Introduction

Exercise training is the core component of cardiac rehabilitation in patients with coronary artery disease (CAD) and the positive effects have been studied extensively (see Chapter 17).1-5 Markedly less information is available concerning the results of exercise training in patients with valvular heart disease (VHD). This is mainly due to the fact that patients with native VHD have rarely been considered candidates for exercise training. In the guidelines on the management of patients with VHD...

The Role of Tobacco Dependence and Addiction

In successful counseling of coronary patients on quitting smoking, physicians as well as other cardiac rehabilitation team members need to understand the role of dependence on and addiction to nicotine. This complex mechanism and the highly individual combination of contributing factors implies a diagnostic and therapeutic challenge. The aim of this chapter is to give insight into the theoretical background of nicotine addiction and thus provide a basis for smoking cessation as part of a...

Nutritional Intervention to Prevent Type 2 Diabetes in Overweight Obese Subjects

Because much of the risk of developing type 2 diabetes is attributable to obesity,10 maintenance of a healthy body weight is strongly recommended as a means of preventing this disease. The relationship between glycemic index and glycemic load and the development of type 2 diabetes remains unclear at this time.9 Studies have been initiated in the last decade to determine the feasibility and benefit of various strategies to prevent or delay the onset of type 2 diabetes. A majority of subjects...

Stress Management

Stress management training aims to change environmental triggers to the stress response and or change inappropriate behavioral, physiological, or cognitive responses that occur in response to this event. High levels of muscular tension can be reduced through relaxation techniques triggers can be identified and modified using problemsolving strategies cognitive distortions can be identified and changed through cognitive techniques such as cognitive restructuring and stressed behaviors can be...

Carbohydrates

The recommended range of carbohydrate intake is 45-65 of total calories. Both the amount (grams) of carbohydrates and the type of carbohydrate in a food influence blood glucose levels. However, with regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in meals or snacks is more important than the source or type. Monitoring total grams of carbohydrate, whether by use of exchanges or carbohydrate counting, remains a key strategy in achieving glycemic control. The use...

CHD Is an Inflammatory Disease

Most investigators agree that atherosclerosis is a chronic low-grade inflammatory disease.26 Proinflammatory factors (free radicals produced by cigarette smoking, hyperhomocysteinemia, diabetes, peroxidized lipids, hypertension, elevated and modified blood lipids) contribute to the injury to the vascular endothelium, which results in alterations of its antiatherosclerotic and anti-thrombotic properties. This is thought to be a major step in the initiation and formation of arterial fibrostenotic...

Arrhythmias Including Atrial Fibrillation

Atrial fibrillation is the most common cardiac arrhythmia. Its prevalence in populations over 75 years may be as high as over 10 .56 The two major challenges in managing patients with atrial fibrillation are the rhythm disturbances on one hand and the prevention of systemic thromboembolism on the other. There are two fundamental approaches to managing the inherent arrhythmia linked to atrial fibrillation either aiming toward the reestablishment and maintenance of sinus rhythm, or the acceptance...

The Saltsjobaden Program A Model of Cardiac Rehabilitation for Women

At the Saltsjobaden rehabilitation center (Sweden) we provide a CR service designed for women. This program, aiming at promoting and maintaining lifestyle changes, commences with a 2-week inpatient residential course participants then return to the center 2 months later for 5 days, and subsequently for 2 days two times yearly over the next 5 years. The groups contain 6-10 mainly younger women with established CHD. The residential course contains theoretical lectures, discussions, and different...

The Impact of Stress Management

In terms of summarizing a large body of evidence, a recent Cochrane review3 reported that stress management procedures are effective in reducing distress. Other goals may be to improve the rehabilitation process, improve health, and or prevent Figure 34-1. A simplified representation of the event-stress process, disease progression. Unfortunately, from a scientific perspective, many stress management interventions are combined with other interventions such as exercise programs, making it...

Dimension Specific Measures

Many dimensions that contribute to HRQoL have been identified as important in patient Table 31-3. Scale profiles of three disease-specific quality of life questionnaires populations. Some of these have been widely studied before the concept of HRQoL was popularized. In the cardiac situation, the dimensions focus on social and emotional aspects of well-being. Some examples were highlighted in Table 31-1. This gives some idea of the variety of instruments - for instance in the area of emotional...

Macronutrient Composition of the Diet

The macronutrient composition of a diet does not affect the rate of weight loss unless macronutrient manipulation influences total energy intake or expenditure. Nevertheless, changes in macro-nutrient composition of the diet have been tested in various clinical trials.8 A low-fat diet is considered the standard approach for the treatment of obesity. Based on several studies suggesting that there are benefits to restricting fat intake as well as calories, many programs also prescribe dietary fat...

Psychosocial Aspects in Prevention and Rehabilitation

Evidence that psychosocial factors are important in the development and prognosis of cardiovascular disease is outlined. Psychosocial problems are common among patients with psychosocial risk factors fitting broadly into two categories external factors (such as financial and socioeconomic circumstances,life events, and work stress) and internal factors (such as anxiety, depression, hostility anger, and perception of external circumstances). The most extensive evidence that psychosocial factors...

