Kardiovaskuläre Rehabilitation

Cardiovascular rehabilitation encompasses the optimization of secondary prevention to reduce morbidity and mortality, the improvement of physical fitness and quality of life as well as the reintegration into social life and employment. This requires a multifactorial intervention on the physical, psychological, educative and social level by a multidisciplinary team. In Germany, cardiac rehabilitation started early after an index event, could demonstrate a significant reduction of total mortality, myocardial infarction and hospitalization during a follow-up of 1–2 years in 4 cohort studies including 10.758 patients with myocardial infarction and bypass surgery. This reduction of clinical events was obtained in addition to rapid revascularization therapy during the acute coronary event and on top of an evidence based secondary preventive medication. By national and international medical societies, cardiac rehabilitation is recommended as well in patients with congestive heart failure, after valve replacement or valve repair, after heart transplantation and cardioverter/defibrillator implantation. In the future, cardiac rehabilitation in Germany should be evaluated by a randomized controlled trial and multifactorial interventions should be tailored individually to specific patient subgroups and medical conditions.     

The role of cardiac rehabilitation in patients with heart disease

Cardiac rehabilitation is a valuable treatment for patients with a broad spectrum of cardiac disease. Current guidelines support its use in patients after acute coronary syndrome, coronary artery bypass grafting, coronary stent placement, valve surgery, and stable chronic systolic heart failure. Its use in these conditions is supported by a robust body of research demonstrating improved clinical outcomes. Despite this evidence, cardiac rehabilitation referral and attendance remains low and interventions to increase its use need to be developed.     

Early short-term intensive cardiac rehabilitation induces positive results as long as one year after the acute coronary event: a prospective one-year controlled study

AIMS: The one-year effects of early and short-term intensive cardiac rehabilitation programmes in patients after acute myocardial infarction or coronary artery bypass surgery (CABG) are not well established. METHODS AND RESULTS: One to four weeks after hospital discharge for acute myocardial infarction (n=55) or CABG (n=54), 109 patients were included in a multidisciplinary ambulatory cardiac rehabilitation programme, lasting 2 to 3 months and including a mean of 33 daily sessions. A complete cardiological assessment of the classical coronary risk factors was performed at entry into the study and again 12 months later, that is 9 to 10 months after the end of the rehabilitation programme. Major effects at one-year follow-up were a high rate of aspirin intake, a low rate of smoking (14% of the patients), a 15% increase in physical capacity, a 7 beats/min decrease in resting heart and a 4 mg/dl increase in the HDL-cholesterol. Body weight increased by 4.9 kg in the patients who stopped smoking; the modest increase in body weight in the other patients reflected a partial weight recovery in the CABG patients. Blood pressure levels also increased at the end of the study but our data in CABG patients and their extrapolation to the post MI patients strongly suggest a progressive return of blood pressure to the pre-acute event levels. In a control group matched for age, sex and type of coronary event, no significant modifications were observed after one year, except for an increase in body weight of 1.7 kg (P < 0.000).CONCLUSIONS: Cardiac rehabilitation which started early after an acute coronary event and regularly followed during 2 to 3 months induced beneficial effects which were still present 9 to 10 months later. Weight gain after smoking cessation was prevalent. The lack of changes in the control group reinforced the benefit of cardiac rehabilitation.     

Cardiac rehabilitation: Effective yet underutilized in patients with cardiovascular disease

Cardiac rehabilitation is a comprehensive program that treats patients with multiple cardiac conditions including post‐myocardial infarction, stable angina, post‐coronary artery bypass surgery, chronic heart failure, and peripheral vascular disease with structured exercise, and nutrition and risk factor counseling. It is an effective tool that has been shown to improve not only quality of life but also reduce adverse cardiac events, including death. While the value of cardiac rehabilitation is supported by a large body of evidence and its recommendation by the American Heart Association/American College of Cardiology it is significantly underutilized due to both patient and systemic factors. Continued efforts should be made to remove the obstacles to make cardiac rehabilitation available to all those who qualify.     

Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation

BACKGROUND: Cardiac rehabilitation is widely recognized as a medical management procedure that reduces mortality, but the cardiovascular safety of exercise training has not been clearly established. Published data are retrospective or outdated, as patient management has substantially progressed in recent years. The aim of this prospective registry was to determine the current complication rate during exercise performed in the course of cardiac rehabilitation. METHODS: This study was conducted by the Functional Evaluation and Cardiac Rehabilitation Working Group of the French Society of Cardiology. During a 1-year period, 65 cardiac rehabilitation centers reported that serious events had occurred during or 1 hour after an exercise stress test or a training session. Severe cardiovascular events were validated by a scientific committee. RESULTS: A total of 25,420 patients (78% men; mean age, 61.3 years) were included in the study. Initial indications for cardiac rehabilitation were post-cardiac surgery (coronary bypass, 34.3%; valvular surgery, 18.4%); recent percutaneous coronary intervention (21.6%); and other coronary (13.2%) and noncoronary (12.5%) conditions. The study population underwent 42,419 exercise stress tests and 743,471 patient-hours of exercise training. Twenty severe cardiac events were reported: 5 were related to exercise testing and 15 were related to exercise training. The event rate was 1 per 8484 exercise stress tests and 1 per 49,565 patient-hours of exercise training; the cardiac arrest rate was 1.3 per million patient-hours of exercise. Neither fatal complications nor emergency defibrillations were reported. CONCLUSION: The frequency of major cardiovascular complications during supervised exercise training in France is quite low.     

The obesity epidemic in the United States: role of cardiac rehabilitation

Obesity is an independent risk factor for the development of coronary heart disease. The vast majority of individuals entering into cardiac rehabilitation are overweight. Weight loss has been shown to be helpful in modifying multiple coronary risk factors. Cardiac rehabilitation programs, as secondary prevention centers, need to develop programs to assist participants with meaningful and permanent weight loss.     

冠状动脉旁路移植术后心脏康复专家共识

冠状动脉旁路移植术(CABG)是治疗冠心病常见的血运重建手段。CABG后心脏康复是一项综合的、整体的全程医疗管理模式,包括运动治疗、二级预防用药、营养支持、心理管理、戒烟等方面,CABG后规范的心脏康复对于降低再住院率,提高患者运动能力和生活质量以及预防心血管不良事件等方面具有积极意义。因此,为了促进我国CABG后心脏康复的规范化发展,国家心血管病中心、CABG后心脏康复专家共识编写委员会在2016年《中西医结合冠状动脉旁路移植术Ⅰ期心脏康复专家共识》的基础上,就CABG后心脏康复相关问题进行深入探讨,制定了我国CABG后心脏康复专家共识。其中,针对CABG后心脏康复的术前评估、围术期营养、早期营养支持、重症监护病房(ICU)期间康复、社会心理因素干预、睡眠管理等重要问题提出了明确建议。     

Aortokoronare Bypass- und Herzklappenoperationen

In Germany, approximately 100,000 patients underwent cardiac surgery in 2005. The most important postoperative problems with prognostic impact for these patients were acute heart failure, acute renal failure, infections, neurological complications, postcardiotomy syndrome, cardiac tamponade and atrial fibrillation. The "EuroSCORE" is a relevant predictor of immediate and long-term outcome in these patients. The patency rates of coronary artery bypass grafts (CABG) are important for the long-term outcome in such surgery. There has been a significant increase in the number of patients aged 80 years and older who are referred for cardiac surgery, which is an outstanding challenge for cardiac surgeons.     

Predicting cardiac rehabilitation enrollment: the role of automatic physician referral.

BACKGROUND: Despite the established benefits of cardiac rehabilitation, evidence suggests referral to, and subsequent enrollment in, cardiac rehabilitation following a coronary event remains low (10-25%). The aim of this study was to identify predictors of attendance to cardiac rehabilitation intake and subsequent enrollment in rehabilitation after coronary artery bypass graft surgery within the framework of an automatic referral system. DESIGN AND METHODS: We conducted a historic prospective study of patients who underwent coronary artery bypass graft surgery between 1 April 1996 and 31 March 2000 and lived within the geographic referral area of a multi-disciplinary cardiac rehabilitation center in central-south Ontario, Canada. Coronary artery bypass graft surgery patients are automatically referred to cardiac rehabilitation at the time of hospital discharge. Consecutive health records of eligible patients were reviewed for medical history, cardiac risk factor profiles, and evidence of cardiac rehabilitation intake attendance and enrolment. RESULTS: A total of 3536 patients met eligibility criteria. Patients were predominantly male (79.1%), approximately 64 years of age, living with a spouse or a partner, English-speaking, retired and had multiple cardiac risk factors. Of eligible patients, 2121 (60.0%) attended the cardiac rehabilitation intake appointment. Of patients who attended cardiac rehabilitation intake 1463 (69%) enrolled in at least one cardiac rehabilitation service, based on their risk factor profile. Selected cardiac rehabilitation services were exercise training (n=1287; 88%), nutrition counseling (n=571; 39.0%), nursing care (n=546; 37.3%), and psychological intervention (n=223; 15.2%). CONCLUSIONS: An institutionalized, physician-endorsed system of automatic referral to cardiac rehabilitation resulted in higher rates of cardiac rehabilitation intake and enrollment following coronary artery bypass graft surgery than previously reported and should be adopted for all cardiac populations.     

