This ongoing process established physical exercise as an evidence-based and guideline-oriented treatment option.In stable coronary artery disease (CAD), exercise therapy has long been used for rehabilitation purposes following an acute myocardial infarction. A recent meta-analysis revealed a significant 27% reduction of total mortality among training patients. Four mechanisms are considered important mediators of the reduced cardiac event rate: improvement of endothelial function, reduced progression of coronary lesions, reduced thrombogenic risk, and improved collateralization. The therapeutic benefit of regular physical exercise has also been confirmed in direct comparison with an interventional strategy: a 12-month exercise therapy in stable CAD patients was associated with a higher event-free survival as compared to conventional percutaneous coronary intervention.In stable chronic heart failure (CHF), physical activity was traditionally discouraged-with negative consequences for the patients: exercise intolerance worsened, the progression of disease-related muscular atrophy accelerated. A carefully designed exercise program at 50-70% of the maximal oxygen uptake was effective in improving exercise capacity by 12-32%. In a recent meta-analysis, exercise therapy reduced the relative risk of CHF mortality by 35% and CHF-related hospitalizations by 28%. Considering the growing body of evidence in favor of sport as a therapy, training interventions should be considered additional/alternative therapeutic strategies as compared with established pharmacological/interventional options.     

抗阻运动对老年心脏康复作用的研究进展

心血管疾病已成为我国居民致残致死的首要病因,心脏康复对心血管疾病患者十分重要,可以提高生活质量、运动能力和体力活动能力,降低再住院率和病死率。抗阻运动是心脏康复的重要组成部分,可以提高肌肉力量、耐力和身体活动能力。本综述旨在总结抗阻运动对老年人群心脏康复的作用,为更好的改善老年心血管病患者的预后提供帮助。     

Value of inpatient rehabilitation measures following myocardial infarct

The primary goal of rehabilitation is to slow down the progression of coronary heart disease via secondary preventive efforts and to reduce the negative social and psychosomatic sequelae of a myocardial infarction to the unavoidable minimum. Cardiac rehabilitation has developed into an active strategy of secondary prevention, based on sufficient diagnostic evaluation, aiming at the modification of risks factors and including the entire psychosocial field into the long-term therapeutic concept. After myocardial infarction the patient carries, in comparison to the normal population, approximately a tenfold risk to die suddenly or to suffer another myocardial infarction. Following a first infarction, risk factors such as smoking, hypercholesterolemia and hypertension are of increased epidemiologic importance. A lower social class will in itself lead to an increase of the incidence of reinfarction and to a decrease in life expectancy. One of the central goals therefore is to convey the importance of a health-oriented behavior pattern, which is achieved in single and group-therapy sessions as well as with the help of physiotherapy. Controlled physical exercise, however, does not only serve as an educational vehicle, but also has direct effects on cardiovascular physiology, leading to a decrease in heart rate and blood pressure for a given work load and thus to an increase of the angina pectoris threshold. Moreover, controlled physical exercise has a substantial antidepressive effect in the critical phase following acute myocardial infarction, and will lead to increased self-confidence.(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of systemic rehabilitation in patients with myocardial infarct--a 4 years' study

Form and results of the rehabilitation of patients with myocardial infarction during and after clinical treatment are described in a 4-year-study. According to the form a system rehabilitation is concerned. It comprises a continuous course of early mobilisation during clinical treatment, immediately following group exercise treatment after clinical treatment, then a sanatory cure and a continuing life-long group training. The results are an ergometrically objectified increase of physical function which is larger than in an untrained patient and a decrease of the factor of risk, on the basis of which a high degree of occupational and social rehabilitation is gained.     

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.     