Patients with Severe Cardiac Failure

Heart failure is not a disease entity but a manifestation of many causes of heart disease, including dilated cardiomyopathy, hypertensive cardiac failure, valvular heart disease, endomycardial fibrosis, and ischemic ventricular dysfunction. Comprehensive Rehabilitation Programs for Patients with Compensated Heart Failure and Severely Impaired Left Ventricular Function Patients with chronic stable heart failure are disabled by breathlessness and fatigue. There is no constant correlation between...

References

Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States findings of the national conference on cardiovascular disease prevention. Circulation 2000 102 3137-3147. 2. Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation 2004 109 1101-1107. 3. Silber S. Quantification of coronary artery calcifications...

Effects of Type of Intervention

Advice given by physicians is effective for smoking cessation.2 Interventions involving professionals from different disciplines have more effect than interventions carried out by professionals from a single discipline.2 In their Cochrane review of interventions by nurses in the area of smoking cessation, Rice and Stead indicate that intensive telephone support after discharge from hospital is an essential component of an effective intervention for heart patients.3 Brief advice given by nurses...

Generic Measures

Generic measures of HRQoL can be used in both general or disease-focused population studies. They are typically profile measures, i.e. they assess a number of dimensions of HRQoL but do not usually sum them into one single scale. The general assumption is that scores on separate dimensions, for example sleep and social function, cannot readily be added together in a meaningful way. The three most commonly used generic instruments, as found in a recent review,4 are outlined in Table 31-2. The...

Deficiency in Specific Micronutrients

As discussed above, an important practical point is that deficiencies in specific micronutrients can actually cause CHF, or at least aggravate it. The prevalence of these deficiencies among patients with CHF (and post-infarction patients) is unknown. Whether we should systematically search for them also remains unclear. In particular, we do not know whether the association of several borderline deficiencies that do not individually result in CHF may result in CHF, especially in the elderly. For...

Exercise Type Endurance Versus Resistance

Endurance training leads to a reduction in after-load with a decrease in systemic resistance at rest and at maximal exertion as well as to a small improvement in LV ejection fraction.20 Similar data for resistance training in CHF patients do not exist. Aerobic endurance training thus still forms the basis of training therapies for CHF patients. Critical appraisal of (predominantly) isometric resistance training (hand-grip training, stress time > 3 min) is based on older studies that found a...

Psychological Reactions to Coronary Heart Disease

A coronary event for most patients and their families is a traumatic experience with major consequences for daily life. Typically, to be diagnosed with CHD causes fears, anxiety, and depres-sion,5 and has implications for the dynamics within the family.6 Research shows that prognosis may be more related to emotional factors than to the seriousness of the event. Outcome of rehabilitation is better predicted by emotional factors than by anatomical features and size of infarction. Thus, anxiety...

Who Should Be Referred

Resources for cardiac rehabilitation and patient education may be limited, depending on local circumstances. It may also be the case that not all CHD patients are equally in need of intensive professional support. It is therefore of clinical importance to screen patients with respect to risk factors for prognosis. Screening for physiological and medical risk factors is covered elsewhere in this book. In the context of patient education, screening for psychological and psychosocial risk factors...

Smoking and Acute Myocardial Infarction Mechanisms

Tobacco smoke is a complex mixture of aerosols and particulate matter containing about 4000 different chemical compounds of which many are highly toxic and more than 40 are carcinogenic. Tobacco smoke interferes with the cardiovascular system in the following ways Smoking increases the risk of thrombosis by increasing platelet aggregation, blood viscosity, and fibrinogen levels. C-reactive protein, a marker of inflammation, is also increased by cigarette smoking. The inhaled carbon monoxide...

Return to Work after Coronary Interventions

One of the objectives of coronary interventions is to enable patients to return to work. This is also one of the aims of the cardiac rehabilitation programs offered to these patients. The inability to resume professional activities after coronary interventions may constitute a stress (and therefore a risk factor) for the patient due to a loss of self-esteem and earnings. The most frequent coronary interventions currently in use are aorto-coronary bypass graft surgery (CABG) and percutaneous...

Vegetables and Fruits

Five servings of fruits or vegetables are recommended each day in patients with diabetes. Most vegetables are naturally low in fat and are good choices to include often in meals or to have as a low-calorie snack. Vegetables are full of vitamins, minerals, and fiber. This group includes spinach, chicory, lettuce, broccoli, cabbage, Brussels sprouts, cauliflower, carrots, tomatoes, cucumbers, French beans, etc. Fruits have plenty of vitamins, minerals, and fiber. They also contain carbohydrates....

Program Structure Staffing and Content

The program structure varies widely across each province, depending upon a particular province's population distribution and availability of appropriate health professionals. In the vast majority of cases, cardiac rehabilitation is in the form of verbal information supplemented by leaflets and booklets emphasizing early mobilization and the identification and control of risk factors. The focus is invariably on patients with myocardial infarction and coronary artery bypass surgery. The duration...

