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European Journal of Cardiovascular Prevention Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position
paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular
Prevention and Rehabilitation
Massimo Francesco Piepoli, Ugo Corrà, Werner Benzer, Birna Bjarnason-Wehrens, Paul Dendale, Dan Gaita, Hannah McGee, Miguel Mendes, Josef Niebauer, Ann-Dorthe Olsen Zwisler and Jean-Paul Schmid European Journal of Cardiovascular Prevention & Rehabilitation The online version of this article can be found at: European Association for Cardiovascular Prevention and Rehabilitation can be found at:
European Journal of Cardiovascular Prevention & Rehabilitation
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Secondary prevention through cardiac rehabilitation:from knowledge to implementation. A position paperfrom the Cardiac Rehabilitation Section of the EuropeanAssociation of Cardiovascular Prevention and RehabilitationMassimo Francesco Piepoli, Ugo Corra , Werner Benzer,Birna Bjarnason-Wehrens, Paul Dendale, Dan Gaita, Hannah McGee,Miguel Mendes, Josef Niebauer, Ann-Dorthe Olsen Zwislerand Jean-Paul Schmid Heart Failure Unit, Cardiac Department, Guglielmo da Saliceto Hospital, Piacenza, Italy Received 19 January 2009 Accepted 13 July 2009 Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commission's European Heart Health Charter in 2008prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity andmortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the corecomponents and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of thecomprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR canbe delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A generaltable applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented. Eur J Cardiovasc Prev Rehabil 17:1–17 c 2010 The European Society of Cardiology European Journal of Cardiovascular Prevention and Rehabilitation 2010, 17:1–17 Keywords: blood pressure, cardiac rehabilitation, diet/nutritional counselling, exercise training, lipid management, physical activity, prevention, psychosocialmanagement, smoking, weight control Background and rationale diagnostic and therapeutic procedures in cardiovascular Recent years have witnessed impressive progress in pharma- diseases. As a consequence, a greater number of men cological therapies and in sophisticated technology-based and women now survive acute events but with a heavierindividual and health system burden of chronic condi-tions driving up health service needs and costs.
Correspondence to Professor Massimo F. Piepoli, MD, PhD, FACC, FESC, HeartFailure Unit, Cardiac Department, Guglielmo da Saliceto Hospital, Cantone delCristo, I-29100 Piacenza, Italy In this context, both health authorities and the general Tel: + 390 523 303217; fax: + 390 523 303220; e-mail [email protected] reviewers: Pantaleo Giannuzzi, Hugo Saner, David Wood.
population have started to recognize that the current EACPR Committee for Science Guideline: Ugo Corra (Chairperson), Massimo F.
approach, based mainly on the interventional cardiology Franc¸ois Carre´; Peter. Heuschmann; Uwe Hoffmann; Monique Verschuren; Julian Halcox.
and pharmacological treatments, is neither effective nor c 2010 The European Society of Cardiology Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 sustainable. Cardiovascular disease is eminently preven- for multidisciplinary team, working together with the table, as outlined in the recent European Heart Health coordination of a cardiologist, to promote the range of Charter: ‘the burden of established cardiovascular disease health behaviour changes, including medication adher- may also be reduced by early diagnosis, appropriate ence that have been shown to reduce further cardiovas- disease management, rehabilitation, and prevention, cular events and increase patients' quality of life.
including structured lifestyle counselling.' (EuropeanHeart Health Charter, article 7) [1].
Aim of this studyA number of recent professional association position state- Cardiac patients after an acute event, intervention or ments have outlined core components of CR [9–11] To diagnosis with a chronic heart condition deserve special complement these recent statements, we aim to move attention to restore their quality of life, to maintain or them toward implementation by making the more concrete improve functional capacity. They require counselling to descriptions of the actions needed in a way that is useful to prevent event recurrence, by adhesion to a medication working CR teams. This study summarizes key steps to plan and adoption of a healthy lifestyle. Cardiac rehabilita- deliver all the components of CR for cardiac conditions tion (CR) is a multifaceted and multidisciplinary interven- and highlights key differences and exceptions for specific tion, which improves functional capacity, recovery and cardiac manifestations, for example CHF or transplantation.
psychological well-being [2]. It is recommended (with the Well-established principles of management for general and highest level of scientific evidence-class I) by the European specific conditions, as well as areas which are currently Society of Cardiology, the American Heart Association and controversial or unresolved, are outlined.
the American College of Cardiology in the treatment ofpatients with coronary artery disease (CAD) [3–5]. More- The study is organized in a series of tables, the first over, it is a cost-effective intervention following an acute presenting commonly agreed CR acivities applicable to coronary event [6] and chronic heart failure (CHF) [7], all conditions as a standard reference. Complementary to as it improves prognosis by reducing recurrent hospita- this are a series of tables oriented to address specific lization and health care expenditures, while prolonging recommendations and current controversies specific for life. It compares favorably in terms of costs per year life each clinical condition. Thus for each condition, the saved with other well-established preventive and ther- reader should first consider the common CR activities to apeutic interventions in the treatment of CAD and CHF be undertaken, as presented in Table 1 (‘Core components such as cholesterol-lowering medication, thrombolysis, and objectives common to all clinical conditions'), coronary angioplasty, surgery or device implantation.
and then combine this with recommendations in thetable specific to the clinical condition of the patient CR programmes are based on long-established models being managed. All recommendations provided are based involving residential or ambulatory programmes, accord- on the scientific evidence with the levels of evidence ing to local and national preferences [8]. To provide this from the most robust (class 1) and reference source approach, CR programmes have become a meeting point Core cardiac rehabilitation components and objectives common to all clinical conditions Patient assessment Clinical history: screening for cardiovascular risk factors, co-morbidities and disabilitiesSymptoms: cardiovascular disease (NYHA class for dyspnoea and CCS class for angina)Adherence: to the medical regime and self-monitoring (weight, BP, symptoms)Physical examination: general health status, heart failure signs, cardiac and carotid murmurs, BP control, extremities for presence of arterial pulses and orthopaedic pathology, cardiovascular accidents with/without neurological sequelae ECG: heart rate, rhythm, repolarizationCardiac imaging (2-dimensional and Doppler echocardiography): in particular ventricular functions and valve heart diseases where appropriateBlood testing: routine biochemical assay, fasting blood glucose, (HbA1C if fasting blood glucose is elevated), total cholesterol, LDL-C, HDL-C, Physical activity level: domestic, occupational, and recreational needs, activities relevant to age, gender, and daily life, readiness to change behaviour, self-confidence, barriers to increased physical activity, and social support in making positive changes Peak exercise capacity: symptom-limited exercise testing, either on bicycle ergometer, or on treadmillEducation: clear, comprehensible information on the basic purpose of the CR programme and the role of each componentExpected outcomes Formulation of ‘tailored', patient-specific, objectives of the CR programme Physical activity counselling A minimum of 30–60 min/session of moderately intense aerobic activity, preferable daily, or at least 3–4/weekEmphasize: sedentary lifestyle as risk factor, and benefits of physical activity: any increase in activity has a positive health benefitRecommend: gradual increases in daily lifestyle activities over time, and how to incorporate it into daily routineAdvise: individualize physical activity according to patient's age, past habits, co-morbidities, preferences and goalsReassure: regarding the safety of the recommended protocolEncourage: involvement in leisure activities which are enjoyable and in group exercise training programme as patients tend to revert to previous sedentary habits Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cardiac rehabilitation Piepoli et al.
