Long-term follow-up of survivors of prehospital sudden cardiac death treated with coronary bypass surgery

Although coronary artery bypass surgery is beneficial to patients with severe coronary artery disease, its role in preventing the recurrence of prehospital cardiac arrest in patients is not clear. In this article, we report on the long-term follow-up of 49 survivors of prehospital coronary arrest who had coronary artery bypass surgery. Prior to their prehospital cardiac arrest, 14% of the patients had a history of unstable angina. Coronary angiograms obtained after prehospital cardiac arrest showed that 71% of the patients had three-vessel coronary artery disease and 6% had single-vessel disease. The mean left ventricular ejection fraction was 45%. There were four postoperative deaths; three were caused by pump failure, and one was caused by refractory ventricular arrhythmias. After a maximum follow-up period of 102 months (mean of 55.4 months), there were seven cardiac deaths; five of the patients died of recurrent ventricular fibrillation, and two patients' deaths were related to refractory heart failure. Actuarial analyses of the 49 patients showed that the probability of survival at 6 months, 1 year, 2 years, 3 years, and 5 years was 92%, 92%, 89%, 82%, and 72%, respectively. After surgery, 35 of the 45 patients who were discharged from the hospital were asymptomatic, and 23 of the 32 patients who were employed when their prehospital cardiac arrest occurred returned to their employment. We concluded that coronary artery bypass surgery is beneficial to certain survivors of prehospital sudden death. After surgery, most patients are asymptomatic and capable of returning to their employment and the recurrence of prehospital sudden death is low.     

Circadian variability in the occurrence of sudden cardiac death in patients with hypertrophic cardiomyopathy

Objectives. The present study examined whether sudden death in patients with hypertrophic cardiomyopathy occurred with a particular pattern of frequency throughout the day.Background. Previous investigators have shown a circadian distribution in the occurrence of sudden death and other cardiovascular events in patients with atherosclerotic coronary artery disease. Sudden death is also an important feature of the natural history of patients with hypertrophic cardiomyopathy.Methods. The study group comprised 94 patients with a time of death (or cardiac arrest) that could be ascertained accurately to the nearest hour. This hourly distribution was analyzed by harmonic regression.Results. Sudden death did not occur uniformly or randomly throughout the day. Rather, it was distributed in a bimodal pattern that conformed to a two-harmonic regression model. A disproportionate number of sudden deaths (43 [46%] of 94) occurred in the first peak in midmorning between 7 amand 1 pm. The second peak of sudden death was less distinct but was in the early evening, between 8 pmand 10 pm. This periodicity in occurnace of sudden cardiac death was not evident for the days of the week or months of the year and, furthermore, did not appear to be influenced by other clinical variables, such as age, gender, severity of symptoms, subaortic gradient or left ventricular wall thickness. Sudden death occurred most commonly during periods of severe exertion (37 [39%] of 94).Conclusions. Sudden death in hypertrophic cardiomyopathy demonstrates a bimodal pattern of circadian variability over the 24-h day, with a prominent midmorning peak similar to that described in patients with coronary artery disease, and a less striking early-evening peak of occurrence. These findings suggest that temporally related physiologic changes, possibly in the electrical vulnerability of the myocardial substrate, may play a role in the sudden death of patients with hypertrophic cardiomyopathy.     

Mitral valve prolapse: cardiac arrest with long-term survival

Cardiac arrest has been reported in patients with mitral valve prolapse; however, clinical characteristics and survival information are limited since most of the cases reported include autopsy data. Nine patients (2 male, 7 female) with mitral valve prolapse were identified who had cardiac arrest; ventricular fibrillation was documented in 8 patients; resuscitation was unsuccessful in 2. Eight had a history of palpitations (months to 15 years duration) and ventricular arrhythmias, 3 had a history (5-15 years) of recurrent syncope, and 1 was totally asymptomatic. Cardiac catheterization-angiographic studies in 8 patients demonstrated normal coronary artery anatomy and mitral valve prolapse. All 9 patients had auscultatory and echocardiographic evidence of mitral valve prolapse. Seven survivors (6 still alive) were followed from 3 to 14 years after cardiac arrest. A subset of patients with mitral valve prolapse and cardiac arrest is described in whom past medical history is compatible with cardiac arrhythmias or syncope, and whose long-term prognosis appears better than patients with other causes of cardiac arrest.     

Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest

Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge. A retrospective cohort of 240 patients with out-of-hospital rSCA caused by ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington from 1999 through 2002. Patients were grouped into those receiving acute catheterization within 6 hours (≤6-hour group, n = 61) and those with deferred catheterization at >6 hours or no catheterization during the index hospitalization (>6-hour group, n = 179). Attention was directed to survival to hospital discharge, neurologic status, extent of coronary artery disease, presenting electrocardiographic findings, and symptoms before arrest. Propensity-score methods were used to adjust for the likelihood of receiving acute catheterization. Survival was greater in patients who underwent acute catheterization (72% in the ≤6-hour group vs 49% in the >6-hour group, p = 0.001). Percutaneous coronary intervention was performed in 38 of 61 patients (62%) in the ≤6-hour group and 13 of 170 patients (7%) in the >6-hour group (p <0.0001). Neurologic status was similar in the 2 groups. A significantly larger percentage of patients in the acute catheterization group had symptoms before cardiac arrest and had ST-segment elevation on electrocardiogram after resuscitation. Age, bystander cardiopulmonary resuscitation, daytime presentation, history of percutaneous coronary intervention or stroke, and acute ST-segment elevation were positively associated with receiving cardiac catheterization. In conclusion, in this series of patients who sustained out-of-hospital cardiac arrest, acute catheterization (<6 hours of presentation) was associated with improved survival.     

Effect of empiric antiarrhythmic therapy in resuscitated out-of-hospital cardiac arrest victims with coronary artery disease

The effect of empiric antiarrhythmic therapy with quinidine and procainamide on long-term mortality was examined in 209 patients with coronary artery disease resuscitated after out-of-hospital cardiac arrest. The antiarrhythmic agent used was determined by the patient's private physician without knowledge of the study ambulatory electrocardiogram. Of the 209 patients, procainamide was prescribed in 45 (22%), quinidine in 48 (23%) and no antiarrhythmic therapy in 116 (55%). Digoxin therapy was initiated in 101 patients. The 2-year total survival rate for the quinidine, procainamide and nontreated patients was 61, 57 and 71% (p less than 0.05), and for sudden death was 69, 69 and 89% (p less than 0.01), respectively. These observations suggest that empiric antiarrhythmic therapy in survivors of out-of-hospital cardiac arrest did not affect total mortality and was associated with an increased frequency of sudden death.     

Sudden cardiac death

Most sudden deaths in industrial nations are the result of underlying coronary artery disease. Longitudinal studies have demonstrated that the percent of all coronary events presenting as sudden death increases with age in both men and women. Relative weight is another important risk factor; the age-adjusted rate of sudden cardiac death for the upper weight tercile in the Framingham study was over 2 times higher for men and 3 times higher for women than the rate for the lower weight tercile. Most patients who die suddenly initially experience ventricular tachycardia that subsequently degenerates into ventricular fibrillation. Patients with a high risk of sudden cardiac death include: survivors of myocardial infarction with left ventricular dysfunction or complex ventricular ectopy, or both; survivors of out-of-hospital cardiac arrest, particularly when the event is not associated with an acute myocardial infarction; patients with recurrent ventricular tachycardia; and patients with dilated congestive cardiomyopathy, particularly when associated with ventricular ectopy. Reducing the risk of sudden death in these patients remains a major challenge.     