The fixed-dose combination drug for secondary cardiovascular prevention project: improving equitable access and adherence to secondary cardiovascular prevention with a fixed-dose combination drug. Study design and objectives

In spite of advances in prevention and treatment, the burden of cardiovascular diseases is increasing. A fixed-dose combination (FDC) pill, or "polypill," composed of evidence-based drugs has been proposed as a means of improving cardiovascular prevention by reducing cost and increasing patient adherence to treatment. The aim of the FOCUS project, funded by the 7th Framework Programme of the European Commission, is to characterize the factors that underlie inadequate secondary prevention and to test a new FDC. To achieve these goals, a 9-member consortium has been constituted, including institutions from Argentina, France, Italy, Spain, and Switzerland. FOCUS Phase-1 will examine factors potentially related to lack of adequate secondary prevention in 4,000 post-myocardial infarction (MI) patients and analyze the relationship between these factors and patient treatment adherence. Primary end points will be (1) the percentage of patients receiving aspirin, angiotensin-converting enzyme inhibitors, and statins and (2) adherence to treatment measured by the Morisky-Green test. FOCUS Phase-2 is a randomized trial that will compare adherence to treatment in 1,340 post-myocardial infarction patients either receiving an FDC comprising aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and simvastatin (40 mg) or receiving the same 3 drugs separately.     

Participation in Cardiac Rehabilitation,Readmissions, and Death After Acute Myocardial Infarction

Background

Participation in cardiac rehabilitation has been shown to decrease mortality after acute myocardial infarction, but its impact on readmissions requires examination.

Methods

We conducted a population-based surveillance study of residents discharged from the hospital after their first-ever myocardial infarction in Olmsted County, Minnesota, from January 1, 1987, to September 30, 2010. Patients were followed up through December 31, 2010. Participation in cardiac rehabilitation after myocardial infarction was determined using billing data. We used a landmark analysis approach (cardiac rehabilitation participant vs not determined by attendance in at least 1 session of cardiac rehabilitation at 90 days post-myocardial infarction discharge) to compare readmission and mortality risk between cardiac rehabilitation participants and nonparticipants accounting for propensity to participate using inverse probability treatment weighting.

Results

Of 2991 patients with incident myocardial infarction, 1569 (52.5%) participated in cardiac rehabilitation after hospital discharge. The cardiac rehabilitation participation rate did not change during the study period, but increased in the elderly and decreased in men and younger patients. After adjustment, cardiac rehabilitation participants had lower all-cause readmission (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.65-0.87; P < .001), cardiovascular readmission (HR, 0.80; 95% CI, 0.65-0.99; P = .037), noncardiovascular readmission (HR, 0.72; 95% CI, 0.61-0.85; P < .001), and mortality (HR, 0.58; 95% CI, 0.49-0.68; P < .001) risk.

Conclusions

Cardiac rehabilitation participation is associated with a markedly reduced risk of readmission and death after incident myocardial infarction. Improving cardiac rehabilitation participation rates may have a large impact on post-myocardial infarction healthcare resource use and outcomes.     

The psychosocial and physical impact of exercise rehabilitation following coronary artery bypass surgery

A number of studies attest to the physical and psychosocial benefits of exercise rehabilitation following myocardial infarction (MI). There is substantially less evidence for rehabilitation following coronary artery bypass (CAB) surgery. In the present study CAB patients were allocated either to a comprehensive ten week exercise based rehabilitation programme or to a routine care condition; psychological well being, psychosocial adjustment and exercise tolerance were assessed before and after treatment. It was found that only the rehabilitation patients improved significantly in terms of self reported measures of general psychological morbidity, happiness, return to family life, and physical capacity. Further the rehabilitation patients showed greater improvement than the routine care patients on measures of well being, social interaction, uptake of household chores, sexual activity, pursuit of hobbies, and fear of exercise. Exercise based rehabilitation would appear to benefit CAB patients over and above changes contingent on routine care or the passage of time. Further research is required to establish whether such benefits persist.     