Forewarn: patients need to be forewarned of the risk of relapses: thus education should underline how benefits may be achieved and the need for its lifelong continuation. If physical activity interruption has occurred, physical, social and psychological barriers to attendance should be explored, and alternative approachessuggested [12] Expected outcomes Increased participation in domestic, occupational, and recreational activitiesImproved psychosocial well-being, prevention of disability, and enhancement of opportunities for independent self-careImproved aerobic fitnessImproved prognosis Exercise training (ET) ET should be prescribed on an individualized approach after careful clinical evaluation, including risk stratification, behavioural characteristics, personal goals and exercise preferences. As general advice, recommend: Z 150 min/week (two and half hours); ideally 3–4 h/weekSub-maximal endurance training, i.e., starting at 50% of maximal work load or VO2 max if available and gradually increasing till 70%Energy consumption: 1000–2000 kcal/ weekExpand physical activity to include weight/resistance training 2 times/week [14] During the initial phases supervised, in-hospital ET programme may be recommended, especially, to verify individual responses and tolerability, clinical stability and promptly identify signs and symptoms indicating to modify or terminate the programme. The supervision should include physical examination, monitoring of HR, BPand rhythm before, during and after ET. The supervised period should be prolonged in patients with new symptoms, signs, BP abnormalities and increasedsupraventricular or ventricular ectopy during exercise Expected outcomes Increased cardiorespiratory fitness and enhanced flexibility, muscular endurance, and strengthReduction of symptoms, attenuated physiological responses to physical challenges, and improved psychosocial well-being Assessment: daily caloric intake and dietary content of fat, saturated fat, sodium, and other nutrients. Assess eating habitsEducation: of patient (and family members) regarding dietary goals and how to attain them; salt, lipid and water content of common foodsHealthy food choices: Wide variety of foods; low salt foods;Mediterranean diet: fruits, vegetables, wholegrain cereals and bread, fish (especially oily), lean meat, low fat dairy productsReplace saturated fat with the above foods and with monounsaturated and polyunsaturated fats from vegetable (oleic acid as in olive oil and rapeseed oil) and marine sources to reduce total fat to less than 30% of energy, of which less than 1 of 3 is saturated Avoid: overweight, particularly beverages and foods with added sugars and salty food Integrate: behaviour-change models and compliance strategies in counselling sessionsExpected outcome Loss of 5–10% of body weight and modification of associated risk factors Weight control management Assessment: analysis of nutrition habits, calories intake and physical activityEducation: provide behavioural and nutritional counselling with follow-up to monitor progress in achieving goalsWeight reduction: is recommended in obese patients (BMI Z 30, or waist circumference Z 102 cm in men or Z 88 cm in women), and should be considered in overweight patients (BMI Z 25, or waist circumference Z 94 cm in men or Z 80 cm in women), particularly if associated with multiple risk factors (such ashypertension, hyperlipidaemia, smoking and insulin resistance or diabetes) Expected outcomes Elaboration of an individualized strategy to reduce 5–10% of body weight and modification of associated risk factorsWhere goal is not attained, consider referring patient to specialist obesity clinic Assessment: lipid profile. Modify diet, physical activity, and medication therapy if appropriateExpected outcomes Primary goal: LDL-C level < 100 mg/dl (2.5 mmol/l) with an option of < 80 mg/dl (2.0 mmol/l) if feasible, particularly if associated with multiple risk factors [12]Secondary goals: HDL-C level > 40 mg/dl (1.0 mmol/l) in men and > 45 mg/dl (1.2 mmol/l) in women; total cholesterol level less than 175 mg/dl with an option of < 155 mg/dl if feasible; fasting triglyceride level less than 150 mg/dl (1.7 mmol/l) Blood pressure monitoring Assessment: BP frequently at rest. During exercise BP should be monitored when hypertension on effort is suspectedEducation: if resting systolic BP is 130–139 mmHg or diastolic BP is 85–89 mmHg, recommend life-style modifications, exercise, weight management, sodium restriction, and moderation of alcohol intake (i.e., < 30 g/day in men and < 15 g/day in women) according to DASH diet [15]; if patient has diabetes or chronic renalor cardiovascular disease, consider drug therapy If resting systolic BP is Z 140 mmHg or diastolic BP is Z 90 mmHg, initiate drug therapy [16]Expected outcomes BP < 140/90 mmHg (or < 130/80 mmHg if patient has diabetes or chronic heart or renal failure); BP < 120/80 mmHg in patients with left ventricular Smoking cessation All smokers should be professionally encouraged to permanently stop smoking all forms of tobacco. Follow-up, referral to special programmes, and/or pharmacotherapy (including nicotine replacement) are recommended, as a stepwise strategy for smoking cessation. Structured approaches to be used, forexample, 5As: Ask, Advise, Assess, Assist, Arrange Ask the patient about his/her smoking status and use of other tobacco products. Specify both amount of smoking (cigarettes per day) and duration of smoking (number Determine readiness to change; if ready, choose a date for quittingAssess for psychosocial factors that may impede successIntervention: provide structured follow-up. Offer behavioural advice and group or individual counsellingOffer nicotine replacement therapy, bupropion, varenicline, or bothExpected outcome Long-term abstinence from smoking Psychosocial management Assessment: screen for psychological distress as indicated by clinically significant levels of depression, anxiety, anger or hostility, social isolation, marital/family distress, sexual dysfunction/adjustment, and substance abuse of alcohol and/or other psychotropic agents. Use interview and/or other standardizedmeasurement tools Copyright Lippincott Williams & Wilkins. 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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Intervention: offer individual and/or small group education and counselling on adjustment to heart disease, stress management, and health-related lifestyle change (profession, car driving and sex activities resumption) Whenever possible, induce spouses and other family members, domestic partners, and/or significant others in such sessions. Teach and support self-help strategies and ability to obtain effective social support. Provide vocational counselling in case of work related stress Absence of clinically significant psychosocial problems and acquisition of stress management skills BP, blood pressure; BMI, body mass index; CCS, Canadian Class Score; CR, cardiac rehabilitation; DASH, dietary approaches to stop hypertension; ET, exercisetraining; HDL-C, high-density lipoprotein cholesterol; HR, heart rate; LDL, low-density lipoprotein cholesterol; NYHA, New York Heart Association.
Core components and objectives common blood pressure (BP) monitoring, smoking cessation, to all clinical conditions psychosocial management] with the issues common to Each individual affected by cardiovascular disease can all clinical conditions being presented [10–12]. Expected benefit from either an in-patient or out-patient CR outcomes of all the CR intervention are improved clinical programme. The first components of CR should start as stability and symptom control; reduced overall cardiovas- soon as possible after hospital admission. Follow-on CR is cular risk; higher adherence to pharmacological advice; a necessary component to reach and maintain CR goals on better health behaviour profile, all leading to superior the medium and long-term. In some countries, this is quality of life and improved prognosis.
provided as an out-patient service whereas in others,mainly for historical service-organization reasons, this is As evidence is constantly informing new targets and provided in in-patient settings. Even where most follow- methods for intervention, the specific detail of some up CR programmes are delivered on an out-patient basis, guidelines are in constant modification according to the some provision of a structured inpatient (residential) CR progress in the knowledge and may be superseded very programme, in a major CR centre preferably for efficiency, quickly. One illustration of this is targets for waist should be considered for high-risk patients to promote circumference. In the fourth Joint Societies Task Force stable clinical conditions and a rapid functional recovery.
guidelines, they are less than 102 cm for men and less These high-risk patients may include: than 88 cm for women [12]. Other recommendationsfrom the International Diabetes Federation are less than (1) patients with severe in-hospital complications after 94 cm for European men and less than 80 cm for acute coronary syndrome (ACS), cardiac surgery, or European women [13]. In this position study of the percutaneous coronary intervention (PCI); EACPR, we report the fourth Joint Societies Task Force (2) patients with persistent clinical instability or compli- recommendation as the expert guidelines of the EACPR cations after the acute event, or serious concomitant and ESC, with the knowledge that this guideline is diseases at high risk of cardiovascular events; constantly under revision and updated (Table 1).
