Bo Hedbäck

Cardiac rehabilitation after coronary artery bypass surgery: 10-year results on mortality, morbidity and readmissions to hospital.

Aim To evaluate the long-term secondary preventive effect of a comprehensive rehabilitation programme after coronary artery bypass grafting (CABG). Methods The study group included 49 consecutive patients who underwent bypass surgery and were then offered a rehabilitation programme consisting of education in risk-factor control, a physical training programme and regular follow-up at a post-CABG clinic. The control group (n = 98), consisting of two well-matched CABG patients for each study patient, was offered the usual care with no access to a cardiac rehabilitation programme. The two groups were followed for 10 years and the results regarding cardiovascular mortality, morbidity, total cardiac events and readmissions to hospital were compared Results The total mortality (study group 8.2%, control group 20.4%) and cardiovascular mortality (8.2 versus 15.3%) after 10 years did not differ significantly between the groups. In the study group, nine patients (18.4%) had 10 cardiac events (four cardiovascular deaths, five non-fatal myocardial infarctions and one CABG) compared to 34 patients (34.7%, P < 0.05) suffering 46 (P < 0.01) cardiac events (15 cardiovascular deaths, 18 non-fatal myocardial infarctions, eight CABG, five coronary angioplasties) in the control group. The number of readmissions to hospital (2.1 versus 3.5 per patient) and length of admissions (11 versus 26 days per patient) was significantly lower in the study group (P < 0.01). Conclusion A comprehensive cardiac rehabilitation programme offered to patients after coronary artery bypass surgery will improve the long-term prognosis and reduce the need for hospital care. J Cardiovasc Risk 2001, 8:153-158

Antianginal and anti-ischemic efficacy of nicorandil compared with nifedipine in patients with angina pectoris and coronary heart disease : a double-blind, randomized, multicenter study

Patients with stable, effort-induced angina pectoris and a typical combination of anginal pain and ischemic ST depression in exercise tolerance tests were randomized to treatment for 8 weeks with nicorandil (a newly developed antianginal and anti-ischemic drug) or nifedipine. After 4 weeks, the dosage of nicorandil was increased from 10 mg b.i.d. to 20 mg b.i.d., but the recommended dosage of nifedipine, 20 mg b.i.d., was kept constant during the study period. Double-blind treatment was preceded by a 2-week prephase during which patients were treated with isosorbide dinitrate. During the study period, patients were asked to report the rate of anginal attacks and consumption of sublingual nitroglycerin. Measurements of blood pressure and heart rate at rest and during exercise always were performed 2 h after drug intake. Fifty-eight patients were randomized-29 to nicorandil and 29 to nifedipine. There were large individual variations in anginal attack rates, which makes group comparisons difficult, but in the nicorandil group, the anginal attack rate decreased significantly compared with baseline frequency. Systolic blood pressure at rest was reduced significantly only with the highest dose of nicorandil, but nifedipine had a significant effect on both systolic and diastolic blood pressures as well as on the heart rate. Both treatments significantly increased exercise duration, time to onset of angina pectoris, and time to 1-mm ST depression. In the nicorandil group, an improvement was noted with the 20-mg dose compared with the 10-mg dose, but no significant differences were noted between the nicorandil and nifedipine groups after either 4 or 8 weeks of treatment. During the double-blind treatment, there were four dropouts in the nicorandil group (one because of palpitation and fatigue, one because of myocardial infarction, and two because of headache) and three dropouts in the nifedipine group (one because of atrial fibrillation, one because of tachycardia and vertigo, and one because of noncompliance). The most common adverse effect reported in both groups was headache of mild-to-moderate intensity. Symptoms caused by peripheral vasodilatation were commonly reported in the nifedipine group. Thus, both drugs caused significant and clinically relevant improvement in exercise test variables. A more pronounced effect on peripheral vasodilatation with nifedipine compared with nicorandil was reflected by a more marked effect on resting hemodynamics and a higher frequency of vasodilator side effects in the nifedipine group.

