Update on preventive cardiology and rehabilitation

The aim of the Preventive Cardiology and Rehabilitation Section of the Spanish Society of Cardiology is to promote knowledge about and adoption of the lifestyle, therapy and rehabilitation program guidelines that are best able to improve cardiovascular health in the Spanish population. To achieve this aim, a number of working groups have carried out research into and provided education about the latest developments in cardiovascular prevention, and have provided information about these developments to all those affected, including physicians, healthcare workers, healthcare administrators and the general public. This year, the working group on smoking produced an key document that was presented to cardiologists in our Society; its intention was to provide a simple algorithm to help patients give up smoking that could be applied in only 3 minutes. The working group on cardiac rehabilitation gave a presentation on the true impact of rehabilitation on survival after percutaneous coronary intervention and heart failure. Also this year, the European Society of Cardiology published a major revision of guidelines on the treatment of dyslipidemia, which was welcomed by many but criticized by others. Our correspondent at the European Society reflects on the role and usefulness of these guidelines in practice.     

Cardiac rehabilitation in the elderly]

Cardiac rehabilitation is an integral component of secondary prevention, and is indicated for patients with a wide variety of cardiac conditions, ranging from coronary artery disease to chronic heart failure. Best results are obtained with integrated, multicomponent cardiac rehabilitation programs, which include exercise training together with counseling and psychosocial measures that may help patients maintain sustained changes toward a more healthy lifestyle. Evidence from randomized controlled trials and meta-analyses supports the efficacy of cardiac rehabilitation on clinically relevant outcomes such as reduced long-term morbidity and mortality, enhanced functional profile and improved control of cardiovascular risk factors. However, the vast majority of this evidence derives from trials with only small numbers of patients > 70 years of age. In elderly patients the goal of cardiac rehabilitation may differ from those of younger patients, and include the preservation of mobility, self-sufficiency and mental function. Cardiac rehabilitation my represent an opportunity to provide effective health care and achieve a high quality of life for older patients. Future research programs should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients.     

Cardiac rehabilitation in the elderly: patient selection and outcomes

In Western countries, the aging and improving survival of patients with coronary heart disease are responsible for an increasing number of older adults (65 years of age and older) who are eligible for cardiac rehabilitation. The elderly with coronary heart disease represent a special population with changes induced by aging and lifestyle, comorbidity, cognitive dysfunction, and high risk of disability. Although the elderly account for the majority of cardiac admissions and procedures, studies on cardiac rehabilitation have traditionally focused on younger patients. In aged experimental animals, there is evidence that exercise training is able to improve hemodynamic parameters and biologic markers. Moreover, in older patients, exercise improves functional capacity and reduces myocardial work, similar to that seen in younger patients. As for younger patients, cardiac rehabilitation requires a multidisciplinary approach, including comprehensive assessment, treatment of risk factors and comorbidity, and psychosocial assessment. Cardiac rehabilitation is safe and helpful for elderly coronary patients. Physicians must be encouraged to prescribe cardiac rehabilitation programs for the elderly following major coronary events and coronary revascularization procedures.     

Cost-effectiveness in preventive cardiology

Opinion statement Cardiovascular disease remains a serious medical problem, which can be associated with death and disability on one hand, and considerable resource utilization on the other. The primary driver for choice of therapy must remain clinical efficacy. Once efficacy is established, cost-effectiveness analysis has an important role. Resources are limited, and responsible choices must be made. The methods involved in costeffectiveness analysis are complicated and data for the analysis are generally not fully optimal. Nonetheless, cost-effectiveness analysis offers the best method for helping society make rational medical decisions. Effective interventions, when reasonably priced, for the prevention of cardiovascular disease have generally proven to be cost-effective.     

Prevention and rehabilitation in cardiology

Preventive cardiology occupies a central place in medicine today. The subject monopolizes a large proportion of epidemiological studies and clinical trials involving a range of drugs. Moreover, preventive cardiology provided the initial impetus for regarding genetic epidemiology as a basis for disease prevention. The aim of this article was to summarize just some of the publications that have appeared during the last few months, with special emphases on obesity and diabetes mellitus as the pre-eminent risk factors for disease, and on their combination as part of the so-called metabolic syndrome.     

The treatment potential in preventive cardiology

The Joint European Societies--European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension--1998 recommendations on prevention of coronary heart disease (CHD) in clinical practice set priorities and goals. The top priority is patients with established CHD, or other atherosclerotic disease, because they are already under the care of cardiologists and are at high risk of further morbidity and mortality. The lifestyle goals are to stop smoking, make healthy food choices and be active physically. The risk factor goals are a BP < 140/90 mmHg, total cholesterol < 5.0 mmol/l (190 mg/dl) and LDL-cholesterol < 3.0 mmol/l (115 mg/dl). The appropriate use of prophylactic drug therapies--aspirin, beta-blockers, ACE inhibitors, lipid modification therapies and anticoagulants--is also a recommended goal. The final goal is to screen relatives of patients with premature CHD (men < 55 years and women < 65 years). Surveys of clinical practice such as EUROASPIRE (European Action on Secondary Prevention) have shown risk can be further reduced in patients with established CHD because many are not achieving these lifestyle and risk factor goals. So there is considerable potential to raise the standard of preventive care for coronary patients through more effective lifestyle intervention and the use of drug therapies with proven efficacy. For the patient, this will mean a longer life with better quality.     

Diet as preventive medicine in cardiology

Because the main cause of death in patients with established coronary heart disease (CHD) is sudden cardiac death (SCD), physicians should develop specific strategy, including dietary changes, to prevent it. In the long term, reduction of the diet-dependent chronic risk factors of CHD, hypercholesterolemia, hypertension, and diabetes, is also important. The association of the cardioprotective effects of the Mediterranean diet (through various mechanisms, likely including the prevention of SCD) with those expected from the reduction of blood lipids and blood pressure and a better control of diabetes (in addition to its gastronomic appeal) renders this dietary pattern extremely attractive for public health purposes. Experimental and epidemiologic studies, as well as randomized trials, clearly demonstrated that n-3 fatty acids reduce the risk of SCD in CHD patients. Their use is now encouraged either as supplements or as part of a Mediterranean-type diet.     

Cardiac rehabilitation for the elderly: Qi Gong and group discussions.

BACKGROUND: Over the last decade several studies have shown that patients with coronary artery disease even above the age of 70 can be successfully treated with advanced medical and surgical methods. Unfortunately, rehabilitation programmes for this group are rarely offered. It is important to develop forms of rehabilitation that are adapted to the specific needs of this increasing group of elderly patients. The aim of this randomized study was to investigate whether the combination of Qi Gong and group discussions would increase physical ability for elderly patients > or =73 years with coronary artery disease. METHODS: A total of 95 patients (66 men and 29 women), with documented coronary artery disease, were randomized to an intervention group (n=48) mean age 77+/-3 (73-82) or to a control group (n=47) mean age 78+/-3 (73-84). The intervention groups met weekly over 3 months. The control group got usual care. Physical ability was assessed at baseline and after the intervention. RESULTS: Patients in the intervention group increased their self-estimated level of physical activity (P=0.011), and their performance in the one-leg stance test for the right leg (P=0.029), co-ordination (P=0.021) and the box-climbing test for right leg (P=0.035). CONCLUSION: A combination of Qi Gong and group discussions appear to be a promising rehabilitation for elderly cardiac patients in terms of improving self-reported physical activity, balance and co-ordination. This could be an option for elderly patients who do not participate in the ordinary cardiac rehabilitation.