(3) clinically unstable patients with advanced CHF (NYHA class III and IV), and/or needing intermittent orcontinuous drug infusion and/or mechanical support; Core components and objectives in specific (4) patients after a recent heart transplantation; clinical conditions (5) patients discharged very early after the acute event, Post acute coronary syndrome and post primary even uncomplicated, if they are older, women, or at coronary angioplasty higher risk of progression of CAD; Although PCI, during the early hours of ST elevation ACS (6) patients unable to attend a formal outpatient CR [17] (defined as primary PCI) and in non ST elevation programme for any logistic reasons.
ACS with intermediate-to-high risk feature [18], hasbecome the preferred therapeutic option, CR with risk Patients should be supported to adopt strategies appro- factor assessment and management is crucial for patient priate to their condition and present status by addressing the core components of CR. This may include grouppatient sessions and also sessions involving family After an uncomplicated procedure, risk factor manage- members to provide efficient education and direction to ment and physical activity counselling can start the patients in a supportive environment with fellow patients next day, and such patients can be walking around the and engaged family members. Table 1 outlines the core flat, and upstairs within a few days. After a large and/or components for CR [patient assessment, physical activity complicated myocardial damage, CR should start after counselling, exercise training (ET), diet/nutritional coun- clinical stabilization, and physical activity be increased selling, weight control management, lipid management, slowly, according to the symptoms.
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Cardiac rehabilitation Piepoli et al.
Core components of cardiac rehabilitation in post acute coronary syndrome (ACS) and post primary percutaneous coronary intervention (PCI) Patient assessment Clinical history: review clinical course of ACS Physical examination: inspect puncture site of PCI, and extremities for presence of arterial pulses Exercise capacity and ischaemic threshold: submaximal exercise stress testing by bicycle ergometry or treadmillmaximal stress test (cardiopulmonary exercise test ifavailable) within 4 weeks after acute events while a maximaltesting at 4–7 weeks Physical activity counselling Exercise stress test guide: in the presence of exercise capacity Should resistance physical more than five METs without symptoms, patient can resume activity 2 days per week be routine physical activity; otherwise, the patients should encouraged? [current resume physical activity at 50% of maximal exercise capacity evidence class II b (C)] [21] and gradually increase Physical activity: a slow gradual and progressive increase of moderate intensity aerobic activity, such as walking, climbingstairs and cycling supplemented by an increase in dailyactivities (such as gardening, or household work) Exercise training The programme should include supervised medically prescribed When should the training aerobic exercise training: programme start? After Low risk patients: at least three sessions of exercise stress testing? 30–60 min/week aerobic exercise at 55–70% of themaximum work load (METs) or HR at the onset ofsymptoms Z 1500 kcal/week to be spent by low risk patients Moderate to high-risk patients: similar to low risk group but starting with less than 50% maximum work load (METs) Resistance exercise: at least 1 h/week with intensity of 10–15 repetitions per set to moderate fatigue Caloric intake should be balanced by energy expenditure (physical activity) to avoid weight gain Weight control management Mediterranean diet with low levels of cholesterol and Foods rich in omega-3 fatty acidsStatins for all patients, intensified to a lipid profile of cholesterol < 175 mg/dl or < 155 mg/dl in high risk patients, LDL-C < 100 mg/dl or < 80 mg/dl in high risk patients; triglycerides Blood pressure monitoring Smoking cessation Psychosocial management ACS, acute coronary syndrome; CR, cardiac rehabilitation; ET, exercise training; HR, heart rate; LDL-C, low-density lipoprotein; METs, metabolic equivalent tasks.
After hospital discharge, structured CR should continue, medical therapies should be initiated for the secon- depending upon local facilities. In-hospital CR for 4 dary prevention of atherosclerosis before the patient weeks can be useful in patients with severe left ventri- leaves the hospital. An important contribution should cular dysfunction or relevant co-morbidity. All other patients come from the interventional cardiologist who should can follow an outpatient CR programme (Table 2).
emphasize the importance of these measures directlyto the patient, because failure to do so may suggest Stable coronary artery disease and elective coronary that secondary prevention therapies are not neces- sary. The interventional cardiologist should interact Secondary prevention measures and exercise-based CR with the primary care physician, and the physicians are an essential part of long-term therapy because they in charge of the CR programme to ensure that the reduce future morbidity and mortality associated with the necessary secondary prevention therapies initiated during atherosclerotic process [6].
hospitalization are maintained after discharge from thehospital.
Thus indications for CR in chronic stable angina pectorisand following elective PCI has been underlined in recent Uncertainties remain for important aspects such as the ET programme or the best way to increase complianceand adherence to a healthy lifestyle. Other general All patients should be instructed about necessary beha- controversies include what to do with Prinzmetal's angina viour and risk factor modification, and the appropriate pectoris or microvascular angina pectoris (Table 3).
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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Core components of cardiac rehabilitation in stable coronary artery disease and following elective percutaneous coronary intervention [25–27] Issues requiring further Patient assessment Risk stratification Blood testing (FBC, creatinine, glucose, lipid profile, PCR)OGTT Arrhythmias by ECG with ambulatory ECG monitoring if neededLV function by cardiac imaging testPhysical activity level by historyExercise capacity and ischaemia threshold by exercise stress test (3–6 months afterPCI)Exercise or pharmacological imaging technique in patients with un-interpretable ECGVascular access site problems Physical activity counselling Activity plan: 30–60 min, 7 days/ weekly (minimum 5 days/week) of moderate intensity Best ways to increase adherence/ compliance Also refer to Table 2 Exercise training Medical supervision: supervised exercise training programmes recommended, particularly Need for continuous ECG for patients with multiple risk factors, and with moderate-to-high risk (i.e., recent monitoring for whom? revascularization, heart failure) Resistance training: expand physical activity to include resistance training on 2 days/week Training above the Also refer to Table 2 ischaemic threshold? Medication: prophylactic nitro-glycerine can be taken at the start of exercise training Daily physical activity and weight management are recommended for all patients Vitamin supplements Diet: mediterranean diet in all patients ( < 7% of total calories as saturated fat and < 200 mg/day of cholesterol) Supplements: add plant stanol/sterols (2 g per day) and/or viscous fibre ( > 10 g per day)Omega-3: encourage consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per day) for risk reduction Also refer to Table 2 Weight control management BMI and waist circumference should be assessed regularly Control of overweight in the Manage-BMI: on each patient visit, it is useful to consistently encourage weight elderly and chronic maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioural programmes when indicated to achieve and maintainhealthy BMI (18.5–24.9 kg/m2) Manage waist circumference: if waist circumference is Z 89 cm in women or Z 103 cm in men, it is beneficial to initiate lifestyle changes and consider treatment strategies formetabolic syndrome as indicated. Some male patients can develop multiple metabolicrisk factors when the waist circumference is only marginally increased (e.g., 94–102 cm). They may have a strong genetic contribution to insulin resistance and couldbenefit from changes in life habits, similar to men with categorical increases in waistcircumference Goal: the initial goal of weight loss therapy should be to gradually reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted ifindicated through further assessment Assess fasting lipid profile in all patients, preferably within 24 h of an acute event. Initiate High dose statins for all lipid lowering medication as recommended below as soon as possible: Statin therapy for all patients What in low cholesterol and/or Triglycerides: if Z150 mg/dl or HDL-C < 40 mg/dl emphasize weight management and physical activity, alcohol abstention, smoking cessation If triglyceride 200–499 mg/dl, consider adding fibrate and niacin Regular monitoring of liver function and creatinekinase is required with com-bined therapy ofstatin and fibrate If triglyceride Z 500 mg/dl, consider adding omega-3 fatty acids Blood pressure monitoring Target: BP less than 130/80 mmHg Lifestyle approach: patients should initiate and/or maintain lifestyle modifications–weight control; increased physical activity; moderation of alcohol consumption; limited saltintake; maintenance of a diet high in fresh fruits, vegetables, and low-fat dairy products Medication: for hypertensive patients with well established CAD, it is useful to add BP medication as tolerated, treating initially with b blockers and/or ACE inhibitors, withaddition of other drugs as needed to achieve target blood pressure Smoking cessation Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended Psychosocial management Role of type D personality?Use of pharmacotherapy in Effect of stress reduction stra- tegies on outcomes? [28] BP, blood pressure; BMI, body mass index; CAD, coronary artery disease; FBC, full blood count; ET, exercise training; HDL-C, high-density lipoprotein cholesterol;HR, heart rate; OGTT, oral glucose tolerance test; PCI, percutaneous coronary intervention.