Factors associated with referral to outpatient cardiac rehabilitation services

BACKGROUND: Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low. PURPOSE: This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia. METHODS: The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral. RESULTS:: Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery. CONCLUSIONS: Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.     

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.     

Kardiologische Rehabilitation

The goal of cardiac rehabilitation is to support heart patients using a multidisciplinary team in order to obtain the best possible physical and mental health and achieve long-term social reintegration. In addition to improving physical fitness, cardiac rehabilitation restores self-confidence, thus better equipping patients to deal with mental illness and improving their social reintegration ("participation"). Once the causes of disease have been identified and treated as effectively as possible, drug and lifestyle changes form the focus of cardiac rehabilitation measures. In particular diseases, rehabilitation offers the opportunity for targeted educational courses for diabetics or drug dose escalation, as well as special training for heart failure patients. A nationwide network of outpatient heart groups is available for targeted follow-up. Cardiac patients predominantly rehabilitated in follow-up rehabilitation are older and have greater morbidity than in the past; moreover, they generally come out of acute clinical care earlier and are discharged from hospital more quickly. The proportion of severely ill and multimorbid patients presents a diagnostic and therapeutic challenge in cardiac rehabilitation, although cardiac rehabilitation was not initially conceived for this patient group. The benefit of cardiac rehabilitation has been a well documented reduction in morbidity and mortality. However, hurdles remain, partly due to the patients themselves, partly due to the health insurers. Some insurance providers still refuse rehabilitation for non-ST-segment elevation infarction. In principle rehabilitation can be carried out in an inpatient or an outpatient setting. Specific allocation criteria have not yet been established, but the structure and process quality of outpatient rehabilitation should correspond to that of the inpatient setting. The choice between the two settings should be based on pragmatic criteria. Both settings should be possible for an individual patient. Cardiac rehabilitation is already focusing on older, sicker and polymorbid patients; this will become ever more the case in the future. There is still a need for future clinical research for these patients.     

Neuropsychological functioning among cardiac rehabilitation patients

PURPOSE: The underlying pathophysiology contributing to coronary heart disease also predisposes patients to cerebrovascular disease and associated cognitive disorders. Although prior studies have focused on the neuropsychological sequelae of specific cardiac problems, few have examined the associated cognitive capacities and limitations of typical cardiac patients. The current study was designed to examine neuropsychological functioning among a sample of cardiac rehabilitation (CR) patients. METHODS: Using neuropsychological instruments, patients were compared in a CR program to age-matched outpatient control subjects who had no known history of cardiac or neurologic disease. Cardiac rehabilitation patients were then divided into dichotomous subgroups based on whether they had undergone coronary artery bypass grafting, had experienced a myocardial infarction, had hypertension, or had impaired ejection fraction. Neuropsychological functioning was examined relative to each of these factors. RESULTS: Cardiac rehabilitation patients had poorer neuropsychological test performance than did control subjects, with subtle relative deficits on measures of response generation, memory, and verbal abstraction, and particularly verbal fluency. Low ejection fraction, hypertension, and prior coronary artery bypass graft were associated with greater relative neuropsychological impairments. CONCLUSIONS: Although CR patients were not grossly neuropsychologically impaired as a group, it appears highly likely that many within a given program exhibit some degree of neuropsychological dysfunction. Including neuropsychological screening as part of pre-CR testing would help to identify such patients. This information may help staff to impart health care information in a manner that is most effective for the individual patient and may also be useful in the formation of realistic goals.     

Low caloric expenditure in cardiac rehabilitation

BACKGROUND: Total physical activity energy expenditure is a determinant of weight loss and risk factor modification in adults. There has been very little study of physical activity energy expenditure in cardiac rehabilitation populations. METHODS: Exercise-related energy expenditure was calculated in 112 patients with coronary artery disease in an outpatient cardiac rehabilitation program. Gross energy expenditure was estimated with the heart rate/oxygen consumption relation as measured during metabolic exercise testing with expired gas analysis. RESULTS: The average exercise training energy expenditure (ETEE) per cardiac rehabilitation exercise session was quite low at 270 +/- 112 kcal. Baseline fitness level (peak oxygen consumption), body weight, total exercise duration per session, age, and body mass index were all significant determinants of ETEE (r = 0.56 to -0.37, all P <.01). Additionally, patients who had undergone coronary bypass surgery and patients with medical comorbidities expended significantly fewer calories during exercise. In women, there was a relation between ETEE and change in total and LDL cholesterol (r = -0.43 and -0.45, respectively), although no such relation was observed in men. CONCLUSION: Cardiac rehabilitation exercise training, as currently structured, burns surprisingly few calories and has little impact in the short term (3 months) on measures of obesity and lipid risk factors. Alternative training programs should be considered to maximize caloric expenditure and modify specific risk factors such as obesity and dyslipidemia.     