Features of cardiac arrest episodes with and without acute myocardial infarction in the Coronary Artery Surgery Study (CASS)

Angiographic evidence of coronary artery disease was present in 16,002 patients in the Coronary Artery Surgery Study (CASS) registry. Of these patients, 551 had a history of cardiac arrest before enrollment angiography. Cardiac arrest was a complication of acute myocardial infarction (AMI) in 372 patients (68%). Electrocardiographic documentation of the responsible rhythm was available in 283 patients. Ventricular fibrillation (VF) was present in 112 (60%), ventricular tachycardia (VT) in 41 (22%) and both VT and VF in 26 (14%) patients. Stepwise linear discriminant analysis comparing the 551 cardiac arrest patients with the other 15,451 patients selected left ventricular wall motion score (F = 265), use of digitalis (F = 71), impaired blood supply to any segment (F = 16) and particularly to the anterior wall (F = 11) as discriminating variables associated with cardiac arrest. Patients with cardiac arrest occurring as a complication of AMI were younger (F = 12), had greater impairment of coronary blood supply (F = 7) and were more likely to be on a cholesterol-lowering diet (F = 16) than were patients with arrest remote from infarction. Comparison of patients with VT versus those with VF showed a positive association of VT with age (F = 8), a trend toward worse left ventricular function and presence of a left ventricular aneurysm, but no difference in severity and collateralization of coronary artery disease. It is concluded that cardiac arrest is related to the extent of myocardial damage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiovascular Effects of the Supraglottic and Super-supraglottic Swallowing Maneuvers in Stroke Patients with Dysphagia

The prolonged voluntary closure of the glottis during the supraglottic and super-supraglottic swallowing techniques may create the Valsalva maneuver. The Valsalva maneuver has been associated with sudden cardiac death and cardiac arrhythmias. This study describes the effects of the supraglottic and super-supraglottic swallowing techniques on the cardiovascular system. Subjects included 23 patients from an acute inpatient rehabilitation hospital. Subject groups included recent stroke, dysphagia, and a history of coronary artery disease (Group 1, N = 11), recent stroke and dysphagia with no known coronary artery disease (Group 2, N = 4), and orthopedic diagnosis with no known dysphagia or coronary artery disease (Group 3, N = 8). Cardiac status was moni-tored for 4 hours during swallowing training, regular therapy sessions, and a meal. For Groups 1 and 2, 86.6% (13 out of 15) of the subjects demonstrated abnormal cardiac findings during the swallowing session including supraventricular tachycardia, premature atrial contractions, and premature ventricular contractions. Arrhythmia subsided within a few minutes after the session and did not occur during other activities. In Group 3 (control group), none of the subjects demonstrated abnormal cardiac findings except for bradycardia in one subject. It is suggested that the supraglottic and super-supraglottic swallow maneuvers may be contraindicated for patients with a history of stroke or coronary artery disease.     

Clinical characteristics and survival experience of out-of-hospital cardiac arrest victims without coronary heart disease

Of 270 patients successfully resuscitated from out-of-hospital cardiac arrest, 16% had no evidence of coronary heart disease. In these 43 patients, other forms of heart disease were found in 81% (35/43): cardiomyopathy in 18 patients, valvular disease in six, congenital heart disease in two, and primary arrhythmia in nine. Seven patients had evidence of only pulmonary disease and one had pancreatitis as his precipitating event. Nineteen of the 43 patients (44%) had serum potassium less than 3.6 mEq l-1 in the initial blood sample after cardiac arrest. One- and two-year mortalities were 30% and 43%, respectively, for the group, which is similar to one-year (20%) and two-year (35%) mortalities of the 227 resuscitated patients with coronary heart disease. Patients who survive a sudden death experience and who have no evidence of coronary artery disease are a unique but heterogeneous group who usually have identifiable cardiac or pulmonary disease.     

Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest.

The effect of coronary bypass surgery on recurrent cardiac arrest was estimated in 265 patients resuscitated from out of hospital cardiac arrest between 1970 and 1988. From this cohort, 85 patients (32%) underwent coronary bypass surgery after recovery from cardiac arrest and 180 patients (68%) were treated medically. A multivariate Cox analysis was used to estimate the effect of coronary bypass surgery on subsequent survival after adjusting for effects of age, prior cardiac history, ejection fraction, year of the event, history of angina, antiarrhythmic drug use and whether the arrest was related to acute myocardial infarction. The use of coronary bypass surgery had a significant effect in reducing the incidence of subsequent cardiac arrest during follow-up study (risk ratio [RR] 0.48, 95% confidence interval [CI] 0.24 to 0.97, p less than 0.04). There was also a trend consistent with a reduction in total cardiac mortality (RR 0.65, 95% CI 0.39 to 1.10, p = 0.10). These findings suggest that coronary bypass surgery may reduce the incidence of sudden death in suitable patients resuscitated from an episode of ventricular fibrillation.     