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Cardiac rehabilitation Piepoli et al.
Cardiac rehabilitation following cardiac surgery: coronary Chronic heart failure artery or valve heart surgery All patients with established CHF, with or without CR programmes should be available for all patients implantable cardioverter defibrillator and with or without undergoing coronary artery surgery [29,30] and valve cardiac resynchronization therapy, require a multi-factorial surgery [31,32]. For surgical patients, the preventive CR approach [33–36]. In-patient rehabilitation should and rehabilitation strategy should also focus on the begin as soon as possible after hospital admission. As the potential effect of preoperative rehabilitation. Similarly to length of stay for acute decompensation and interven- other sub-groups of patients, CR should be tailored tion procedures continues to decrease, structured out- according to the individual risk profile, physical, psycho- patient CR is crucial for the development of a life-long logical and social status assessed as part of the peri- approach to prevention. This may be provided in a operative medical history and examination (Table 1).
wide range of settings, such as CHF clinics, non-clinic Furthermore, it should be appreciated that the clinical settings (community health centres and general medical condition and concerns of surgical patients often relate to practices), or a combination of these. Out-patient CR the surgical procedure itself. Approaching and resolving may also be provided on an individual basis at home, these issues in addition to understanding the underlying including a combination of home visits, telephone clinical conditions should be part of comprehensive CR support, telemedicine or specially developed self-education materials (Table 5).
Core Components of cardiac rehabilitation following cardiac surgery – coronary artery or valve heart surgery Patient assessment Assess: wound healing, co-morbidities, complication and disabilitiesEchocardiography: pericardial effusion, prosthetic function and disease at other valve sites, when Exercise capacity to guide exercise prescription Sub-maximal exercise stress test as soon as possibleA maximal exercise test about 4 weeks after surgery Patient education: about anticoagulation, including drug interactions and self-management if appropriate; in-depth knowledge on endocarditic prophylaxis Physical activity counselling Physical activity counselling (Table 1) should be offered to all patients taking into account wound healing and exercise capacity (Table 2) Exercise training Exercise training can be started in the early in-hospital phaseIn-patient and/or out-patients ET programmes immediately after discharge lasting 8–12 weeks are Upper-body training can begin when the chest is stable, i.e. usually after 6 weeks.
ET should be individually tailored according to the clinical condition, baseline exercise capacity, ventricular function (Table 2) and different valve surgery:After valve surgery exercise tolerance will take a significant time to recoverAfter mitral valve replacement exercise tolerance is much lower than that after aortic valvereplacement, particularly if there is residual pulmonary hypertension Note interaction between anticoagulation and k-vitamin rich food and other drugs, in particularly Tobacco cessation Risk of complications depends on how long before surgery the smoking habit has been changed, whether smoking was reduced or stopped completely Psychosocial management Sleep disturbances, anxiety, depression and impaired quality of life may occur after surgery Core components of cardiac rehabilitation in chronic heart failure Issues requiring further evidence Patient assessment Haemodynamic and fluid status: signs of congestion, peripheral and central oedema Cachexia signs: reduced muscle mass, muscle strength and endurance Blood testing: serum electrolytes, creatinine, BUN Peak exercise capacity: maximal symptom-limited cardiopulmonary with metabolic gas exchange. Fortesting protocol small increments 5–10 W per minon bicycle ergometer or modified Bruce orNaughton protocols are indicated Six minute walk test is accepted stress test to assess exercise toleranceOther tests: coronary angiography, haemodynamic measurements, endomyocardial biopsy, sleep test Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Issues requiring further evidence are necessary for selected patients or cardiactransplantation candidates Physical activity counselling At least 30 min/day of moderate-intensity physical activity to be gradually increased to 60 min/day Exercise training Progression of aerobic ET for stable patients: Limited information about combined aerobic and strength Initial stage: intensity should be kept at a low level training, interval, resistance and respiratory ET is available (40–50% of peak VO2), increasing duration from Resistance training: short stress phases (10 repetitions max.) at 15 to 30 min, 2–3 times/week according to < 60% MVC, interrupted by phases of muscle relaxation [14] perceived symptoms and clinical status for the first1–2 weeks Improvement stage: a gradual increase of intensity Respiratory training: 20–30 min/day on 3–5 days/week for a (50, 60, 70–80% of peak VO2, if tolerated) is the minimum of 8 weeks, starting at 30–35% maximum inspiratory primary aim. Prolongation of exercise session is a pressure and readjusting every 7–10 days Supervised, in-hospital training programme may be Monitoring exercise intensity: HR can be used for exercise recommended, especially during the initial phases, prescription, but its applicability is limited in patients with to verify individual responses and tolerability, clinical advanced HF (chronotropic incompetence), in those treated stability and promptly identify signs and symptoms with b-blockers and when atrial fibrillation is coexisting indicating to modify or terminate the programme Exercise training and patients with ICD: limited experiences are available. ET seems feasible and safe. Supervision by qualifiedstaff and constant surveillance during exercise activity arestrongly recommended. Exercise intensity: pre-determined HRthreshold = ICD detection rate minus 20–30 beats/min Prescribe specific dietary modifications: Particular dietary recommendations: Fluid intake: less than 1.5 l/day (or 2 litres in hot How to regain weight: with episodes of acute HF, appetite is much reduced and weight loss may occur. After clinicalstabilization, recovery of appetite leads to slow regain of weight Sodium intake: severe restriction should usually be A liberalized fat intake is allowed to weight maintenance and considered in severe HF adequate caloric intake in poorly nourished CHF patients, withnormal or low levels of total and LDL-CThe role of chronic sodium supplementation in severe patientstreated with high dose of diuretics with fluid balance butunvarying low natriaemia is unknownCombined increases in saturated fat intake and weight, andincreasing insulin resistance and BP, may lead to furtherepisodes of myocardial infarction or ischaemia with severeadverse consequences Weight control management Weight monitoring: the patients must be educated to Unintentional weight loss: clinical or sub clinical malnutrition is weight themselves daily. Weight gain is commonly common in HF. Cardiac cachexia is a serious complication and because of fluid retention, which precedes the is associated with bad outcome. Although the definition of appearance of symptomatic pulmonary or systemic cardiac cachexia remains arbitrary, its prevalence is increasing congestion. A gain > 1.5 kg over 24 h or > 2.0 kg The mechanism of the transition from CHF to cardiac cachexia over 2 days suggest developing fluid retention is complex and not completely known. The effects of medicaltreatment, dietary and physical activity are still poorly evaluated Weight reduction: In moderate-severe HF, weight reduction is not recommended since unintentionalweight lost and anorexia are commoncomplications. It may occur because of loss ofappetite, induced by renal and hepatic dysfunction,hepatic congestion, or it may be marker ofpsychological depression Statins should be considered only in patients with established atherosclerotic disease Tobacco cessation Smoking is a risk factor for cardiovascular disease, but no studies have evaluated the effect of smoking cessation in HF cohorts Psychosocial management Depression is common in HF. Recognition and Depression commonly goes undiagnosed: management of depression may be enhanced Patient's unwillingness to disclose emotional distress for fear through the use of multidisciplinary team or disease of being stigmatized with the label of mental illness management programmes Treatment of depression is an important clinical Physicians may not address depression because they have strategy as this condition is associated with more not been adequately trained frequent hospital admissions, decline in activities ofdaily living, worse NYHA functional classificationand increased medical costs BNP, brain natriuretic peptide; BP, blood pressure; BUN, blood urea nitrogen; CHF, chronic heart failure; ET, exercise training; HR, heart rate; ICD, implantablecardioverter defibrillator; MVC, maximal voluntary contraction; NYHA, New York Heart Association.
