Neil Oldridge

Improved Exercise Tolerance and Quality of Life With Cardiac Rehabilitation of Older Patients After Myocardial Infarction Results of a Randomized, Controlled Trial

Background—Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL). Methods and Results—Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR. Conclusions—Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.

AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services

Endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons

Economic burden of physical inactivity: healthcare costs associated with cardiovascular disease:

Increasingly important objectives for developed and especially for developing countries include increasing the numbers of individuals who do not smoke, who eat healthy diets and who are physically active at levels that are health enhancing. In developing countries, deaths from chronic disease are projected to increase from 56% of all deaths in 2005 to 65% by 2030 (driven largely driven by deaths due to cardiovascular and coronary heart disease); in developed countries, however, the increase is only from 87.5 to 88.5%. The data on physical inactivity presented in this review were derived primarily from World Health Organization (WHO) publications and data warehouses. The prevalence of physical inactivity at less than the levels recommended for enhancing health is high; from 17 to 91% in developing countries and from 4 to 84% in developed countries. In developed countries, physical inactivity is associated with considerable economic burden, with 1.5–3.0% of total direct healthcare costs being accounted for by physical inactivity. Other than on some exciting work in Brazil, there is little information on the effectiveness and cost-effectiveness of physical activity-enhancement strategies in developing countries. The WHO has signaled a shift from the treatment of illness to promotion of health, with an emphasis on changing modifiable health-risk factors, including smoking, unhealthy diets and physical inactivity: the real question, especially for developing countries, is ‘what is the future healthcare cost of not encouraging healthier lifestyles today?’

Reasons for dropout from exercise programs in post-coronary patients.

The dropout rate in the 7-yr Ontario Exercise Heart Collaborative Study of post-coronary men engaged in exercise programs was examined in order to determine possible contributing factors. A questionnaire pertaining to psychosocial and program-related variables was distributed to 728 subjects who were previously assigned randomly on the basis of four prognostic risk factors (occupation, personality, hypertension, and angina) into exercise groups: low intensity exercise (LIE), and high intensity exercise (HIE). Comparisons of answers by the 639 respondents (266 dropouts; 373 compliers) were made initially by chi-square analysis to determine significant categories of questions and, subsequently, by a logistic transform to determine the specific questions which related significantly to the dropout rate. It was found that three main categories were associated with a high dropout rate: convenience aspects of the exercise center, perceptions of the exercise program, and family/lifestyle factors. These three main categories should be carefully considered when designing and implementing potential compliance-improving strategies for secondary prevention exercise programs entailing long-term adherence.

Discriminant properties of commonly used quality of life measures in heart failure.

Health-related quality of life (HRQL) instruments have been used to measure HRQL in heart failure patients, but how different instruments compare in the same groups of patients is not known. The purpose of this study was to compare the reliability and validity of three HRQL measures in 211 heart failure patients recruited from clinics affiliated with an urban hospital. Two disease-specific instruments, the chronic heart failure questionnaire (CHQ) and the living with heart failure questionnaire (LHFQ), and one generic instrument, the short-form 12 (SF-12), were administered. Patients reported moderate to low HRQL scores. Floor or ceiling effects were noted in the disease-specific instruments. Internal consistency reliabilities of the CHQ and LHFQ were satisfactory. Construct, convergent, and discriminant validity were supported for each instrument. Each scale and subscale, except for the SF-12 mental component scale, differentiated between patients with New York Heart Association (NYHA) class I, II, and III plus IV; the LHFQ physical subscale was the only measure to differentiate between patients with NYHA class III and IV. All three instruments were satisfactory for measuring HRQL, but the disease-specific instruments were preferable to the generic instrument. The decision of which instrument to use depends on the purpose of the study.

Arm cranking and wheelchair ergometry in elite spinal cord-injured athletes.

ABSTRACTWe investigated the cardiorespiratory responses to progressive incremental arm cranking (AC) and wheelchair ergometry (WCE) and upper limb strength in 72 elite male (N=61) and female (N=11) physically disabled athletes. Peak Vo2 in the two tests increased progressively in athletes categorize

Predictors of Health-related Quality of Life With Cardiac Rehabilitation After Acute Myocardial Infarction

BACKGROUND Health-related quality of life (HRQL) instruments provide valid and responsive outcome measures to assess the impact of disease and the response to interventions. However, they have not been applied widely to studies of rehabilitation after myocardial infarction. PURPOSE To examine the extent to which baseline sociodemographic and clinical characteristics predict baseline and change in generic and specific HRQL. METHODS A randomized controlled trial of an 8-week cardiac rehabilitation intervention or usual care, with follow-up for 12 months, in 201 patients with acute myocardial infarction (MI). Multiple regression analysis was used to identify predictors of HRQL. RESULTS Specific HRQL scores and exercise tolerance improved significantly more in rehabilitation patients than usual care patients by the end of the 8-week intervention. All HRQL measures and exercise tolerance in both groups improved significantly during the 12 month follow-up period but the differences between the groups were trivial. A poor baseline HRQL was the predominant predictor of improved generic and specific HRQL. Furthermore, greater improvement in HRQL consistently was associated with lower levels of cardiovascular risks such as absence of a previous MI or coronary artery bypass surgery, absence of angina, less smoking, and higher exercise tolerance. CONCLUSIONS Improved generic and specific HRQL was associated with poorer baseline HRQL and less baseline cardiovascular risk. This reinforces the importance of addressing health behavior changes as soon as possible after MI and the usefulness of assessing both generic and specific HRQL in evaluating treatment effectiveness.

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability. Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …

Relation of exercise to the recurrence rate of myocardial infarction in men: Ontario exercise-heart collaborative study

The Ontario Exercise-Heart Collaborative Study was a multicenter randomized clinical trial of high Intensity exercise for the prevention of recurrent myocardial infarction in men. The 4-year recurrence rate among 379 patients on a program of high intensity exercise did not differ significantly from that among 354 control patients on a program of light exercise, despite the greater reduction in heart rate in the former group. The relative odds of recurrence in the high intensity group were 1.09, with 95% confidence limits of 0.61 and 1.96.

Predictors of dropout from cardiac exercise rehabilitation: Ontario exercise-heart collaborative study*

The Ontario Exercise-Heart Collaborative Study was a multicenter randomized clinical trial of high intensity exercise for the prevention of recurrent myocardial infarction in 733 men. Of the 678 subjects who could have participated for at least 3 years, 315 (46.5%) dropped out. Stepwise multiple linear logistic regression analysis was carried out to examine the relation between subject characteristics and the probability of dropping out during the study. Analysis was performed on the entry group as a whole by considering those subjects who had reinfarction while complying with the program and also by excluding all subjects with reinfarctions. The consistent and statistically significant predictors of dropout in both analyses were smoking and a blue collar occupation. Angina was significantly associated with dropout only when reinfarctions were excluded. It may be important to consider these factors when investigating the potential for compliance-improving strategies in reducing dropout from exercise rehabilitation programs.