Exercise-based cardiac rehabilitation improves heart rate recovery in elderly patients after acute myocardial infarction

BACKGROUND: Heart rate recovery (HRR), defined as the fall in HR during the first minute after exercise, is a marker of vagal tone, which is a powerful predictor of mortality in patients with coronary artery disease and in older patients. Whether exercise training (ET) modifies HRR in elderly patients recovering from acute myocardial infarction (AMI) is still unknown. Therefore, this study aims at evaluating the effect of ET on HRR in elderly AMI patients. METHODS: This was a prospective observational study including 268 older patients after AMI (217 men, 51 women), subdivided in two groups: Group A (n = 104), enrolled in an ET program; Group B (n = 164), discharged with generic instructions to continue physical activity. At baseline and at 3-month follow-up, all Group A and 54/164 Group B patients underwent a cardiopulmonary exercise stress test, whereas 110/164 Group B patients underwent an exercise stress test. RESULTS: After completion of the ET program, in Group A we observed an improvement in oxygen consumption at peak exercise (VO2peak; from 14.7 +/- 1.3 to 17.6 +/- 1.9 mL/kg/min, p < .001), in the rate of increase of ventilation per unit of increase of carbon dioxide production (VE/VCO2slope; from 34.2 +/- 3.8 to 30.4 +/- 3.0, p < .001), and in HRR (from 13.5 +/- 3.7 to 18.7 +/- 3.5 beats/min, p < .001). The changes in VO2peak and in VE/VCO2slope after ET were correlated with the improvement of HRR (r = -0.865, p < .01; r = -0.594, p < .01, respectively). No changes in these parameters were observed in Group B patients. CONCLUSIONS: In older AMI patients, ET results in HRR improvement, which was correlated to the improvement in cardiopulmonary parameters. These findings may shed additional light on the possible mechanisms of the beneficial prognostic effects of ET in this patient population.     

Improvement in heart rate recovery after cardiac rehabilitation

PURPOSE: Exercise-based cardiac rehabilitation has been shown to reduce mortality in patients with coronary artery disease. Although the exact mechanisms by which exercise reduces mortality are unclear, one hypothesis invokes the effect of exercise on autonomic tone. Heart rate recovery (HRR) immediately after exercise is a marker of vagal tone that findings have shown to be a powerful predictor of all-cause mortality. This study aimed to evaluate the effect of exercise-based cardiac rehabilitation on HRR. METHODS: A retrospective study was performed. Patients who completed phase 2 cardiac rehabilitation and had entry and exit exercise stress tests (n = 34) were included in the study. A control sample was identified by review of the exercise stress laboratory database (n = 35). Then HRR at baseline and on follow-up were compared. RESULTS: After completion of phase 2 cardiac rehabilitation, the HRR improved from 18 +/- 7 bpm to 22 +/- 8 bpm (P <.001). Among controls, the HRR on serial testing were 21 +/- 10 bpm and 21 +/- 9 bpm (P =.649). The mean difference in HRR on follow-up testing was different between those enrolled in a cardiac rehabilitation program and those who were not (P =.002). CONCLUSION: Exercise training in a cardiac rehabilitation program results in HRR improvement. As a simple parameter for assessing autonomic tone, HRR may be used in a cardiac rehabilitation facility to identify patients with higher risk profiles, and can be useful for evaluating patient outcomes.     

Effect of completion of cardiac rehabilitation on heart rate recovery

To evaluate the effects of a cardiac rehabilitation program on heart rate recovery after percutaneous transluminal coronary angioplasty, a historical cohort study was performed on 436 patients of whom 285 were grouped on completion of 5, 10, or 24 training sessions. All 3 groups showed significant improvements in heart rate recovery, peak heart rate during treadmill testing, and end-training heart rate, from baseline to follow-up. Heart rate recovery on follow-up correlated significantly with the number of completed exercise sessions. The number of sessions, baseline ejection fraction, and age were independent predictors of mean post-training heart rate recovery. The cardiac rehabilitation program had a significant effect on peak heart rate and heart rate recovery, regardless of the underlying characteristics of the patients.     

Use of exercise cardiac rehabilitation after acute myocardial infarction.