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Cardiac rehabilitation Piepoli et al.
Core components of cardiac rehabilitation in cardiac transplantation Issues requiring further Patient assessment Clinical: wound healings (and self-assessment) Echocardiography: pericardial effusionExercise capacity: cardiopulmonary exercise stress test 4 weeks after surgery to guide detailed exercise recommendations. For testing protocols, small increments of 10 W per min on bicycleergometer, or modified Bruce protocols or Naughton protocols on treadmill are appropriate Physician knowledge of the anatomical and physiological reasons for limited exercise tolerance: e.g.
the immune-suppression therapy side effect (impairments of inflammatory response, metabolism,osteoporosis) Risk of acute rejection: rapid, appropriate treatment is necessary. Patients should be instructed to practice self-monitoring: an unusually low BP, a change of HR, unexplained weight gain or fatiguemay be early signs of rejection even in the absence of major symptoms Patients and physiotherapists should be educated to adhere to the recommendations concerning personal hygiene and general measures to reduce the risk of infection (Table 7) Physical activity counselling Chronic dynamic and resistance exercises prevents the side-effects of immunosuppressive therapyExercise intensity relies more on perceived exertion than on a specific HR. Borg scale: scores of 12–14 to achieve. For example: instruct the patients to start walking 1.5 or 2 km five times weekly ata pace resulting in a perceived exertion of 12–14 on the Borg scale. The pace should be increasedslowly over time to nordic walking Exercise training Early training programme can be beneficial in the early post-operative period as well as in the long-term Although exercise training would theoretically delay orprevent CAD progression inthe transplanted heart, thisstill has to be studied Before hospital discharge, respiratory kinesiotherapy, active and systematic mobilization of the upper and lower limbs are advisable After discharge, aerobic exercise may be started in the second or third week after transplant but should be discontinued during corticosteroid bolus therapy for rejection. Resistance exercise should beadded after 6–8 weeks Regimen: at least 30–40 min/day of combined resistance exercise (muscle strength) and aerobic training (walking) at moderate level, slowly progressing warm-up, closed-chain resistive activities(e.g., bridging, half-squats, toe raises, use of therapeutic bands) and walking/nordic walking/cycling Resistance training: 2–3 sets with 10–12 repetitions per set at 40–70% MVC with a full recovery period ( > 1 min) between each set. The goal is to be able to do five sets of 10 repetitions at 70% ofMVC Aerobic training: the intensity of training should be defined according to peak VO2 ( < 50% or 10% below anaerobic threshold) or peak work load ( < 50%) Dietary infection prophylaxis – food to be avoided: There are good reasons to follow a Mediterranean style diet, even though controlled Un-pasteurized milk studies in these patients to Cheese from un-pasteurized milk assess the influence of nutri- tion on CAV or survival have not been published Weight control management Avoidance of overweight is mandatory to balance the side-effects of immunosuppressants, to limit the classical cardiovascular risk factors Obesity increases the risk of cardiac allograft vasculopathy. It should be controlled by daily exercise Hyperlipidaemia increases the risk of CAV. It should be controlled by statins, daily exercise and healthy Statins are now part of standard therapy, butdose-related myopathy andmyolysis because ofinteraction with ciclosporinmust be considered Statins (pravastatin, simvastatin) not only lowered LDL-C levels but also decreased the incidence of CAV and significantly improved survival Blood pressure monitoring Target BP is 130/80 mmHgHypertension is linked to immunosuppressive therapy and denervation of cardiac volume receptorsIt is sensitive to a low-sodium diet. Treatment with diltiazem and ACE inhibitors are first choice, usually completed by diuretics. Beta-blockers are contra-indicated as they hamper the already delayedchronotropic response of the denervated heart Tobacco cessation Cessation of smoking is a prerequisite for transplantation in most centres. Psychological support may be needed so patient does not resume smoking post-transplantation Psychosocial mangement Clear medical information and advice on life after transplant are needed to manage challenges such as patient guilt or problems with high levels of anxiety and apprehensiveness Careful presentation of recommendations is necessary, leaving the choice up to the patient and offering every possible support he/she may need to adjust ACE, angiotensin-converting enzyme; BP, blood pressure; CAD, coronary artery disease; CAV, cardiac allograft vasculopathy; ET, exercise training; HR, heart rate;LDL-C, low-density lipoprotein cholesterol; MVC, maximal voluntary contraction.
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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Cardiac transplantation Diabetes mellitus It is hard to imagine a group of patients more obviously in Impaired glucose tolerance is one of the strongest need of rehabilitation than heart transplant recipients, prognosticators after acute myocardial infarction (AMI).
because of the multifaceted physical and mental pro- Furthermore, worldwide we see an epidemic of diabetes blems encountered preoperatively and postoperatively mellitus (DM), which is associated with an increased risk [37]. Of all patients surviving the first year, 50% will live of CAD and an impaired prognosis after AMI. Never- more than 12 years. As short-term survival is no longer the theless, a substantial proportion of adults meeting the key issue for heart transplant recipients, a return to criteria of DM are not identified as patients with DM.
functional lifestyle with good quality of life becomes the As adequate diagnosis and treatment is associated desired outcome [38] (Tables 6 and 7).
with improved survival, screening for impaired glucose General measures to reduce the risk of infection after cardiac transplantation Good dental hygiene, no toothbrush older than 4 weeksFrequent hand washing using liquid soapAvoidance of close contact with people with infectious diseases (measles, chickenpox, mumps, mononucleosis, common cold, flu)Avoidance of contact with persons having received oral polio vaccination for 8 weeksIf indispensable, pets in the household only under strict precautions and with limited contact with patientNo gardening without glovesNo contact with decaying plants, fruits, vegetablesNo stay near construction work and compost heapsNo mould inside the homeHydroculture (hydroponics) better than potting compost in the homeAvoidance of swimming in public baths Core components of cardiac rehabilitation in diabetes mellitus Issues requiring further evidence Patient assessment Predicted type 2 DM: combination of risk score tools (e.g., OGTT: often lack of time during hospital FINDRISK), and OGTT (2 h post-load plasma glucose level) stay; thus, recommendation for OGTT in Patients with CAD and unknown DM: OGTT discharge note to GP or CR facility? Functional capacity and exercise induced ischaemia by maximal Cardiopulmonary stress test as an adjunct symptom-limited exercise stress testing to exercise testing? Physical activity counselling Daily walking for more than 30 min Three hours per week of moderate intensity (i.e., brisk walking on a slight [approximately 3%] incline, 5–7 days/week) or One hour per week of vigorous-intensity exercise (i.e., jogging for 20 min, 3 days/week) Exercise training Z 150 min/week of moderate-intensity aerobic physical activity Relative benefits of resistance training (e.g., ( Z 4.5 METs) and/or 90 min/week of vigorous aerobic exercise eight muscle groups, two sets per muscle group, 8–12 repetitions, 70–80% of The physical activity should be distributed at least 30 min on at least repetition maximum) versus Endurance training (e.g., 8 muscle groups, Resistance training three times/week, targeting all major muscle 2 sets per muscle group, 25–30 groups, 2–4 sets of 7–40 repetitions repetitions, 40–55% of repetition In case of overweight, caloric restriction to approx. 1500 kcal/day Anti-atherogenic diet: low fat, that is, 30–35% of daily energy uptake (10% for monounsaturated fatty acids, e.g., olive oil); avoidance oftrans fats; high fibre, that is, 30 g/day; low in industrialised sugars;five servings of fruits/vegetables per day Diet is more effective when combined with exercise training (see Weight control management Regular weight control Statins for all aiming at LDL < 80 mg/dl Need mortality and cost-effectiveness Initiate therapy regardless of baseline LDL levels; evidence for Ezetimib If monotherapy with a statin is not sufficient it can be combined with aim: LDL < 70 mg/dl; Blood pressure monitoring Aim at BP < 130/80 ACE inhibitors or ARBs are first choice therapy Usually combination therapy required; choice according to concomitant diagnoses Anti-hypertensive therapy is more important than glucose control Tobacco cessationPsychosocial management In selected patients ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CR, cardiac rehabilitation; CAD, coronary artery disease; DM, diabetesmellitus; ET, exercise training; METs, metabolic equivalent tasks; OGTT, oral glucose tolerance test.