Multidisciplinary Programs

Cardiac rehabilitation services are available in a continuum that includes inpatient and outpatient rehabilitation (Table 48-8). Inpatient rehabilitation should begin as soon as possible after hospital admission every eligible HF patient should receive appropriate strategies for optimal therapy and have access to an individualized program, and when possible, group education, according to clinical assessment and risk stratification. Education should be interactive with full participation of...

Evidence That Psychosocial Factors Predict CHD Events

During the last two decades, considerable evidence has accumulated with respect to the association of markers of stress and other psychosocial factors with coronary disease.4,5 However, compared to other major risk factors, psychosocial variables are more difficult to define objectively, because several different dimensions are involved. Despite this, several separate constructs within the broad conceptual framework of psychosocial factors are increasingly considered as being causally related...

The Role of the Nurse in Phase III Rehabilitation

By its definition, the cardiac rehabilitation service promotes lifestyle amendments for patients but specifies that it must be by their own efforts. The goal of the cardiac rehabilitation nurse is to educate patients in the means to do this. Phase III rehabilitation mostly concerns maintenance of a heart-healthy lifestyle. The nurse can encourage this by completing the formal aspects to the rehabilitation program. This should include the following recommendations Send a report of the patient's...

Ischemic Heart Disease and Systemic Atherosclerosis Including Stroke and PostAMI Therapy

The central role of cholesterol in atherosclerosis is based on epidemiological studies, molecular biology, and randomized clinical trials. The first pharmacological intervention studies achieving cholesterol reduction manifested unequivocally the tight correlation between the achieved LDL cholesterol reduction on the one hand, and the reduction in cardiovascular events on the other hand. In general for every 1 mmol of reduction in LDL cholesterol an approximately 21 risk reduction in...

Lifestyle Exercise Studies and Their Application to the Corporate Setting

The SCRIP trial (Stanford Coronary Risk Intervention Project) in 1994 showed the effectiveness of intermittent tracking on cardiac risk factor reduction in cardiac patients.9 Significantly less progression of heart disease in the experimental group (29 progression) was noted when compared with those patients who were not treated (41 progression). Low-fat diets, moderate-intensity exercise (15-45 minutes every other day), smoking cessation relapse prevention, weight management, and lipid therapy...

Lipids

The recommended range of fat intake is 30-35 of total calories. One of the primary dietary fat goals in patients with diabetes is to limit saturated fat intake. Many studies have shown that diets low in saturated fat decrease plasma LDL cholesterol and reduce cardiovascular disease. Thus, it is recommended in patients with diabetes, as in the general population, to reduce dietary saturated fats less to than 10 of energy intake. In persons with plasma LDL cholesterol > 100mg dL, the saturated...

Psychological and Behavioral Support

This section addresses important psychosocial issues and their implications for cardiac patients. The section starts with a broad overview of psychosocial research in cardiac populations. This provides some historical perspective and covers issues such as the influence of the workplace and economics on well-being and cardiovascular function. Many notable associations have been documented but the causal mechanisms, and thus methods of intervention, are much less clear. The overall goals of...

Summary

To emphasize the potential need for a seamless care corporate wellness model that includes cardiac rehabilitation, the following comment relating to the WHO MONICA Project and cardiovascular disease is very apt In the light of shrinking resources for healthcare worldwide, the preventative approach is the only way to stop the growing epidemic and deal with the problem in future generations. (Dr Ingrid Martin, Head, WHO Cardiovascular Diseases Programme, February 2000) Add to this comment, recent...

Smoking and Cardiovascular Diseases

In the first half of the last century German clinicians were among the first who contributed to our knowledge on the relationship between smoking and lung cancer.6 The classical epidemiological studies on this relationship were started at the end of the 1940s and the beginning of the 1950s in England and in the US. A cohort study of 34,000 British male physicians was started by Doll et al. in 1951 with follow-up periods of 20, 40, and 50 years.7-9 For the 20-year follow-up, the relative risk...

Smoking Cessation

Smoking cessation has immediate positive consequences not only in younger, but also in elderly patients. Smoking cessation after aortocoronary bypass surgery in patients over 65 years of age decreases the mortality within a year after surgery by approximately 40 .24 Smoking leads to an immediate increase in blood pressure, peripheral vascular resistance and heart rate and leads to a decrease in flow-mediated vasodilatation of the arteries with concomitant increase in clotting tendency and a...

The Effects of Tobacco on Public Health

According to recent data from McNeill21 for the 25 countries of the EU, there were 656,000 deaths caused by smoking in the year 2000. This amounts to more than one in seven of all deaths across the EU. In the ten new member states smoking alone caused nearly one in five of all deaths. Table 27-3 shows the number of deaths due to smoking as a proportion of all deaths in the EU, stratified by cause of death. From Table 27-3 we learn that 10 of all deaths from cardiovascular disease in the EU are...

Information Requirements

Information requirements may differ greatly between patients, hence the benefit of individual counseling, but nonetheless there are some integral components that must be included This activity is often described by patients as one of the most important pieces of information required.16 The amount and type of data collected can vary and often might be dictated by the auditing policies in place. The identification of specific coronary risk factors must be performed for each patient. The...