Physical activity after myocardial infarction

Experimental and clinical research has provided substantial knowledge of the potential benefits and risks associated with the performance of physical activity by patients with uncomplicated myocardial infarction. This knowledge has resulted in the earlier mobilization, a reduction in length of hospitalization, an increase in physical working capacity and a more successful return to work of many patients. These improvements have been associated with a variety of physiologic and psychological changes produced by increased activity during each stage of the patient's recovery. During hospitalization, changes in posture and low intensity activity minimize the cardiovascular and psychological complications caused by prolonged bed rest. After hospitalization, the most valuable benefit of regularly performed exercise appears to be a reduction in myocardial oxygen demand at rest and during submaximal exertion. The unique contribution of increased physical activity to reducing the frequency and severity of reinfarction has not been adequately established but, when combined with other behavior designed to reduce risk factors, the preliminary results are favorable. For these benefits to be obtained without undue risk, exercise for the postmyocardial infarction patient needs to be individually prescribed and periodically reevaluated.     

Cardiovascular exercise and wellness. Exercise training for cardiac rehabilitation patients: meeting the challenges of the millennium

Exercise training for cardiac rehabilitation has evolved over the past decades in response to a growing knowledge base in exercise physiology, an expanding understanding to the knowledge base of coronary disease, and a change in the patients presenting for cardiac rehabilitation. The patient population has changed from a post myocardial infarction patient group, to patients who have had coronary artery revascularization (coronary artery bypass surgery or percutaneous transluminal coronary angioplasty) with the implantation of intraarterial stents. Program goals have evolved from enhancing endurance fitness in deconditioned patients to initiating the long-term adoption of an active exercising lifestyle with the use of strength training to complement endurance training. An increased understanding of behavioral issues in the adoption of an active lifestyle will influence the evolution of cardiac rehabilitation exercise training. During the next several years, it is anticipated that the patient population will change to include patients with significant left ventricular systolic dysfunction and congestive heart failure. The exercise training programs will then further evolve to reflect the successful exercise training formats utilized in the multicenter trials of exercise training for patients with congestive heart failure. (c) 2000 by CHF, Inc.     

Eplerenone: a selective aldosterone receptor antagonist for hypertension and heart failure

Aldosterone has been implicated for many years as an important substance in the pathogenesis of heart disease. Elevated aldosterone concentrations have been documented in patients with hypertension and heart failure, leading to the use of aldosterone antagonists for the treatment of these conditions. Spironolactone has been used for nearly 2 decades for the treatment of hypertension, and more recently, has become a standard agent for the treatment of systolic heart failure. Spironolactone, however, is a nonselective antagonist of the aldosterone receptor, binding also to other steroid receptors and causing a significant percentage of patients to have sex hormone-related adverse effects such as gynecomastia. Eplerenone is the first of a new class of drugs known as selective aldosterone receptor antagonists, which selectively block the aldosterone receptor with minimal effect at other steroid receptors, thereby minimizing many of the hormonal side effects seen with spironolactone. Eplerenone has been shown to be beneficial both as monotherapy and combination therapy for lowering elevated blood pressure in patients with hypertension. The antihypertensive efficacy of eplerenone is roughly similar to that of other antihypertensive agents, although in 1 study black patients responded better with eplerenone than losartan. In addition, eplerenone has demonstrated some renoprotective effects in diabetic patients with hypertension. Recently, eplerenone was shown to significantly reduce mortality and cardiovascular morbidity in post-myocardial infarction patients with systolic heart failure currently taking standard heart failure medications. Eplerenone is generally well tolerated, although hyperkalemia with this agent is of some concern. Eplerenone is metabolized by CYP3A4 and administration with potent inhibitors of this enzyme is contraindicated because of the risk of hyperkalemia. In summary, eplerenone has proven to be beneficial in treating hypertension and post-myocardial infarction heart failure. Its exact place in therapy will in large part be determined by its cost and whether or not future studies will be able to demonstrate a clinical benefit of this agent over spironolactone or other currently available treatments.