The purpose of this study was to determine the rate of participation of patients after acute myocardial infarction (AMI) in phase II cardiac rehabilitation with exercise training (ie, exercise cardiac rehabilitation, ECR) in Japan. Forty-six hospitals treating patients with AMI were surveyed for their implementation of phase II ECR after AMI in 1996-98. Of the 46 hospitals, 19 were approved and 27 were not approved for health insurance payment for ECR. A total of 13685 patients with AMI were admitted to the 46 hospitals. There were no differences between approved and non-approved hospitals in the annual number of patients with AMI (Approved, 117+61 vs Non-approved, 86+71 patients per hospital, NS), the rate of performance of emergency coronary angioplasty (63+16 vs 65+20%, NS), or the rate of emergency coronary stenting (31+16 vs 34+22%, NS). However, ECR was performed routinely in 84.2% (16/19 hospitals) of the approved hospitals, but in only 22.2% (6/27 hospitals) of the non-approved hospitals (p<0.001). Although the participation rate of AMI patients in ECR was 21.0% (2875/13685 patients) overall, it was markedly lower in the non-approved hospitals (8.0%, 557/6999 patients) than in the approved hospitals (34.7%, 2318/6686 patients, p<0.0001). Based on the present result, the overall rate of participation of AMI patients in ECR in Japan was estimated at 4.8-11.7%. Despite similar patient volumes and acute phase interventional treatment of AMI between the hospitals approved and not approved for health insurance payment for ECR, ECR was markedly underused in the non-approved hospitals in Japan. To promote ECR for all AMI patients in Japan, the number of hospitals approved for ECR should be substantially increased.     

Long-term prognosis after recovery from acute myocardial infarction

754 cases of acute myocardial infarction survivors were followed up for 28 days to 14 years, the missing rate was 1.86%. The factors influencing long-term prognosis were analyzed. Single factor analysis revealed sex, occupation, age, amount of cigarette smoked, history of stroke, and COPD, complications of heart failure, and arrhythmia, stroke and COPD, heart rate higher than 110/min, lung rales, frequency of infarction, quit smoking after infarction exerted significant influence on over all and cardiac death rate. Multiple factors Cox model analysis revealed quit smoking, complications of stroke heart failure, arrhythmia and occupation were the independent predicting factors for over-all causes of death. Frequency of myocardial infarction, quit smoking, amount of cigarette smoked, occupation, stroke were the independent prognostic factors of cardiac death.     

Personality traits and heart rate variability predict long-term cardiac mortality after myocardial infarction.

AIMS: To investigate personality traits and sympatho-vagal modulation of heart rate variability (HRV) during acute myocardial infarction (AMI), assessing their relationships and their long-term prognostic value. METHODS AND RESULTS: Psychological traits and 24 h HRV were prospectively investigated in 246 patients at discharge of an AMI. Patients were followed-up to 8 years for the occurrence of cardiac death and non-fatal reinfarction. Low coping and anxiety traits associated with reduced HRV characterized the study population. At univariate analysis, low emotional sensitivity and insecurity, relative tachycardia, reduced high frequency (HF), and low frequency power and pNN50 were predictive of cardiac death at 8-year follow-up. At multivariable analysis, low emotional sensitivity and low HF power remained predictive, with a relative risk of 4.18 (P=0.003) and 2.76 (P=0.007), respectively; also the type of infarction (Q vs. non-Q) and hospital length of stay were independent predictive variables. CONCLUSION: Anxiety and emotional sensitivity were significant predictors of 8-year cardiac mortality after AMI. Reduced HF power, a recognized marker of vagal withdrawal, increased the risk.     

Long-term effects of in-hospital cardiac rehabilitation on the cardiac risk profile. A case-control study in pairs of siblings with myocardial infarction.

AIMS: In the general population, measures for secondary prevention of myocardial infarction are poorly utilized. Our aim was therefore to analyse whether post-myocardial infarction in-hospital rehabilitation and education programmes improve the subsequent utilization of preventive strategies. METHODS AND RESULTS: We screened 93 500 patient charts in cardiac rehabilitation clinics to identify a myocardial infarction patient with a sibling, who likewise had a myocardial infarction prior to the age of 60 years but was discordant with respect to the participation in cardiac in-hospital rehabilitation. In 92 such sibling pairs the coronary risk profile was studied by standardized questionnaire, biochemical measurements and physical examination. At the time of the acute myocardial infarction, both groups showed an equal risk factor distribution. However, at follow-up (on average 5.5 years after myocardial infarction), rehabilitation-siblings presented with significantly lower systolic (137+/-2 vs 150+/-3 mmHg, P<0.01) and diastolic blood pressure (82+/-1 vs 89+/-1 mmHg, P<0.01). Antihypertensive drug therapy resulted more often in effective (相似文献   

Effects of cardiac rehabilitation on atrial wave in patients after myocardial infarction.