Sudden cardiac death associated with isolated congenital coronary artery anomalies.

OBJECTIVES AND BACKGROUND. Congenital coronary anomalies are associated with sudden death and exercise-related death. Clarification of the risk and mechanisms of sudden death in patients with coronary anomalies may aid in decisions on intervention. METHODS. The clinicopathologic records of 242 patients with isolated coronary artery anomalies were reviewed for information on mode of death and abnormalities of the initial segment (acute angle takeoff, valvelike ridges or aortic intramural segments) and course of the anomalous coronary artery. RESULTS. Cardiac death occurred in 142 patients (59%); 78 (32%) of these deaths occurred suddenly. Of sudden deaths, 45% occurred with exercise. Sudden death (28 of 49, 57%) and exercise-related death (18 of 28, 64%) were most common with origin of the left main coronary artery from the right coronary sinus. Anomalous origin of the right coronary artery from the left coronary sinus was also commonly associated with exercise-related sudden death (6 of 13 sudden deaths, 46%). High risk anatomy involved abnormalities of the initial coronary artery segment or coursing of the anomalous artery between the pulmonary artery and aorta. Younger patients (less than or equal to 30 years old) were significantly more likely than older patients (greater than or equal to 30 years old) to die suddenly (62% vs. 12%, p = 0.0001) or during exercise (40% vs. 2%, p = 0.00001) despite their low frequency of significant atherosclerotic coronary artery disease (1% vs. 40%, p = 0.00001). CONCLUSIONS. Younger patients (less than or equal to 30 years old) with an isolated coronary artery anomaly are at risk of dying suddenly and with exercise. Therefore, greater effort for early detection and surgical repair of these lesions is warranted.     

Clinical features and prognosis of patients with out of hospital cardiac arrest and a normal electrophysiologic study

Nineteen patients survived a cardiac arrest not associated with an acute myocardial infarction, and had a normal electrophysiologic study with no inducible ventricular tachycardia despite programmed stimulation with one to three extrastimuli at two or more ventricular sites. Among 14 patients who had obstructive coronary artery disease, cardiac arrest occurred during exertion or an episode of angina pectoris in 11; 24 hour ambulatory electrocardiographic recordings demonstrated infrequent or no premature ventricular complexes in 10 and an ischemic response occurred during stage I or II (Bruce protocol) in 6 of 9 patients who underwent exercise testing. Treatment of these patients consisted of myocardial revascularization (eight patients) or antianginal medications (six patients). Only three patients were also treated with an antiarrhythmic drug. Over a follow-up period of 26 +/- 15 months (mean +/- standard deviation), only one patient died suddenly. Two patients who had coronary artery spasm were treated with coronary vasodilator medications and had no recurrence of cardiac arrest over 7 and 36 months of follow-up, respectively. Three patients who had cardiomyopathy or no identifiable structural heart disease were treated with nadolol or amiodarone and had no recurrence of cardiac arrest over 3 to 27 months of follow-up. Among patients who survive a cardiac arrest and have a normal electrophysiologic study, those with obstructive coronary artery disease or coronary artery spasm generally have an excellent prognosis with treatment directed primarily at the underlying heart disease. The clinical features of these patients suggest that cardiac arrest was related to ischemia rather than a primary arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Safety of cardiac rehabilitation in a medically supervised, community-based program

The time to occurrence of cardiovascular complications after the beginning of an exercise rehabilitation program is variable. It is not clear whether such complications are related to the duration in the program. The aim of the present study was to assess the timing of cardiovascular events occurring during the activity and the long-term safety of a medically supervised cardiac rehabilitation program performed in the community, in a large cohort. We retrospectively evaluated 3,511 patients with a history of myocardial infarction, coronary artery bypass grafting and risk factors for coronary artery disease, participating in exercise training, for 69 months. The total number of patient-hours was 338,688 with an event rate of 1/58,902 patient-hours/year (0.02%). Non-fatal events occurred in 11 patients and fatal cardiovascular events in 2 patients; 1 was successfully resuscitated. Most of the non-fatal events (62%) occurred during the first 4 weeks from the beginning of the exercise program. One third of the patients who experienced cardiovascular events, resumed the exercise program with no further complications. Medically supervised cardiac rehabilitation program is accompanied by a very low incidence of cardiovascular events. Nevertheless, special caution should be undertaken during the first sessions of the program.     