Effects of cardiac rehabilitation on exercise capacity in Type 2 diabetic patients with coronary artery disease.

AIM: To determine whether Type 2 diabetic patients with coronary disease can obtain, after cardiac rehabilitation, a similar benefit on exercise capacity to non-diabetic coronary individuals. RESEARCH DESIGN AND METHODS: Fifty-nine Type 2 diabetic patients and 36 age-matched non-diabetic patients were enrolled in a 2-month cardiac rehabilitation programme, after an acute coronary event. At the beginning and at the end of the cardiac rehabilitation programme, each subject underwent a cardiopulmonary exercise test to assess exercise capacity as measured by peak workload, duration of test, maximal heart rate, peak VO2 and anaerobic threshold. The two groups of patients were not different in age, sex ratio, type of coronary event or left ventricular ejection fraction. RESULTS: The baseline exercise capacity parameters were not different between diabetic and non-diabetic subjects. After cardiac rehabilitation, improvement of exercise capacity was significantly less in patients with diabetes compared with those without diabetes: peak workload (19% vs. 29%, P = 0.022), peak VO2 (13% vs. 30%, P = 0.002), anaerobic threshold (12% vs. 31%, P = 0.017). In the diabetic patients, a significant inverse relation between fasting blood glucose and change in peak VO2 was observed on both univariate (r = -0.40, P = 0.002) and multivariate (P = 0.001) analyses. CONCLUSIONS: The benefit of cardiac rehabilitation, after an acute ischaemic heart event, in exercise capacity is significantly lower in Type 2 diabetic patients. The response to cardiac rehabilitation in those with diabetes appears to be influenced by blood glucose levels.     

Research related to rehabilitation.

Progress in cardiac rehabilitation demands that rehabilitation efforts for the patient after myocardial infarction or aortocoronary bypass surgery be integrated into a comprehensive program of acute and ambulatory cardiac care. To permit a more rapid return of coronary patients to a normal or near-normal lifestyle and role in society, further delineation of the scientific bases for all components of rehabilitation programming and identification of both barriers to and facilitators of rehabilitation are necessary to improve rehabilitative services.     

Rehabilitation of patients after heart surgery: experience and problems

The problem of rehabilitation of cardiac surgical patients is of great humane and socioeconomic significance. Over years, a great scientific and practical experience has gained in rehabilitating patients with acquired and congenital heart diseases after surgical correction. Stages of rehabilitation, a complex of medical, somatic, psychological, and socio-occupational measures are specified. Substantial shortcomings in medical labour examination of operated patients lead to an increase in the number of disabled persons. There is a lag in the study into the problem of patients with coronary heart disease after aortocoronary bypass.     

冠心病患者综合康复疗效观察

目的：观察综合康复治疗对冠心病患者的临床疗效。方法：60例冠心病患者随机分为康复组（30例）和对照组（30例）,康复组在常规药物治疗的基础上,采用生活指导,运动锻炼等综合康复治疗;对照组采用常规药物治疗,自然生活。6周以后,记录心脏事件发生率,观察体重指数、血脂、血压的变化。结果：6周后,康复组的心脏事件发生率明显低于对照组（16．7％;50．0％,P〈0．01）,两组体重指数,血脂,血压均有一定改善,但康复组优于对照组（P〈0．05-〈0．01）。结论：综合康复治疗可降低心脏事件的发生率,改善患者的体重指数,血脂及血压。     

Nontransplant surgical alternatives for heart failure

Optional statement Heart failure is a tremendous burden on society, and on the health care system in particular. Historically, medical treatments have been the only therapies available because patients were felt to be too high risk to undergo conventional cardiac surgical procedures. Cardiac transplantation remains an established therapy for certain patients with end-stage heart failure but it is limited by donor availability and the need for lifelong immunosuppression. Recent advances in myocardial protection, operative techniques, and perioperative care have made it possible for conventional surgery, such as coronary bypass, ventricular reconstruction, and valve repair, to be offered to many patients with advanced heart failure with good short- and long-term results. In 2005, few patients are inoperable.