Cardiac rehabilitation (CR) can improve cardiac hemodynamic performance in patients after myocardial infarction (MI). Little evidence is provided concerning the consequences of CR on atrial wave duration, and less is known about the link between pre-arrhythmogenic patterns and the cardiovascular performance improvement in these subjects. Twenty-six patients, post-MI 0 to 7 days, underwent a complete CR cycle and a signal-averaged electrocardiogram (SAECG) for the evaluation of atrial activation parameters (group 1) to appreciate if physical training can promote parallel improvement in cardiovascular and intra-atrial conduction parameters. A control group of 24 well-matched nonischemic subjects (group 2) was chosen for data comparison. Resting heart rate (p < 0.01) and resting double product (p < 0.01) decreased after CR in groups 1 and 2, while diastolic blood pressure at maximal stress was decreased in group 1 (p < 0.01) with a parallel increase in the time of physical training (p < 0.05). SAECG parameters of atrial activation were unchanged in group 1 after the comparison and only total atrial duration activation (dA) reached statistical significance (113.3 +/- 17.2 msec vs 120.8 +/- 14.2 msec, subjects after CR vs before CR, p < 0.01). CR could improve intra-atrial activation in subjects after MI, but the consequences of hemodynamic adjustment of the trained heart must undergo a more accurate evaluation to verify if CR can prevent adverse arrhythmogenic complications of MI through cardiovascular performance improvement.     

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.     

Heart rate recovery in heart failure patients after a 12-week cardiac rehabilitation program

Heart rate recovery (HRR) after maximal exercise is a predictor of all-cause mortality. It was hypothesized that aerobic exercise training would increase HRR in patients with heart failure (HF), because it has been shown to be accelerated in athletes and improved in patients with coronary artery disease after cardiac rehabilitation. To date, no study has examined the effects of exercise training on HRR in HF. This was a retrospective study of patients with HF who had completed a phase II aerobic cardiac rehabilitation program with entry and exit maximal stress tests (n = 46). Thirty-five patients exhibited a training effect, 18 had abnormal HRR of < or =12 beats/min and the lowest initial functional capacity (L12), and 17 had HRR of >12 beats/min before training (G12). A group of 11 other patients did not achieve a training effect. After training, the L12 and G12 groups improved their estimated peak oxygen uptake (by 6.7 +/- 3.1 and 8.6 ml/kg/min, respectively) and treadmill time (by 117 +/- 62 and 181 +/- 108 seconds, respectively) compared with the no-training effect group (p <0.05). Only the L12 group demonstrated improvement in HRR (7 +/- 1 to 12 +/- 2 beats/min). In conclusion, the results indicate that short-term aerobic training can favorably modify HRR in patients with HF with low exercise capacity.     

Influence of heart rate on mortality after acute myocardial infarction

Elevated heart rate (HR) during hospitalization and after discharge has been predictive of death in patients with acute myocardial infarction (AMI), but whether this association is primarily due to associated cardiac failure is unknown. The major purpose of this study was to characterize in 1,807 patients with AMI admitted into a multicenter study the relation of HR to in-hospital, after discharge and total mortality from day 2 to 1 year in patients with and without heart failure. HR was examined on admission at maximum level in the coronary care unit, and at hospital discharge. Both in-hospital and postdischarge mortality increased with increasing admission HR, and total mortality (day 2 to 1 year) was 15% for patients with an admission HR between 50 and 60 beats/min, 41% for HR greater than 90 beats/min and 48% for HR greater than or equal to 110 beats/min. Mortality from hospital discharge to 1 year was similarly related to maximal HR in the coronary care unit and to HR at discharge. In patients with severe heart failure (grade 3 or 4 pulmonary congestion on chest x-ray, or shock), cumulative mortality was high regardless of the level of admission HR (range 61 to 68%). However, in patients with pulmonary venous congestion of grade 2, cumulative mortality for patients with admission HR greater than or equal to 90 beats/min was over twice as high as that in patients with admission HR less than 90 beats/min (39 vs 18%, respectively); the same trend was evident in patients with absent to mild heart failure (mortality 18 vs 10%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term reduction of cardiac mortality after myocardial infarction: 10-year results of a comprehensive rehabilitation programme