Effects of Cardiac Rehabilitation after Coronary Artery Bypass Grafting on Readmissions, Return to Work, and Physical Fitness. A Case-control Study

In a case-control study 49 consecutive post-coronary artery bypass grafting (CABG) patients (10 f, 39 m) participating in a comprehensive rehabilitation programme were compared with 98 individually matched double control patients, receiving standard care. The rehabilitation programme, starting 6 weeks after surgery, consisted of follow-up at a coronary clinic, repeated health education, and physical training in out-patient groups. During the first year after CABG, fewer study group patients were readmitted to hospital (14% vs 32%, p<0.01) and on fewer occasions (1.1 vs 2.9, p<0.05). Fewer patients used anxiolytic drugs (0% vs 15%, p<0.01). At the one year post-CABG exercise test we found in the study group a tendency to a greater increase in work capacity, as compared with the values obtained at the preoperative exercise test (33 vs 25 W ns). There were no differences in the rates of returning to work (59% vs 64%). In a long-term follow-up study (av. 38 months post-CABG) the patients were asked to fill in a questionnaire evaluating perceived physical work capacity and training habits. The study group patients rated their physical work capacity higher, and more patients had continued with regular physical training (66% vs 46%, p = 0.05). There were fewer patients using anxiolytic drugs (9% vs 30%, p<0.01). Although the programme did not influence the return to work we conclude that it improved the quality of life of our patients as it entailed fewer readmissions and reduced the use of anxiolytic medication; in addition it promoted physical fitness and training habits.

Depressive mood after a cardiac event : Gender inequality and participation in rehabilitation programme

Background: Depressive mood after a cardiac event is common with serious consequences for the patient. Aims: To compare gender in depressive mood during the first year after a cardiac event and to evaluate the effect of participating in a multidimensional secondary prevention program on depressive mood. Methods: 166 men and 54 women, <73 years, consecutively answered a questionnaire concerning depressive mood at 2 weeks, 6 weeks, 5 months and 1 year after discharge after a cardiac event. At 2 weeks, each patient met a nurse, and was informed about the disease and received individual support about lifestyle changes. Of those invited to participate in a secondary prevention program, 127 patients accepted, and 93 declined participation. Results: At each of the four follow-ups, women had significantly higher depression scores than men. Depressive mood in both women and men was significantly reduced at 6 weeks. Thereafter, it increased to the 2-week level in women and to above the 2-week level in men. No differences were seen in patients participating or not in secondary prevention programs. Conclusion: Women had higher depressive mood scores than men and secondary prevention programs failed to improve depressive mood in both women and men.

Gender differences in secondary prevention of coronary heart disease: reasons to worry or not?

Scand J Prim Health Care 2003;21:37-42. ISSN 0281-3432 Objective - To analyse potential gender differences in cardiovascular risk factors and treatment patterns, reflecting clinical practice in secondary prevention. Design - Observational national study during 3 years of patients eligible for secondary prevention of coronary heart disease (CHD). Setting - Fifty-two healthcare districts in Sweden, involving primary health care and hospitals in collaboration, participating in a national quality assurance programme for the prevention of CHD. Subjects - A national sample of male and female patients surviving acute myocardial infarction, or following CABG/PTCA interventions for CHD, controlled at 3-6 months (n=9135) and 12 months (n=4802) of follow-up. The proportion of female patients (25%) did not differ between visits. Main outcome measures - Self-reported data on lifestyle, drug treatment and cardiovascular risk factor levels after consultation in general practice or at hospital policlinics. Results - No major gender differences were recorded in risk factor levels or in cardiovascular drug treatment patterns at 12 months of follow-up. Female patients participated in educational programmes to improve lifestyle to a higher degree than males (52.0 vs 45.1%), but after 1 year were more often (p<0.001) self-reported smokers (11.7 vs 8.4%). Female patients showed higher levels of blood pressure, total cholesterol and HDL cholesterol, but not LDL cholesterol compared to male patients. Conclusions - In general, a gender-equal level of lipid control and access to medical drug treatment has been established for patients in secondary prevention from a national sample in Sweden, followed for 1 year after CHD manifestations and related interventions.