Exercise Training and Ischemia

Later reports also demonstrated an increase in the rate-pressure product at the onset of angina as well as a reduction in the ischemic response measured as angina or ST-segment depression, at a given rate-pressure product, suggesting that exercise training improves myocardial oxygen delivery. Ehsani and coworkers in a non-randomized study examined whether an intense endurance exercise training program over 12 months could decrease ST-segment depression at a given rate-pressure product in...

Diagnostic Groups Suitable for Rehabilitation

The categories of patients with coronary heart disease and its complications who may need rehabilitation services include the following - those who have been admitted to a hospital for unstable angina - those with chronic ischemic heart disease who are starting an exercise program - those who have undergone coronary bypass surgery and percutaneous transluminal coronary angioplasty. The largest group will be patients who have sustained acute myocardial infarction, and this should be taken into...

Prevalence and Persistence of Depression Following Myocardial Infarction

Depressive symptoms and major depression have been consistently reported as common psychological reactions to MI. Major depression, a syndrome characterized by persistently depressed mood, and or loss of interest and pleasure, with symptoms lasting for a minimum of 2 weeks, occurs with an annual prevalence of between 1 and 6 in the general population, with rates typically higher among patients following MI, at approximately 16-18 .12 Apart from major depression, depressive symptoms are quite...

Cholesterol Lowering and SCD

Another important issue at a time when so many people are taking cholesterol-lowering drugs with the hope to improve their life expectancy is whether cholesterol lowering might reduce the risk of SCD. According to recent data standardized to the 2000 US population,2 of 719,456 cardiac deaths among adults aged > 35 years, 63 were defined as sudden cardiac death (SCD). In that study, SCD was defined as death occurring out of the hospital or in the emergency room or as dead on arrival with an...

Antidepressants and Other Pharmacotherapy

The withdrawal symptoms of smoking cessation can be stress, depression, anxiety, anger, insomnia, and weight gain. For that reason antidepressants can be helpful.10 Bupropion is an antidepressant with dopamin-ergic and norepinephrenic activity. It relieves the withdrawal symptoms and the craving for a cigarette. Because bupropion lowers the thresh old for seizures it is contraindicated in patients who are at risk for seizures. The daily dose is 150mg day for 6 days, then 150mg twice a day. In...

Special Considerations for Type 1 Diabetes

Nutrition recommendations for a healthy lifestyle for the general public14 are also appropriate for persons with type 1 diabetes. Since the body weight of patients with type 1 diabetes is usually normal, energy intake does not have to be modified. Many type 1 diabetic patients are now treated with intensive insulin therapy (insulin pumps or basal-bolus insulin regimen). For these patients, the total carbohydrate content of meals (and snacks) is the major determinant of the premeal insulin dose...

Benefits of Cardiac Rehabilitation

The most substantial evidence-based benefits of cardiac rehabilitation include an improvement in exercise tolerance, improvement in symptoms, improvement in blood lipid levels, reduction in cigarette smoking, improvement in psychosocial well-being and reduction of stress, and reduction in mortality. These are addressed in turn. Appropriately prescribed and conducted exercise training is an integral component of cardiac rehabilitation, particularly for patients with decreased exercise tolerance....

Pharmacotherapy for Smoking Cessation

Quitting smoking is one of the primary lifestyle changes that reduce the risk of cardiovascular disease in primary and secondary prevention. However, the addictive nature of nicotine makes smoking cessation difficult to initiate, and withdrawal symptoms, including cravings for cigarettes, make continued abstinence difficult to maintain. Studies show that the majority of serious quit attempts will fail within 1 year.67 This is understandable in the light of evidence showing that cigarette...

The Cardiovascular Prevention and Rehabilitation CVPR Program Hospital

The EUROACTION CVPR program is a nurse-led comprehensive, multidisciplinary, hospital-based 16-week program for coronary patients and their families. The aim of the program is to help coronary patients and their partners, and first degree relatives of patients with premature coronary disease, to achieve the European lifestyle, risk factor, and therapeutic goals as defined in the 1998 Joint European Societies' guidelines (Table 58-1).11 The partners of coronary patients, together with first...

Exercise Testing in Special Groups

Cardiovascular disease is one of the leading causes of death in women, exceeding mortality due to breast cancer by a factor of 11. However, the probability of CAD in women is most commonly in the low to intermediate probability range, especially in premenopausal women, and the investigation of CAD in women presents difficulties that are not experienced in the identification of the disease in men. These difficulties reflect gender differences in exercise physiology, coronary physiology, and...

Nicotine Pharmacodynamics

It is not only due to the pharmacokinetic properties of nicotine administered by smoking, mentioned earlier, that nicotine is as addicting as it is, its pharmacodynamics play an important role as well. Nicotine interacts with the nicotinic cholinergic receptors in both the central and peripheral nervous system. The effect of nicotine can be stimulating but in a high dose it can be dampening too, due to complex electrochemical processes. Stimulation of the nicotinic cholinergic receptor causes...

Diet and the Risk of Heart Failure Following AMI

The incidence of chronic heart failure (CHF), the common end-result of most cardiac diseases, is increasing steadily in many countries despite (and probably because of) considerable improvements in the acute and chronic treatment of CHD, which is nowadays the main cause of CHF in most countries.25 In recent years, most research effort about CHF has been focused on drug treatment, and there has been little attention paid to non-pharmacological management. Some unidentified factors may indeed...

