Exercise Training Improved Pulmonary Gas Exchange Abnormalities in Pulmonary Hypertension due to Heart Failure: A Case Report

Abstract Heart failure (HF) is the most common cause of pulmonary hypertension (PH), and reduced exercise capacity and exertional dyspnea are the most frequent concerns in patients with PH-HF. Indeed, carbon dioxide end-tidal partial pressure (PETCO 2 ) during exercise is a well-established noninvasive marker of ventilation/perfusion ratio in PH. We aimed to evaluate the effect of aerobic exercise training on PETCO 2 response during exercise in a 59-year-old woman with PH secondary to idiopathic dilated cardiomyopathy. The patient with chronic fatigue and dyspnea at mild-to-moderate efforts was admitted to a cardiorespiratory rehabilitation program and had her cardiorespiratory response to exercise assessed during a cardiopulmonary exercise testing performed before and after three months of a thrice-weekly aerobic exercise training program. Improvements in aerobic capacity (23.9%) and endurance time (37.5%) and reduction in ventilatory inefficiency (-20.2%) was found after intervention. Post-intervention improvements in PETCO 2 at ventilatory anaerobic threshold (23.3%) and change in PETCO 2 kinetics pattern, with progressive increases from rest to peak of exercise, were also found. Patient also improved breathing pattern and timing of ventilation. This case report demonstrated for the first time that aerobic exercise training might be able to improve PETCO 2 response during exercise in a patient with PH-HF.

The effectiveness of cardiac rehabilitation in non-ischemic dilated cardiomyopathy patients: A pilot study.

BACKGROUND/PURPOSE: We aimed to investigate the efficacy of cardiac rehabilitation (CR) through parameters of cardiopulmonary exercise testing (CPET) and echocardiography in non-ischemic dilated cardiomyopathy (DCM) patients. METHODS: We retrospectively identified non-ischemic DCM patients through medical records (between October 2011 and October 2018) in rehabilitation outpatient-clinics. Patients were divided into rehabilitation and control groups. Patients in the rehabilitation group eligible for inclusion had CR for 3-6 months. Control group patients were without rehabilitation. We recorded CPET and echocardiography parameters at the baseline and follow-up time-points. For safety evaluation, we investigated all adverse effects during training sessions. We utilized Mann-Whitney U test for between- and Wilcoxon signed-rank test for within-group comparisons. RESULTS: Twenty-five patients (14 in rehabilitation and 11 in control group) were included. In the rehabilitation group, significantly increased peak V˙O2/kg, peak V˙O2%, peak workload and peak O2 pulse were observed after completing CR, and echocardiographic parameters including left ventricular ejection fraction and end-systolic volume. Rehabilitation group patients demonstrated better improvement (change from the baseline) in peak V˙O2/kg, peak V˙O2% and peak workload vs. control. No adverse effects during rehabilitation trainings were observed. CONCLUSION: For non-ischemic DCM, rehabilitation led to superior cardiopulmonary outcomes vs. no rehabilitation, without adverse effects.

What Is the Optimal Exercise Prescription for Patients With Dilated Cardiomyopathy in Cardiac Rehabilitation? A SYSTEMATIC REVIEW.

PURPOSE: Dilated cardiomyopathy (DCM) is 1 of the major causes of advanced heart failure. However, relatively little is known about the effects of exercise specifically in patients with DCM. This purpose of this literature review was to identify optimal exercise training programming for patients with DCM. METHODS: A systematic review was conducted by 3 clinical specialists and the level of evidence of each study was rated using Sackett's levels of evidence. Multiple databases (PubMed Central, EMBASE, and EBSCO) were searched with the inclusion criteria of articles published in English. RESULTS: A total of 4544 studies were identified using the search strategy, of which 4 were included in our systematic review. The exercise frequency of the reviewed studies ranged from 3 to 5 times/wk, and exercise intensity was prescribed within a range from 50% to 80% of oxygen uptake reserve. Exercise time was as high as 45 min by the final month of the exercise prescription. Exercise type was mainly aerobic exercise and resistance training. The average improvement of exercise capacity was 19.5% in reviewed articles. Quality of life also improved after intervention. CONCLUSIONS: According to this systematic review of the literature, data related to exercise therapy specifically for patients with DCM are scarce and exercise interventions in articles reviewed were prescribed differently using the FITT (frequency, intensity, time, and type) principle. Exercise intensity tailored to individual exercise capacity should be used for optimal exercise prescriptions that are safe and efficacious in patients with DCM.