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.     

Increased QT dispersion in patients with Prinzmetal's variant angina and cardiac arrest

OBJECTIVES: We sought to compare QT dispersion in patients presenting with Prinzmetal's variant angina complicated by cardiac arrest or syncope and patients with uncomplicated variant angina. BACKGROUND: Despite the usually benign course of treated Prinzmetal's variant angina, a proportion of vasospastic angina patients develop ventricular arrhythmias and sudden death in association with coronary spasm. Increased QT dispersion has been suggested to increase susceptibility to ventricular arrhythmias in patients with coronary artery spasm. METHODS: We studied 25 consecutive patients (mean age 58 years; 14 men) with classical Prinzmetal's variant angina and documented coronary artery spasm. None of the patients had coronary artery stenoses < or =40%. Five patients had suffered a documented cardiac arrest, two had recurrent syncope and 18 had no arrhythmic events or syncopal episodes. In all patients QT dispersion (QT maximum-QT minimum in every ECG lead) was measured on the baseline 12-lead electrocardiogram at study entry using a digitising board. RESULTS: Mean (+/-S.D.) QT dispersion of study patients was 62.3+/-19.5 ms. QT dispersion in patients with cardiac arrest and syncope (79.4+/-17.3 ms) was significantly higher compared to patients with no such events (56.3+/-16.9 ms), (95% CI 7.5-38.8, P=0.005). No significant clinical, biochemical or angiographic differences were found between patients with and those without cardiac arrest or syncope. CONCLUSION: QT dispersion is increased in patients with Prinzmetal's variant angina complicated by cardiac arrest and syncope compared to patients without such events. Increased QT dispersion may be both a substrate for sudden cardiac death and a marker of risk in patients with Prinzmetal's variant angina.     

Prediction of coronary artery disease in a population of insulin-requiring diabetic patients: results of an 8-year follow-up study

To identify predictors of clinical coronary artery disease, 110 insulin-requiring diabetic patients with no symptoms suggestive of cardiac disease and with a normal resting ECG underwent metabolic and noninvasive cardiovascular screening including a history and physical examination, exercise ECG, M-mode echocardiography, and chemical laboratory testing. During a median follow-up interval of 100 months, 14 of these patients had clinical evidence of coronary artery disease consisting of acute myocardial infarction, sudden cardiac death, or anginal chest pain with angiographic documentation of occlusive coronary artery disease. Baseline variables that were univariately predictive of subsequent clinical coronary disease included age, peak treadmill heart rate, and retinal neovascularization. According to multivariate analysis the peak treadmill heart rate was the single most important predictor of subsequent development of clinical coronary disease. A treadmill ECG result that was either abnormal or inconclusive because of failure to achieve 90% of predicted maximal heart rate identified each patient in whom clinical coronary artery disease developed within 50 months after entry testing. Thus the entry treadmill ECG provided prognostic information not available from the history and physical examination results, but little further prognostic information was provided after the first 50 months of follow-up, suggesting the need for serial testing.     

Clinical and genetic evaluation after sudden cardiac arrest

Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) can be attributed to cardiac, respiratory, metabolic, and toxicologic etiologies. Most cases of SCD are caused by coronary artery disease and approximately 40% of cardiac arrests are unexplained. Inherited arrythmias and cardiomyopathies are important contributors to SCA and SCD. Identifying an inherited condition after such an event not only has important ramifications for the individual, but also for relatives who may be at risk for the familial condition. This review will provide an overview of inherited cardiovascular disorders than can predispose to SCA/SCD, review the diagnostic evaluation for an individual and/or family after an SCA/SCD, and discuss the role of genetic testing.     