Exercise Testing in Patients with Mitral Stenosis MS

Increasing numbers of asymptomatic patients with severe MS are being diagnosed with echo-Doppler. Due to the long duration of their disease these patients have slowly adjusted to their restrictions and frequently do not report symptoms or nonspecific symptoms like fatigue. This is particularly the case in elderly patients. In these patients exercise testing is of clinical value. Induction of dyspnea during exercise, excessive heart rate responses to a relatively low level of exercise, and...

The Dilemma of Traditional Identification of High Risk Patients

Two large cohort studies revealed that 80 to 90 of the patients with CHD had at least one of four traditional risk factors (cigarette smoking, hyper-lipidemia, arterial hypertension, or diabetes).54,55 In the clinical practice of prevention, however, we have the opposite problem of course we treat arterial hypertension and diabetes anyway, but which asymptomatic patient without demonstrable myocardial ischemia with which risk factors is at high risk for developing a cardiovascular event The...

Returning to Work after Myocardial Infarction

One of the main goals of a cardiac rehabilitation (CR) program is to support the patient in returning to work strong economic and quality of life arguments exist. It has been stated that patients after an acute myocardial infarction (MI) without complications such as left ventricular dysfunction or exercise-induced myocardial ischemia may safely resume their previous work for light office work 2 weeks of sickness absence are recommended, for average manual work 3 weeks, and for strenuous...

The Swiss Heart Foundation

A cardiac event or a cardiovascular disease requires life-long aftercare. This insight led to the establishment of the first training groups for heart patients (heart groups) in Switzerland in the early 1980s, which was driven by the private initiative of committed physicians and heart patients. Four years ago, the Swiss Heart Foundation started to take care of the heart groups with the aim of promoting the establishment of a nationwide network. Today, 85 heart groups for long-term...

Pharmacotherapy for Weight Management and Prevention of Diabetes

Weight reduction for the prevention of cardiovascular disease is an imperative in the current environment of epidemic obesity and metabolic syndrome. However, the failure rate is 70-95 within 1-2 years of weight loss. Weight loss is followed by a number of adaptations including decreased thyroid and immune function and changes in signaling in the central nervous system that result in weight regain. Thus, the treatment of obesity, which is the common denominator underlying the variable symptoms...

Antiplatelet Drugs

Primary prevention with antiplatelet agents is focused almost solely on acetylsalicylic acid (ASA).7 The effect of ASA has been scrutinized in six large primary prevention trials (Table 53-3).8-13 Although some of these trials investigated high-risk patients with one or more risk factors, the yearly cardiovascular event rate was rather low in all of these studies. The reduction in the odds ratio for adverse cardiovascular events in favor of ASA was in the range of 0-29 , which translates into...

Exercise Testing in Asymptomatic Individuals Without Known CAD

The use of exercise testing for diagnosis of CAD in asymptomatic individuals is a controversial topic. The rationale of screening is the early detection of a disease that is the leading cause of death worldwide in the hope that treatment may prolong life or improve its quality and reduce the costs of treating acute events. Unfortunately, the accuracy of exercise testing in asymptomatic individuals has never been defined and probably never will be, because it is unethical to perform coronary...

The Finnish Heart Association

In Finland, secondary prevention and cardiac rehabilitation are part of public healthcare by legislation. The Social Insurance Institution of Finland also offers rehabilitation to patients who are at work. During the last decade, however, the budget cuts and personnel shortages in the public sector have reduced the availability of cardiac rehabilitation and secondary prevention. Finland participated in the EUROASPIRE study,3 which proved that the present patient guidance system has been...

Exercise Training Combined with Blood Glucose Control

The importance of early diagnosis and subsequent therapy of diabetes has been highlighted by the United Kingdom Prospective Diabetes Study (UKPDS). The results showed that it is necessary to keep HbA1c levels < 6.0mmol L in order to reduce the incidence of cardiovascular events.14 These data were confirmed by a study of Hu et al. in 84,941 nurses where it could be demonstrated in a subgroup with a low-risk profile (body mass index < 25, healthy diet, > 30 minutes of physical exercise per...

Hypertension

Hypertension is defined as systolic blood pressure (BP) 140mmHg or above and or diastolic BP 90mmHg or above, or patients on antihypertensive treatment. The prevalence is approximately 15 , 30 , and 55 in males aged 18-39 years, 40-59 years, and above 60 years. Corresponding numbers in females are 5 , 30 , and 65 . However, 25 of patients with hypertension by conventional measurements have a normal blood pressure on 24-hour monitoring.7 According to a meta-analysis by Fagard and Amery,8...

Dietary Influence on Blood Pressure Regulation

Medical nutrition therapy for the management of hypertension has focused on weight reduction and reducing sodium intake.20 In both normoten-sive and hypertensive individuals, a reduction in sodium intake lowers blood pressure. In hypertensive patients, the goal should be to reduce sodium intake to 2400mg (100mmol) or sodium chloride (salt) to 6000mg day. Other nutritional variables that have been considered include alcohol, potassium, calcium, and magnesium intake. An association between high...