Effects of Lower Limb Cycle Training on Echocardiographic Parameters of Left Ventricle in Dilated Cardiomyopathy Patients.

OBJECTIVE: To determine the effect of lower limb ergometric training on echocardiographic parameters of left ventricle in dilated cardiomyopathy (DMC) patients. STUDY DESIGN: Randomized control trial. PLACE AND DURATION OF STUDY: Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan, from September 2016 to February 2017. METHODOLOGY: Clinically stable patients with DCM (n=60), were randomly allocated into an interventional group with two-month interventional program and a non-trained control group (n=30 each). Treatment protocol for interventional group was lower limb ergometer exercise for 8 weeks, 4 days/week. Pre and post-treatment echocardiography was done in both groups at baseline and after 8 weeks. SPSS 21 was used for data analysis. RESULTS: The median (IQR) age of the patients was 51 (18) years in interventional group and 62 (11) years in control group. Male to female ratio was 18:9 in control group and 17:12 in Interventional group. Statistically significant results were detected within the groups regarding ejection fraction (EF), left ventricular internal dimension systole (LVIDS) and left ventricular internal diastolic dimension (LVIDD) (p <0.001). CONCLUSION: Exercise training with lower limb ergometer was effective in improving the ejection fraction and left ventricular dimensions in patients with dilated cardiomyopathies.

Cardiac Rehabilitation Improves Cardiometabolic Health in Young Patients with Nonischemic Dilated Cardiomyopathy.

Nonischemic dilated cardiomyopathy is deadly and costly, and treatment options are limited. Cardiac rehabilitation has proved safe and beneficial for adults with various types of heart failure. Therefore, we retrospectively evaluated the hypothesis that rehabilitation is safe and improves cardiometabolic health in young patients with nonischemic dilated cardiomypathy. From 2011 through 2015, 8 patients (4 males) (mean age, 20.6 ± 6.6 yr; range, 10-31 yr) underwent rehabilitation at our institution. They were in American Heart Association class C or D heart failure and were on maximal medical therapy. Their mean left ventricular ejection fraction at baseline was 0.26 ± 0.15. Two patients had a left ventricular assist device, and 2 were inpatients. To evaluate safety, we documented adverse events during rehabilitation sessions. Clinical endpoints were measured at baseline, immediately after completing rehabilitation, and after one year. Patients attended 120 of 141 possible sessions (85%), with no adverse events. There were no marked changes in mean left ventricular ejection fraction or body mass index. The patients' mean waist circumference decreased by 1.37 ± 0.6 in (n=5; 95% CI, -2.1 to -0.63). Their 6-minute walk distance increased by a mean of 111 ± 75 m (n=5; 95% CI, 18-205). In our small sample of young patients with nonischemic dilated cardiomyopathy, cardiac rehabilitation was feasible and was associated with minimal risk. Our findings suggest that prospective studies in this population are warranted.

Prospective randomized trial of moderately strenuous aerobic exercise after an implantable cardioverter defibrillator.