The Swedish National Programme for Quality Control of Secondary Prevention of Coronary Artery Disease--results after one year.

Background Guidelines for the prevention of coronary artery disease (CAD) have been developed both in Europe and in the USA. However, several surveys have shown that these guidelines are poorly implemented in clinical practice. Design/methods The Swedish Quality Control Programme on Secondary Prevention of CAD includes patients after myocardial infarction, or having undergone coronary artery surgery or percutaneous coronary intervention. Fifty of Swedens 79 hospital districts are currently participating. Patients are asked to send report-cards regarding risk factor management to a central registry after discharge from hospital, at a 3-6 month visit and then yearly for 5 years. Results Results based on data from 1 year after the index event show that a majority of patients reach targets for serum cholesterol (70%), and low-density lipoprotein (LDL)-cholesterol (71%). Mean value for total cholesterol is 4.6 (± SD 0.9) mmol/l, LDL-cholesterol 2.7 (± SD 0.8) mmol/l. Blood pressure targets are less often achieved, with 58% reaching the European Society of Cardiology target for systolic (<140 mmHg) and 81% for diastolic (<90 mmHg) blood pressure. A large proportion of patients are prescribed preventive drugs: aspirin (96%), beta-blockers (78%) and lipid-lowering drugs (83%). Conclusions The Swedish Quality Control Programme is one of the first attempts to assess implementation of guidelines on a national level based on patient participation. It is hoped that shared care programmes and increased patient involvement with feedback on achieved treatment goals in relation to guidelines will improve outcomes in patients with CAD.

Does stress reduction change the levels of cortisol secretion in patients with coronary artery disease

PURPOSE It has been shown that behavioral therapy has effects on stress behavior in patients with coronary artery disease. Salivary cortisol measurements are widely used to assess psychological stress, stress reactivity, or both. The aim of this study was to investigate whether improved stress behavior in type A patients with coronary artery disease involved changes in cortisol secretion pattern. METHODS Twenty-four male patients were identified as type A individuals and completed a 12-month cognitive-behavioral stress management program. Stress behavior was evaluated by using a validated questionnaire. Morning and evening salivary cortisol levels were measured over 3 consecutive days at baseline and after 12 months. RESULTS Although the patients showed a significant improvement in psychosocial well-being after 12 months, their basal cortisol levels or diurnal rhythm of cortisol did not change. There was no correlation between stress score and cortisol levels. CONCLUSIONS The value of salivary cortisol as both a stress marker and a new cardiovascular risk factor has been discussed but the data from this small pilot study raise the question of its utility as a stress marker in cardiac rehabilitation.

Hartrevalidatie na implantatie van een coronaire arterie-bypass: effecten op fysiek prestatievermogen en risicofactoren

Na een coronaire arterie bypass-operatie volgden 49 niet-geselecteerde patienten een hartrevalidatieprogramma, dat medische nazorg en fysieke training inhield. De laatste zowel groepsgewijs, poliklinisch, als op individuele basis thuis. Het effect van het programma op inspanningstestvariabelen, coronaire risicofactoren en medicatie een jaar na de operatie werd vergeleken met een controlegroep die geen oefeningen had gekregen (n = 98). De testgroep vertoonde minder toename in het frequentie/drukprodukt, hetgeen wijst op een gunstig effect op het myocardiale zuurstofverbruik (0,7 ± 5,4 tegen 2,8 ± 5,6; p < 0,05); een minder hoge frequentie van angina pectoris tijdens inspanningstests (6% tegen 18%; p < 0,01); een vermindering van de systolische en diastolische bloeddruk in rust (9/4 mm Hg; p < 0,01); minder rokers (6% tegen 17%; p < 0,05) en minder patienten die langwerkende nitraten gebruikten (0% tegen 10,2%; p < 0,05). Gezien deze resultaten lijkt een georganiseerd hartrevalidatieprogramma na een coronaire arterie bypass-operatie zinvol.