Recurrence12 Alcohol and SCD

The question of the effect of alcohol on heart and vessel diseases has been the subject of intense controversy in recent years. The consensus is now that moderate alcohol drinking is associated with reduced cardiovascular mortality, although the exact mechanism(s) by which alcohol is protective are still unclear. In experimental models, an ethanol preconditioning phenomenon13 has been reported, suggesting that low dose ethanol drinking protects the myocardium against damages provoked by...

Treatment of Hypertension

Hypertension is a major risk factor for PAD, but data are not available to clarify whether treatment will alter the progression of the disease or the risk of claudication. Beta-adrenergic-antagonist drugs have been thought to have unfavorable effects on symptoms in patients with PAD. This concern arose from several early case reports of worsening claudication and decreases in blood flow in the legs in patients taking these drugs. A meta- analysis and a critical review of different studies,...

Rehabilitation in Cardiac Transplantation

Patients awaiting transplantation are often decon-ditioned and exhibit severe cardiac impairment, breathlessness on exertion, and cardiac cachexia they are also at increased risk of sudden cardiac death. The goal of exercise is to prevent further deconditioning and, in some patients, to improve skeletal muscle status. Standard exercise testing or cardiopulmonary exercise testing is valuable in formulating recommendations for physical activity.39 Education and counseling can introduce the...

Alternative Modes of Delivery of Cardiac Rehabilitation Services

Alternative approaches to the delivery of cardiac rehabilitation services, other than traditional supervised group interventions, were considered effective and safe for stable cardiac patients.1 Transtelephonic and other means of monitoring and surveillance were advocated to extend cardiac rehabilitation services beyond the setting of supervised, structured, and group-based rehabilitation. The American Heart Association 2005 Scientific Statement7 further offered models that included home-based...

Future Developments in Preventive Cardiology The Euroaction Project

Although there is substantial scientific evidence that professional lifestyle intervention on smoking, diet and physical activity, together with control of blood pressure, cholesterol and glycemia, and selective use of cardioprotective drug therapies can reduce cardiovascular morbidity and mortality, the translation of that evidence into everyday clinical practice remains a challenge. The joint European Societies guidelines on prevention of cardiovascular disease (CVD) define priorities for...

Prevention Guidelines Management of the Coronary Patient

Guidelines on prevention of coronary heart disease (CHD) in clinical practice have been issued by Joint Task Forces of European and other Societies1-3 and the latest update was released in 2003 by the Third Joint Task Force.3 The objectives of these guidelines are the prevention of disability and early death from cardiovascular disease (CVD) through lifestyle changes, management of risk factors and when needed the prophylactic use of certain drugs. The guidelines represent a state of the art...

Developments in Rehabilitation Care

Enormous changes in the rehabilitative approach to the care of patients with cardiovascular disease have occurred since the WHO Expert Committee on the Rehabilitation of Patients with Cardiovascular Disease was organized by WHO in 1963. At that time, rehabilitation was concerned predominantly with individuals recovering from acute, essentially uncomplicated, myocardial infarction the rehabilitative interventions recommended for such patients were considered to encompass the sum of activities...

Antihypertensive Drugs

Blood pressure lowering therapy should be considered in individuals with repeated measures of systolic blood pressure > 140mmHg and or diastolic blood pressure > 90mmHg. Guidelines recommend that the overall cardiovascular risk should be considered.1 Treatment directed at lowering blood pressure should include lifestyle change encompassing smoking cessation, moderation of alcohol consumption, weight reduction, physical exercise, reduction of high salt intake and other dietary changes. When...

Physical Exercise

Physical Benefits Exercise Cardiac

The incidence of diabetes mellitus correlates inversely with the degree of physical activity.4 Regular aerobic exercise of 30 min day at a moderate intensity can cut the risk for impaired glucose tolerance by half and the diabetes risk by up to three-quarters.5-7 Although there is no direct proof that endothe-lial dysfunction leads to atherosclerosis, it has been shown that endothelial dysfunction is associated with increased cardiovascular mortality.8 Endothelial dysfunction is found when the...

The Causes of Exercise Intolerance in Cardiovascular Diseases

Exercise intolerance is a key feature of most cardiovascular diseases. Its value for describing the stage of the disease is so important that standardized classification systems of exercise limitation i.e. the New York Heart Association Classification were developed more than half a century ago. While the symptoms of reduced maximal exercise capacity may be similar, the underlying mechanisms causing exercise limitations are fundamentally different between major disease entities In stenotic...

Grown up Congenital Heart Disease GUCH

Patients with congenital heart disease CHD reaching adulthood are a growing population.4 Most of them require lifelong care. The hemo-dynamic situation of the patient with CHD varies considerably. This makes it impossible Table 22-1. Classification of sports Table 22-1. Classification of sports Running mid long Swimming Squash Tennis single Team handball Symbols Danger of bodily collision, y Increased risk if syncope occurs. Source Adapted and modified after Mitchell et al.' to give...