Perioperative sublingual isosorbide dinitrate for the prevention of cardiac complications in cardiac patients undergoing noncardiac surgery

One hundred fifty-two consecutive patients with a known or suspected diagnosis of atherosclerotic coronary artery disease were administered 5 mg sublingual isosorbide dinitrate 2 hours and (1/2) hour preoperatively and every 4 hours postoperatively for 3 days, for the prevention of cardiovascular morbidity and mortality, which could result from various noncardiac surgical procedures; 125 patients received general anesthesia. Cardiovascular complications occurred in 3 patients (1.9%). Two patients did not enter the study, owing to side effects of the medication (1.3%). The complications were 1 each (0.6%) of the following: atrial fibrillation, hypotension, and cardiac arrest. Mortality was 0%. These results are exceptionally favorable when compared to the average cardiovascular morbidity rate of 2.8% to 49% in patients assigned to various risk stratifications in the medical literature.     

Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries

The clinical presentation and prognosis of 1,977 consecutive patients with normal coronary arteries or “insignificant” coronary artery disease (CAD) (no major epicardial artery with 75% or more luminal diameter narrowing) were examined. Compared with patients with significant CAD, these patients had a lower frequency of traditional cardiac risk factors and abnormalities on the rest and exercise electrocardiogram. Cardiac survival was 99% at 5 years of follow-up and 98% at 10 years for patients with normal or insignificantly narrowed coronary arteries. Patients with normal coronary arteries differed from those with insignificant CAD in their myocardial infarction free survival rate: 99% at 5 years and 98% at 10 years for patients with normal coronary arteries, compared with 97% at 5 years and 90% at 10 years for patients with insignificant CAD. A strong relation occurred between the amount of insignificant CAD and follow-up cardiac events (χ² = 21.5, p < 0.0001). Cardiac risk factors were statistically related to the risk of follow-up cardiovascular events when considered alone (χ² = 4.93, P = 0.026), but this relation lost significance after adjusting for the effect of coronary anatomy. Patients in both groups continued to have cardiac symptoms that resulted in frequent hospitalizations, medication use and job disability. Almost 50% in any given year of follow-up could not perform activities of high metabolic equivalent requirement and 70% had continuing symptoms of chest discomfort. Although these patients are at low risk of death, many remain functionally impaired for years.     

Contemporary cardiac rehabilitation: patient characteristics and temporal trends over the past decade

BACKGROUND: Recent and dramatic therapeutic advances, aggressive care of the elderly, and a heightened awareness of secondary prevention have had a significant, albeit incompletely described, impact on cardiac rehabilitation (CR) programs. The authors did a retrospective analysis on 1,848 patients from their phase II CR program that were treated over the past decade. The authors sought to identify and analyze how advances in cardiovascular care might be related to temporal changes in demographics, medical comorbidities, coronary artery disease risk factors, and cardiovascular history among individuals with cardiac disease who have completed the phase II CR program over a 10-year period. METHODS: Cardiac rehabilitation records were reviewed from 1986 to 1996 at Akron City Hospital. The data were compiled prospectively by nurses and exercise physiologists and were subsequently analyzed. The charts reviewed were from 1,848 patients who completed outpatient phase II CR. RESULTS: The program began in 1986 with 53 patients completing CR and evolved to 309 in 1996. There has been an increase in the number of elderly patients referred to and completing the program. The number of participants older than 65 years of age increased from 28.3% in 1986 to 52.1% in 1996. Cardiac rehabilitation participants reflect the known demographics of patients with clinical coronary artery disease. Men outnumber women and, on average, the female participants are older than the male participants. There has been a statistically significant increase in medical comorbidities over the course of the study. Although the absolute number of patients entering CR after coronary artery bypass graft survey has remained fairly constant, there has been a dramatic increase in the absolute number of patients entering CR after percutaneous tansluminal coronary angioplasty (with the latter recently comprising a majority of CR participants). CONCLUSION: There is a significant trend in the attendance and completion of CR programs by older individuals, which suggests a greater awareness of patients and their physicians. The growth of the program is fueled by high-risk patients with more comorbidities who potentially are the group of patients able to obtain the greatest absolute benefit from CR.