The long-term outcome of different methods of post-MI care hasbeen studied in two non-selected groups of MI patients: an interventiongroup (n = 147), participating in a cardiac rehabilitation (CR)programme, was compared to a reference group receiving standardcare (n = 158). The CR programme included a post-MI clinic,physical training, information on smoking and diet, and psychologicalsupport. After 5 years there was no difference in mortality (29.3 vs31.6%), but the recurrence rate of non-fatal MI (17.3 vs 33.3%P <0.05) and of total cardiac events (39.5 vs 53.2%, P <0.05) was lower in the intervention gro up, and more patientswere still at work (51.8 vs 27.4% P < 0.01). After 10 years there was a reduction in total (42.2 vs 57.6%P < 0.001) and cardiac mortality (36.7 vs 48.1% P < 0.001).Fewer patients in the intervention group suffered from non-fatalreinfarction (28.6 vs 39.9%, P < 0.001). Among those patientswho had not yet reached the age of retirement more patientshad resumed employment (58.6 vs 22.0% P < 0.05). We conclude, that the secondary preventive effect of the programmehas contributed to the higher rate of survival.     

Long-term survival after counterpulsation for medically refractory heart failure complicating myocardial infarction and cardiac surgery

Intra-aortic balloon counterpulsation (IABP) was performed in225 patients over a 12-year period for the treatment of severeleft ventricular failure following acute myocardial infarctionand cardiac surgery, and which had failed to respond to conventionaltherapy. Of these patients, 97 (43%) were discharged alive fromhospital. Patients were followed-up for a mean of 5.8 years(3 months to II years) and assessment of functional status wasmade. In patients with shock after myocardial infarction, themost favourable outcome was seen in patients who had mechanicalcardiac defects which were corrected after institution of IABPand in those treated within 8 hours of the onset of shock; ofthose patients without shock, best results were seen in patientswho had evidence of continuing ischaemia prior to IABP. In patientstreated after cardiac surgery, long-term results were favourableinpatients with goodpre-operative left ventricular functionandin those who underwent coronary artery bypass grafting oraortic valve replacement. Long-term results inpatients treatedwith IABP for refractory cardiac failure are encouraging andsuggest that IABP should have a continuing role in certain highrisk patient groups.     

Impaired parasympathetic control of heart rate after myocardial infarction

We measured the variation in heart rate during deep breathing, a sensitive non-invasive measure of cardiac parasympathetic activity, in 95 patients 3 weeks after myocardial infarction and in 40 asymptomatic healthy controls. The variation in rate was significantly lower (11.6 +/- 6.1 vs 17.6 +/- 7.3 beats/min, P less than 0.001) in patients with myocardial infarction than in controls. Forty-nine patients (52%) and 5 controls (13%) were considered to have diminished (less than or equal to 10 beats/min) variation of rate. The diminution in this variation was not related to the type or location of myocardial infarction, to maximum release of CK-MB or to cardiovascular medication. Our results suggest that impairment of vagal control of heart rate is common after myocardial infarction. The impairment cannot be predicted by any specific feature of the disease.     

急性心肌梗死介入治疗术后的康复运动疗法研究进展

急性心肌梗死(acute myocardial infarction,AMI)是临床上常见的急危重症,发病率呈现逐年升高的趋势,死亡率均随年龄的增加而增加。经皮腔内冠状动脉介入治疗（percutaneous coronary intervention PCI）术成为AMI的重要治疗手段。但PCI没有改变动脉粥样硬化的进程,且支架本身还存在再狭窄和支架内血栓等并发症,因此,冠心病的康复治疗也从传统的心肌梗死后的康复发展到AMI介入性治疗后的康复。本文就AMI介入治疗术后的康复运动疗法及现状作简要综述。     

Long-term recovery of left ventricular function after primary angioplasty for acute myocardial infarction.