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Cardiac rehabilitation Piepoli et al.
Core components of cardiac rehabilitation in peripheral artery disease Issues requiring further evidence Patient assessment Clinical: any exertional limitation of the lower extremity muscles or any history of walking impairment, that is, fatigue, aching, numbness, orpain Primary site(s) of discomfort: buttock, thigh, calf, or footAny poorly healing wounds of the legs or feetAny pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions Reduced muscle mass, strength and enduranceBilateral arm BP: palpation of peripheral arteries and abdominal aorta with annotation of any bruits and inspection of feet for trophic defects Ankle-brachial index measurement: values 0.5–0.95: claudication range; 0.20–0.49: rest pain; less than 0.20: tissue necrosis Functional capacity: markedly impaired. Peak O2 consumption is 50% of the predicted value Difficulty in walking short distances, even at a slow speed, associated with impairment in the performance of activities of daily living To exclude occult CAD, perform treadmill or bicycle exercise testing to monitor symptoms, ST–T wave changes, arrhythmias, claudicationthresholds, HR and BP responses, useful for exercise prescription Physical activity Exercise activities, such as walking, lasting more than 30 min, Z 3 times/ week, until near-maximal pain Exercise training Supervised hospital- or clinic-based ET programme ensures that Usefulness of unsupervised ET programmes patients are receiving a standardised exercise stimulus in a safe environment, is effective and recommended as initial treatmentmodality for all patients Exercise–rest–exercise: each training session consists of short periods Time course of the response to a ET of treadmill walking interspersed with rest throughout a 60-min programme (clinical benefits have been exercise session, three times weekly observed as early as 4 weeks after the Treadmill exercise: more effective. The initial workload is set to a speed initiation and may continue to accrue after 6 and grade that elicit claudication symptoms within 3–5 min. Patients months of supervised ET rehabilitation three are asked to continue to walk at this workload until they achieve times/week and were sustained when claudication of moderate severity. This is followed by a brief period of continued for an additional 12 months) rest to permit symptoms to resolve. The exercise–rest–exercise cycleis repeated several times during the hour of supervision. (Table 10) Resistance training: appropriately prescribed, is generally recommended To achieve a serum LDL concentration < 100 mg/dl (2.6 mmol/l) Treatment with statin to achieve a target LDL < 80 mg/dl (1.8 mmol/l) in high risk patients A statin should be given as initial therapy, but niacin and fibrates may play an important role in patients with low serum HDL or high serumtriglyceride concentrations ( > 150 mg/dl or 1.7 mmol/l) Antihypertensive therapy to achieve a goal < 140 mmHg systolic over Does treatment alter the progression of the 90 mmHg diastolic (non-diabetics) or < 130 mmHg systolic over disease or the risk of claudication? 80 mmHg diastolic (diabetics and individuals with chronic renal (antihypertensive drugs may decrease limb perfusion pressure and potentiallyexacerbate symptoms of claudication or The use of ACE-inhibitors in patients with PAD may confer protection critical limb ischaemia, even though most against cardiovascular events beyond that expected from BP lowering patients tolerate anti-hypertensive treatment.
Smoking cessation Stopping smoking is exceptionally important in PAD, smoking-cessation Beta-adrenergic-antagonist drugs have been programmes involving nicotine-replacement therapy, and the use of thought to have unfavourable effects medications such as bupropion or varenicline should be encouraged on symptoms. Critical reviews however concluded that beta-adrenergic antagonists are safe, except in the most severely affectedpatients [I (A)]) ACE, angiotensin-converting enzyme; BP, blood pressure; CAD, coronary artery disease; ET, exercise training; HDL, high-density lipoprotein; HR, heart rate; LDL, Low-density lipoprotein; PAD, peripheral arterial disease.
tolerance and DM has to be improved. Participation in a female patients. Among patients presenting with CAD CR programme offers late but optimal opportunities for or cerebrovascular disease, 32% of men and 25% of screening [39–41] (Table 8).
women have also peripheral arterial involvement, which istwo to three times the prevalence in respective control Peripheral artery diseases groups. The patient with PAD should therefore be Peripheral artery disease (PAD) is part of the multi-site regarded as an actual or potential polyvascular patient presentation of atherosclerosis. At the time of diagnosis and an integrated approach to prevention and treatment of PAD, a history of AMI or stroke, or related surgery can of atherothrombosis as a whole is highly warranted [42] be expected in approximately 30% of male and 20% of (Tables 9 and 10).
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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Key elements of a therapeutic exercise-training programme for rehabilitation from peripheral artery disease in patients with claudication [43] Exercise guidelines for claudication Warm-up and cool-down periods of 5–10 min each Types of exercise Treadmill and track walking are the most effectiveResistance training has benefit for patients with other forms of cardiovascular disease, and its use, as tolerated, for general fitness is complementary to walking but nota substitute for it The initial workload of the treadmill is set to a speed and grade that elicits claudication symptoms within 3–5 minPatients walk at this workload until claudication of moderate severity occurs, then rest standing or sitting for a brief period to permit symptoms to subside The exercise–rest–exercise pattern should be repeated throughout the exercise sessionThe initial session usually includes 35 min of intermittent walking; walking is increased by 5 min each session until 50 min of intermittent walking can be accomplished Treadmill or track walking 3–5 times per week Role of direct supervision As the patient's walking ability improves, the exercise workload should be increased by modifying the treadmill grade or speed (or both) to ensure that the stimulus ofclaudication pain always occurs during the workoutAs walking ability improves, and a higher HR is reached, there is the possibility that cardiac signs and symptoms may appear. These symptoms should be appropriatelydiagnosed and treated HR, heart rate.
Cardiac rehabilitation in older patients Patient assessment Clinical history: cardiovascular disease (e.g., CAD, HF, arterial fibrillation, PAD, renal failure) and risk factors as well as concomitant diseases (e.g., stroke, neurological dysfunction, COPD, visual/hearing impairment, arthritis, osteoporosis, urinaryincontinence, cognitive impairment, dementia) Education: take into account the fact that older patients typically more often have visual, hearing and cognitive impairmentsExpected outcomes: formulation of a therapeutic regime with a high level of individual care and support Physical activity counselling Emphasize participation in supervised group activities to advance social integration and social support Exercise training Tailored exercise recommendations: prescriptions for a given patient should: Depend on existing co-morbidities and on the baseline level of physical capacity as well as existing activity limitationInclude activities to develop endurance, strength, flexibility, coordination (balance skills) and body awarenessStart at a very low level and gradually progress to a goal of moderate activityFrailty: for frail patients stationary cycling may provide a greater degree of stability and less risk of injury than walking exercise Recommended intensity for resistance exercise < 30–60% of one repetition maximum (RM)Select exercise appropriate to musculoskeletal conditions in older patientsAvoid exercises that require rapid postural variations for orthostatic hypotension riskGreater benefits from shorter single exercise session with prolonged duration of the CR/ET programmes Diet/nutritional counsellingWeight control management Less likely to be severely obese than younger patients, especially those with HF which are at higher risk to develop cardiac BMI 28–29 kg/m2 is the target value Benefit from lipid lowering medication (statins) as for other patients Target BP in older people is r 130/89 mmHg, r 120/80 in patients with diabetes, HF, CAD or renal failureA careful management of hypertension in older patients is mandatory including pharmachological and nonpharmacological interventions (weight reduction, exercise and low salt intake) Smoking cessationPsychosocial management Treatment should focus on identifying and reducing depression and anxiety, improving social adaptation and reintegration as well as overall quality of life BP, blood pressure; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; HF, heart failure; PAD, peripheral arterial disease.