Practice Worldwide

Different programs and approaches have been developed in different areas of the world, all aiming at a similar outcome, utilizing a variety of different ways. The Anglo-Saxon countries have largely preferred a primarily ambulatory approach, favoring long-term exercise-based rehabilitation programs, to which educational, psychological, and social components are being added in a stepwise fashion R. Mulcahy16 . Countries with a long-standing spa tradition such as Germany, Austria, some eastern...

Prevention Programs The Role of the Nurse

Cardiac rehabilitation services have developed worldwide over the last few decades. The World Health Organization definitions of cardiac rehabilitation of 1969 and 1993 outlined what was required of a cardiac rehabilitation service for patients with coronary heart disease. However, as might be expected, different countries and health provision services developed different styles of programs in response to local funding, available staff, and patient profiles. As a result of this, many...

Sexual Counseling

Health professionals must take the initiative to bring up the topic of sex with the cardiac patient. Often, the patient may feel too embarrassed to ask questions about such a private area. By bringing up the topic, health professionals are acknowledging that sexual concerns are both normal and common for cardiac patients. Health professionals must be aware of their own biases in regard to sexuality, and be careful to approach sexual counseling in a non-judgmental way. Drench and Losee15 provide...

Contraindications for Exercise Training in CHF

Any patient who wants to start regular physical training in the presence of CHF has to pass two lists of contraindications, the first for exercise testing, the second for exercise training. Contraindications for exercise testing apply because a maximal exercise test ergometry, treadmill, or spiroergometry is required to calculate the correct training heart rate Table 19-2, A . Contraindications for exercise training are less well defined. However, it is generally agreed that patients may not...

Effects of Lifestyle Change on MetS Components

The underlying conditions that promote the development of MetS are overweight and obesity, physical inactivity, and an atherogenic diet.16,17 Therefore, lifestyle modification is first-line therapy to prevent and treat MetS.14,15 The most important therapeutic intervention effective in subjects with MetS should focus on modest weight reduction and regular leisure-time physical activities. The Finnish Diabetes Prevention Study11 and the Diabetes Prevention Program DPP in the United States12...

Imaging for Early Detection of Atherosclerotic Disease

Sonography of superficial arteries is a relatively inexpensive means of noninvasively visualizing the lumen and walls of arteries which are involved in the ubiquitous process of atherosclerosis. Risk assessment using carotid ultrasound focuses on measurement of the intima-media thickness IMT and plaque characteristics. Intima-media thickness is an integrated measurement of the involvement of both the intima and the media in the atherosclerotic process. Current ultrasound instrumentation with...

Nicotine Replacement Therapy

Before starting the nicotine replacement therapy the user has to quit smoking. Nicotine replacement therapy provides an alternative form of nicotine to relieve symptoms of withdrawal in a smoker who is abstaining from tobacco use.8 The pharmacokinetic properties of available products differ, but none deliver nicotine as fast as does inhaling nicotine. The patch provides a relatively stable, fixed dose of nicotine over a period of 16 or 24 hours. The other products have a more rapid onset and a...

Contents

xiii Section I Introduction Edited by Peter Mathes 1. From Exercise Training to Comprehensive Cardiac Rehabilitation 3 2. The Evidence Base for Cardiac Rehabilitation 9 3. Indications for Cardiac Rehabilitation 19 4. Prevention Guidelines Management of the Coronary Patient 26 L. Vanhees, M. Martens, S. Beloka, A. Stevens, A. Avram, and Dan Gaita 6. Cardiac Rehabilitation United States 34 8. Cardiac Rehabilitation Australia 41 Michael V. Jelinek and Stephen J. Bunker 9. Cardiac Rehabilitation...

Preventing Reinfarction

The largest study involving the use of stress management in post-MI patients7 targeted type A men i.e. those who scored highly on measures such as time urgency, competitiveness, hostility, and easily aroused anger a form of self-stress who had experienced a recent MI. Over a 4-year intervention, participants in the type A management program were at half the risk for further infarction than those in a similarly long, but traditionally focused, rehabilitation program, with total infarction rates...

Summary and Conclusion

Because of nicotine, smoking is quickly and strongly addictive. This will result in a chronic change in the brain, causing a strong craving and a high chance of relapse after quitting. Greater understanding of the neurophysi-ological background of addiction, that is, the disruption of the neuroreceptors, has increased the possibilities of treatment with medication. Cardiac rehabilitation plays an important role in supporting the patient to quit smoking. Fur...

The Molecular Base of Exercise

The pathogenesis of exercise intolerance in cardiovascular diseases is more complex than previously thought. In coronary artery disease CAD it was commonly believed that the degree of epicar-dial coronary stenoses correlated with the severity of myocardial ischemia. This is, however, not necessarily the case. With the increasing knowledge about endothelial dysfunction it has become evident that even mild stenoses may cause critical ischemia when combined with pathologic endothelial...

Exercise Training in Coronary Artery Disease

Training Coronary Artery Disease

Effects of Exercise on the Vascular Endothelium in Atherosclerotic Disease Despite the clear prognostic benefits of exercise training in reducing cardiovascular events, the underlying mechanisms have long remained obscure. Basically, regional myocardial hypoper-fusion in CAD results from a combination of four pathogenetic components A vascular stenosis, B coronary vasomotion, C microrheology and hemostasis, and D mobilization of EPCs. All four components may be affected by exercise training in...