AIMS: To investigate changes in left ventricular function in the first 6 months after acute myocardial infarction treated with primary angioplasty. To assess clinical variables, associated with recovery of left ventricular function after acute myocardial infarction. METHODS: Changes in left ventricular function were studied in 600 consecutive patients with acute myocardial infarction, all treated with primary angioplasty. Left ventricular ejection fraction was measured by radionuclide ventriculography in survivors at day 4 and after 6 months. Patients with a recurrent myocardial infarction within the 6 months were excluded. RESULTS: Successful reperfusion (TIMI 3 flow) by primary angioplasty was achieved in 89% of patients. The mean ejection fraction at discharge was 43.7%+/-11.4, whereas the mean ejection fraction after 6 months was 46.3%+/-11.5 (P<0.01). During the 6 months, the mean relative improvement in left ventricular ejection fraction was 6%. An improvement in left ventricular function was observed in 48% of the patients; 25% of the patients had a decrease, whereas in the remaining patients there was no change. After univariate and multivariate analysis, an anterior infarction location, an ejection fraction at discharge < or =40% and single-vessel disease were significant predictors of left ventricular improvement during the 6 months. CONCLUSIONS: After acute myocardial infarction treated with primary angioplasty there was a significant recovery of left ventricular function during the first 6 months after the infarction. An anterior myocardial infarction, single-vessel coronary artery disease, and an initially depressed left ventricular function were independently associated with recovery of left ventricular function. Multivessel disease was associated with absence of functional recovery. Additional studies, investigating complete revascularization are needed, as this approach may potentially improve long-term left ventricular function.     

Influence of residual ischaemia on heart rate variability after myocardial infarction

Despite the growing evidence for the positive predictive valueof depressed baroreflex sensitivity and/or reduced heart ratevariability after myocardial infarction, the mechanisms involvedin these autonomic alterations are not fully understood. Specifically,the possible influence of residual ischaemia has not been assessed. To address this problem we studied the spectral analysis ofheart rate variability in 21 patients with a first myocardialinfarction in whom the only clinical correlate was the presenceof residual ischaemia, as documented by the positive responseto both an exercise stress test and an echocardiographic stresstest. Data from these patients were compared with those obtainedin a group of postmyocardial infarction patients similar forseveral risk factors, age, site of myocardial infarction, butwithout residual ischaemia. Patients positive for residual ischaemiahad lower power in the whole spectrum (1146±158 vs 1631±159ms², P=0—032) as well as in the low and high frequencybands of heart rate variability. A nocturnal increase in highfrequency was observed in those without residual ischaemia (from167 ± 35 to 242 ± 51 ms², +45%, P0·034),but not in those with residual ischaemia (from 111 ±19 to 141 ± 29 ms², +27%, ns). Thus, residual ischaemia reduces heart rate variability aftermyocardial infarction. The autonomic effects of residual ischaemiaprobably contribute to its negative prognostic value after myocardialinfarction.     

Determination of exercise training heart rate in patients on beta-blockers after myocardial infarction.

BACKGROUND: In patients with coronary artery disease, the target intensity-level of exercise training is usually based on a training heart rate that aims to be close to the upper level of metabolic aerobic exercise. AIM: We intended to evaluate whether a training heart rate calculated with the Karvonen formula after a conventional exercise test is comparable with the heart rate at the anaerobic threshold in patients after myocardial infarction treated with beta-blockers and if not to propose a new formula. METHODS AND RESULTS: In this multicenter prospective study, 115 consecutive beta-blocked patients recovering from myocardial infarction performed a cardiopulmonary exercise test to determine the anaerobic threshold. The training heart rate determined by the Karvonen formula was compared with the heart rate at the anaerobic threshold in a derivation sample (n=58) and a validation sample (n=57) of patients. The Karvonen training heart rate was significantly lower than the heart rate at the anaerobic threshold (91+/-5 versus 102+/-17 bpm, P<0.0001) in the first sample of patients and this difference was clinically relevant in 40% of patients. Thus, a 'modified Karvonen training heart rate', equal to 0.8xx(maximum heart rate-resting heart rate)+resting heart rate, was calculated by linear regression in the derivation sample and prospectively assessed in the validation sample. The modified Karvonen training heart rate was closer to the heart rate at the anaerobic threshold than the Karvonen training heart rate, and the difference between the modified Karvonen training heart rate and the heart rate at the anaerobic threshold was clinically relevant in only 5% of patients. CONCLUSION: The Karvonen formula underestimates the heart rate at the anaerobic threshold in beta-blocked patients, which may lead to undertraining of patients with coronary artery disease; we propose another formula more adapted to these patients.