Core components and objectives in challenging populations Older cardiac patients are often excluded from CR It is important to emphasize that there is typically more programmes [44]. However, benefits of CR and ET in variety within groups such as older people and women, than exercise capacity, in functional capacity, in behavioural between them and comparison groups – in this case characteristics (depression, anxiety, somatization and younger people and men. It is nonetheless important to hostility) and in overall quality of life, modification of signal some issues, which will be more prominent in groups cardiovascular risk factors, smoking cessation, antihyper- who have been less involved in CR programmes to date.
tensive therapy and lipid lowering medication has been Five such groups are identified here. These groups are older documented also in older patients, even in those with and female patients and patients with specific co-morbidity, severe clinical status and multiple co-morbidity condition transient ischaemic attack or stroke, chronic obstructive [45]. The planning and implementation of CR in older pulmonary disease (COPD) and chronic renal failure groups requires a high level of individual care and support (CRF). Of course many others could also be identified.
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Cardiac rehabilitation Piepoli et al.
function, including psychosocial assessment and evalua- History of transient ischaemic attack/stroke tion of co-morbidities. Accordingly, residential CR may be Owing to the common underlying risk factors, patients an appropriate option. Main goals of CR in the aging admitted to CR may sometimes have a history of patient are preservation of mobility, independence and transient ischaemic attack or stroke, which has therefore mental function, prevention/ treatment of anxiety and to be screened. Depending on the localization of stroke, depression, improving quality of life, encouragement of residual neurological deficits might influence the CR social adaptation and reintegration, and enabling the process [47] (Table 13).
patient to return to the same lifestyle as before the acuteevent (Table 11).
History of chronic obstructive lung diseaseLong-time smokers often develop COPD, thus itsprevalence is high in patients admitted to CR. COPD (stage II, III and VI) has significant extra pulmonary Women benefit from comprehensive CR as much as men effects including reduced exercise capacity, weight loss [46]. This is also true for older women. The planning and and skeletal muscle dysfunction similar to those known implementation of CR in women needs to consider that in HF patients. All COPD patients will benefit from women are more likely to be older, to have hypertension, exercise based CR programmes improving exercise diabetes, hypercholesterolemia, obesity and HF, as well as tolerance and symptoms of dyspnoea and fatigue [48] lower exercise and functional capacity compared to male patients and may therefore carry a higher cardiac risk as aCR population. Beyond the impact of the cardiac disease,older women in particular are more likely to experience History of chronic renal failure (CRF) activity limitations and other exercise-limiting co-morbid In patients with CRF, cardiovascular disease is the major conditions such as arthritis, osteoporosis and urinary cause of morbidity and mortality [49]. The prevalence of incontinence. At recruitment to CR, women typically CRF in patients admitted to CR is therefore high and has score lower in health-related quality of life and they are to be considered by a comprehensive screening for cardio- more likely to be diagnosed with depressive disorders and vascular co-morbidities in these patients. Depending on higher scores of anxiety (Table 12).
the duration and classification of renal failure a moderate Cardiac rehabilitation in women Patient assessment Clinical history: (see also Table 11)Patient education: crucial to provide comprehensive information on the contents and the basic purpose of the CR programme to improve adherence and reduce possible barriers Physical activity counselling Advise and encourage to perform regular physical activities (e.g., walking or biking > 30 min 5–7 days a week) Women who need to lose weight or sustain weight loss should accumulate a minimum of 60–90 min of moderate-intensity physical activity (eg, brisk walking) on most, and preferably all, days of the week Emphasize participation in supervised group activities to advance social integration and support Exercise training Exercise recommendations and prescriptions (see also Table 11): Incorporate individual preferences which might be different from those of male patientsInclude combined programme of endurance (cycle, walking, nordic walking) and resistance exercise (major functional, postural and pelvic flour muscle) Include callisthenics to develop flexibility, coordination (balance skills) and, body awarenessInclude activities and games which enhance communication and social integration A diet rich in fruits and vegetables, whole-grain, high-fibre foods; fish, especially oily fish, Z twice a week; Limit intake of saturated fat to less than 10% of energy ( < 7% if possible), cholesterol to less than 300 mg/day, alcohol intake to r 1 drink/day, sodium intake to less than 2.3 g/day (approximately 1 tsp salt). Consumptionof trans-fatty acids should be as low as possible ( < 1% of energy) Weight control management Maintain/achieve a BMI between 18.5 and 24.9 kg/m2 and a waist circumference < 88 cm In obese women, weight reduction and maintenance is mandatory through appropriate caloric intake, physical activity and exercise as well as behavioural programmes Older women with CHF and other chronic diseases are at risk to develop cardiac cachexia Encourage optimal lipid management through lifestyle approaches and lipid lowering medication (statin therapy, unless contraindicated) Use LDL-C lowering drug therapy simultaneously with lifestyle therapy in women with CAD Blood pressure monitoring Management of hypertension should include non-pharmacological interventions (weight reduction, exercise and low salt intake) and antihypertensive therapy Target BP are r 130/80Pharmacotherapy is indicated when blood pressure is > 140/90 mmHg or at an even lower blood pressure in the setting of chronic kidney disease or diabetes ( > 130/80 mmHg). Thiazide diuretics should be part of thedrug regimen for most patients unless contraindicated Smoking cessation Psychosocial management Focus on identifying and treating anxiety and depression, improvement in social adaptation and reintegration as well as overall quality of life BP, blood pressure; BMI, body mass index; CAD, coronary artery disease; CHF, chronic heart failure; CR, cardiac rehabilitation; tsp, teaspoon.
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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 Cardiac rehabilitation in patients with history of TIA/stroke Established/generally agreed issues Patient assessment Risk factors and (a history of) neurological symptoms and deficits (e.g., amaurosis fugax, diplopic images, aphasia, hemiparesis, paresthesia, dementia, vertigo) Gait ability, sitting balance, standing balance and functional mobility [e.g., Berg Balance Scale (], Clinical Outcome Variables Scale ( Residual neurological deficits especially those which might affect the patients ability to participate in the CR-programme (e.g., paresis, motor deficits, movement deficits, impaired sensibility, cognitive deficits, and/or neuro-psychological symptoms, suchas attention deficits, apraxia, aphasia) In patients with residual and severe deficits, consider if participation in the usual educational programme can be of benefit Physical activity counsellingExercise training Provided there are no contraindications, all heart patients with history of TIA or stroke should be encouraged to participate in exercise-based CR When possible the patient should participate in the normal CR exercise programme. However, ET prescriptions for a given patient should depend on the baseline level of physical capacity as well as existing exercise-limiting neurological deficits and/or disabilities In the presence of impaired sitting or standing balance and gait ability, as well as the dependence on supports or mobility devices, the exercise programme has to be modified to meet the patient's special needs. In case of reduced sitting ability,balance cycling in supine position or with other available sitting support should be considered. In case of reduced standingability, balance gymnastic programme to improve flexibility, coordination and strength (low to moderate intensity) should beperformed in sitting position. In the presence of reduced gait ability, individual physiotherapy, example, special gait training onthe treadmill should be considered The implementation of relaxation training also has to take into account possible motor deficits and consider if the participation in the sitting position might fit better In the presence of spastic paresis, motor deficits and impaired sensor-motor function, individual physiotherapy is indicatedTo avoid cardiac overload, it has to be considered that patients with motor deficits or disabilities (e.g., caused by spasticity) have higher energy demands for given activity Diet/nutritional counsellingWeight control managementLipid managementBlood pressure monitoringSmoking cessationPsychosocial management CR, cardiac rehabilitation; ET, exercise training; TIA, transient ischaemic attack.