Physiologic Fitness and Health

In the last two decades, a striking amount of data have been published demonstrating the importance of fitness level in predicting risk for adverse health outcomes.2,3,13,14 A consistent observation in these studies is that after adjustment for age and other risk factors, exercise capacity has been shown to be a stronger marker of risk for cardiovascular morbidity or all-cause mortality than established risk factors such as hypertension, smoking, obesity, hyperlipidemia, diabetes, and obesity....

Definition of MetS and Health Implications

MetS also called deadly quartet, syndrome X, insulin resistance syndrome, plurimetabolic syndrome, dysmetabolic syndrome, cardiometabolic syndrome comprises a cluster of abnormalities that occur as a result of perturbations in multiple metabolic pathways, leading to insulin resistance and hyperinsulinemia, hyperglycemia, athero-genic dyslipidemia, hypertension, fibrinolytic abnormalities, etc.3 Numerous other disturbances have been progressively added to the syndrome, including a prothrombotic...

Conclusion

After the end of the acute phase, all patients should be able to follow a multidisciplinary CR program. Thereafter, everyone should be advised to maintain an active lifestyle and adherence to secondary preventive measures. This lifelong secondary preventive lifestyle must be promoted by all healthcare providers and can be facilitated by specialized sports clubs or by specifically designed heart groups. Professionals who are responsible for rehabilitation programs need to develop a European...

Myths and Misconceptions

Myth 1 Sex and sexuality are the same. Truth The term sex is often used to refer to the sex act, whereas sexuality reflects both the psychosocial and physical aspects of intimacy. Engaging in sex can be fun, passionate, and has been called a restorative forcethat can be both healing and energizing.7 Myth 2 Older adults with cardiac disease are less interested in information on resuming sex. Truth Older adults have many of the same questions and sexual concerns as younger individuals. Studies...

Nutritional Counseling for Patients with MetS

MetS has been identified as a target for dietary therapies to reduce CVD risk other than LDL cholesterol lowering by the NCEP ATP III.13-15 Clear evidence from metabolic studies, epidemiological studies, and clinical trials supports the consumption of unsaturated fats from natural liquid vegetable oils and nuts at the expense of saturated and trans fats rather than simply lowering total fat in the treatment of various components of the MetS e.g. dyslipidemia, insulin resistance, and Table 25-4....

Who Is the Patient Psychological Factors Readiness to Change

Health professionals' knowledge of the different phases of a patient's acceptance of chronic disease is fundamental. It is often a long period of time from the initial phases of psychological shock, denial, opposition or anger, to coping strategies and progressive acceptance. It would be unrealistic to propose major nutritional behavior modifications for a patient in the denial phase, which may be felt as a partial loss of their identity or familial culture, or even aggression. Readiness to...

Competitive Sports in Cardiac Diseases

Cardiovascular disease may induce an increased risk of sudden death or deterioration of disease on competitive athletic activity therefore recommendations are important to provide careful directions for physicians and consultant cardiologists. By competitive athletes is meant individuals of young or adult age who are engaged in regular exercise training and participation in official sports competitions. The recommendations are particularly important in elite athletes due to the intense pressure...

Historical Perspective

Regular physical exercise and a high exercise capacity have been hallmarks of health and vitality for millennia and were associated with a distinct survival advantage in a hostile environment. In the modern civilized environment it is usually not the external enemy who is to be defeated. One of the enemies of survival is lack of physical activity and the resulting decreased physical fitness both emerge once again as enemies of survival, this time in an all too friendly and comfortable...

Current Status and Future Directions

Through its CR policy and guidelines6 the NHF promotes the routine referral of all patients with cardiovascular disease to an appropriate CR program. Patients are encouraged to attend as soon as possible after discharge. Currently, there are almost 300 structured post-discharge CR programs throughout Australia, mainly in urban areas. Programs vary in length from a minimum of one session a week for 6 weeks through to more comprehensive programs. Despite the abundant evidence supporting the...

Valvular Heart Disease Mitral Valve Disease

Mitral valve disease is the most common problem among patients with rheumatic heart disease. In dominant mitral stenosis, closed valvular mitral commissurotomy reduces the symptoms, improves function, and provides cost-effective rehabilitation. Patients in classes III and IV with mitral valve disease are candidates for surgery and subsequent exercise training programs. Such patients usually have a long history of disability and severely limited activity. Exercise after Heart Valve Replacement...

Contributors

Attikon University Hospital Athens, Greece Department of Cardiology Karolinska University Hospital Solna Stockholm, Sweden Dan Atar, MD, FESC, FACC FAHA Department of Cardiology Aker University Hospital Oslo, Norway Cardiac Rehabilitation Clinic University of Medicine and Pharmacy Victor Babes Timisoara Timisoara, Romania Guy de Backer, MD, PhD Department of Public Health Ghent University Ghent, Belgium Service de Cardiologie Hopital Beaujon Clichy, France Cardiovascular Rehabilitation Unit...