Cardiac rehabilitation in patients with COPD Patient assessment Risk factors and symptoms (dyspnoea, chronic cough, chronic sputum production)Spirometry (for classification of COPD severity; specific cut points e.g., post-bronchodilator FEV1/FVC ratio or FEV1)Exercise capacity by cardio pulmonary stress test and/or 6 min walk testEchocardiography (exclusion/diagnosis of pulmonary hypertension; cor pumonale) Physical activity counselling Introduction to peak flow-based self management Exercise training ET prescriptions should depend on the baseline level of physical capacity and the COPD severity. The programme should include endurance (interval training), resistance exercise (especially lower body exercise), breathing exercise and instructioninto postures to help shift and cough up phlegm Patients with measurable obstruction should be advised to use a bronchodilator medication before starting the exercise. In case of post-bronchodilator FEV1:More than 75%, the patient can be integrated into the regular CR exercise training regimeLess than 75% > 50% the level of endurance exercise should be reduced by 10–15%Less than 50%, participation to low dose endurance/interval cycle ergometer training as well as gymnastics(Borg-Dyspnoea-Scale value r 5, breathing rate r 20/min) is advisableLess than 30%, O2 saturation should not exceed values less than 90% Educational programmeDiet/nutritional counsellingWeight control management Patients with severe COPD are at risk of developing cachexia Lipid managementBlood pressure monitoringSmoking cessation Stopping smoking is a particularly important intervention and all forms of treatment programme should be offered Psychosocial management COPD, chronic obstructive pulmonary disease; CR, cardiac rehabilitation; ET, exercise training.
to severe reduction of physical capacity can be assumed, Future challenges generated by renal anaemia, uraemic myopathy and poly- Despite the body of professional recommendations on neuropathy, disturbances in volume status, electrolyte cardiovascular disease prevention, integration of prevention balance and or acid-base metabolism, physical inactivity strategies into daily practice is still inadequate. In Europe as well as immunosuppressive therapy in patients after only about a third of CAD patients receive any form of CR, kidney transplantation (Table 15).
with considerable variation between European regions [50].
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Cardiac rehabilitation Piepoli et al.
Cardiac rehabilitation in patients with chronic renal failure (CRF) Patient assessment Risk factors (hypertension, diabetes, family history of kidney disease) and symptoms of CRF (e.g., proteinuria)Glomerular filtration rate by the modification of diet in renal disease equation ( is essential Physical activity counsellingExercise training The programme should include a combination of endurance and resistance exercise (especially lower body exercise) and activities to develop flexibility, coordination and body awareness For a given patient, ET should depend on the baseline level of physical capacity and the CRF severity. In stage I–III, the CRF usually does not affect the exercise programme which should be deduced by the heart disease Special advices for haemodialysis patients (stage V): To avoid injury of the arteriovenous fistula and pain in the shunt-arm: the puncture-area should be protected with dressingwhile exercisingPatients should not wear wristwatches or wristbandsBP should not be measured on the shunt-arm sideHR can more easily be measured on the shunt-arm sideAvoid exercises (gymnastics and resistance exercises) which include pressing on the arms and/or holding the arms in head uppositionET should be performed on the day between haemodialysis treatments Special advice for patients after kidney trans-plantation Consider the vulnerability of the kidney transplant in the fossa iliaca directly under the abdominal wall, the reduced perfusionof the transplantand adverse effects of the immunosuppressive therapyAvoid exercises performed in face down position and extreme stretching exercises for the upper part of the body Educational programDiet/nutritional counselling In patients with higher stage of the CRF ( Z IV stage CRF)hyper-phosphataemia and hypocalcaemia have to be considered and the intake of foods rich of phosphate (e.g., milk products, eggs and meat) should be reduced, whereas calcium supplementation is recommended The intake of food rich of potassium (e.g., fresh fruits, nuts, fruit juice) should be reducedThe supplementation of a vitamin D analogue (calcitol, afacitol or paracitol) should be consideredIn stage V CRF, supplementation of water soluble vitamins should be considered Weight control managementLipid managementBlood pressure monitoringSmoking cessationPsychosocial management BP, blood pressure; ET, exercise training; HR, heart rate; RF, renal failure.
Discontinuation of medication after acute events is was evaluated in a cluster randomized controlled trial in frequent and occurs early after hospital discharge. Patients 24 hospital and general practice centres across eight with other clinical manifestations of atherosclerotic cardio- countries [52]. Patients presenting with coronary disease vascular disease receive little or no formal preventive and in hospital, and individuals at high risk of developing rehabilitative care. The results of the EUROASPIRE audits cardiovascular disease in primary care, were randomized of preventive care of coronary patients over the last 12 years to either a family-based comprehensive lifestyle inter- show adverse lifestyle trends; increasing prevalence of vention with management of BP and lipids or to usual smoking among younger (< 50 years) patients, especially care. The EuroAction programme reduced the risk of women, and increasing obesity, central obesity and cardiovascular disease compared with usual care through diabetes. Control of BP is unchanged over this period, lifestyle changes by families, who together made heal- with over half of all patients still above the therapeutic thier food choices and became more physically active over target, despite increasing use of anti-hypertensive medica- 1 year. These lifestyle changes led to modest weight loss tions. Only lipid management has improved with the use of in both groups of patients and, for high-risk patients, statins [51]. Moreover, even when implemented, most of there was also a significant reduction in central obesity.
the CR programmes rely mainly on short-term interven- BP control was significantly improved in both groups of tions and are not adequately implemented on the long patients, and for those with CAD this was achieved term. Short-term approaches are, in fact, unlikely to yield without the use of additional antihypertensive drugs.
long-term benefits, impact quality of life, or decrease Control of blood cholesterol concentrations improved in morbidity and mortality. Some lessons and optimism may both groups of patients and significantly so in high-risk have been provided by recent studies on prevention and patients because of increased use of statins. Overall the CR, specifically aimed at maintaining beneficial long term use of all cardioprotective drugs was substantially higher life changes and improving prognosis in cardiac patients, for in the hospital compared to the primary care programme, example, the EuroAction and GlObal Secondary Prevention although for high risk patients ACE inhibitors and strategiEs to Limit studies.
statins were both prescribed more frequently comparedto usual care. EuroAction is one model of preventive The EuroAction demonstration project in preventive care, successfully implemented and objectively assessed, cardiology was a nurse-managed, multidisciplinary, lifestyle, which shows that standards of care can be raised in risk factor and therapeutic management programme. It routine clinical practice.
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European Journal of Cardiovascular Prevention and Rehabilitation 2010, Vol 17 No 1 The GlObal Secondary Prevention strategiEs to Limit American Association of Cardiovascular and Pulmonary Rehabilitation.
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Modeling the Invasion of Community-AcquiredMethicillin-Resistant Staphylococcus aureus intoHospitals Erica M. C. D'Agata,1 Glenn F. Webb,2 Mary Ann Horn,2,3 Robert C. Moellering, Jr.,1 and Shigui Ruan4 1Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; 2Department ofMathematics, Vanderbilt University, Nashville, Tennessee; 3Division of Mathematical Sciences, National Science Foundation, Arlington, Virginia;and 4Department of Mathematics, University of Miami, Coral Gables, Florida

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