BACKGROUND: Despite its salutary effects on health, aerobic exercise is often avoided after receipt of an implantable cardioverter defibrillator (ICD) because of fears that exercise may provoke acute arrhythmias. We prospectively evaluated the effects of a home aerobic exercise training and maintenance program (EX) on aerobic performance, ICD shocks, and hospitalizations exclusively in ICD recipients. METHODS AND RESULTS: A total of 160 patients (124 men and 36 women) were randomly assigned who had an ICD for primary (43%) or secondary (57%) prevention to EX or usual care (UC). The primary outcome was peak oxygen consumption, measured with cardiopulmonary exercise testing at baseline and 8 and 24 weeks. EX consisted of 8 weeks of home walking for 1 h/d, 5 d/wk at 60% to 80% of heart rate reserve, followed by 16 weeks of maintenance home walking for 150 min/wk. Adherence to EX was determined from exercise logs, ambulatory heart rate recordings of exercise, and weekly telephone contacts. Patients assigned to UC received no exercise directives and were monitored by monthly telephone contact. Adverse events were identified by ICD interrogations, patient reports, and medical charts. ICD recipients averaged 55±12 years and mean ejection fraction of 40.6±15.7; all were taking ß-blocker medications. EX significantly increased peak oxygen consumption (EX, 26.7±7.0 mL/kg per minute; UC, 23.9±6.6 mL/kg per minute; P=0.002) at 8 weeks, which persisted during maintenance exercise at 24 weeks (EX, 26.9±7.7 mL/kg per minute; UC, 23.4±6.0 mL/kg per minute; P<0.001). ICD shocks were infrequent (EX=4 versus UC=8), with no differences in hospitalizations or deaths between groups. CONCLUSIONS: Prescribed home exercise is safe and significantly improves cardiovascular performance in ICD recipients without causing shocks or hospitalizations. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00522340.

Cardiac rehabilitation in a pediatric patient with heart retransplantation. A single case study.

BACKGROUND: Cardiac rehabilitation (CR) after heart transplantation is known to benefit physical capacity in adults, but the advantages of CR on pediatric patients with heart retransplantation remain undetermined. AIM: The purpose of the present study was to report the effect of structured CR for a boy receiving heart transplantations twice. DESIGN: Single case study. SETTING: Inpatient and outpatient rehabilitation department. POPULATION: A pediatric patient underwent heart transplantation due to dilated cardiomyopathy at 13.6 year-old and retransplantation owing to severe cardiac allograft vasculopathy at 16.2 year-old. METHODS: CR was arranged after both transplantations. Bicycle or treadmill exercises were conducted three times weekly with the intensity adjusted to the ventilatory threshold. Serial cardiopulmonary exercise tests were performed to evaluate the sequential cardiorespiratory function changes using the peak oxygen uptake (VO2peak) as the primary outcome. RESULTS: The patient had undergone 10 times of exercise tests during rehabilitation. The VO2peak increased from 12.27 to 15.63 mL·kg-1·min-1 within 6 months after the primary transplantation. However, the VO2peak dropped intensively after a rejection episode and failed to improve since the development of cardiac allograft vasculopathy. Following retransplantation, the VO2peak appeared worse initially but increased gradually with rehabilitation. One year subsequent to retransplantation, the VO2peak reached 17.7 mL·kg-1·min-1 with a 7.22 mL·kg-1·min-1 improvement compared with his baseline value. CONCLUSION: Structured CR improves aerobic capacity of a pediatric patient with heart retransplantation. CLINICAL REHABILITATION IMPACT: CR is safe and beneficial for pediatrics with heart retransplantation. Cardiopulmonary exercise testing can be considered as an adjuvant tool for detecting rejection or cardiac allograft vasculopathy in pediatric heart transplantation recipients.

Exercise capacity in an individual with LVAD explantation without heart transplantation.

PURPOSE: Left ventricular assist devices (LVADs) have become a viable treatment alternative to heart transplantation, in some instances providing for a level of improvement of native heart function to allow for device explantation. The aim of this case study was to describe changes in physical work capacity following 9 months of LVAD support. CLINICAL CASE: The patient described here was diagnosed with idiopathic dilated cardiomyopathy and demonstrated worsening heart failure over a 5-year period with a maximum left ventricular end-diastolic diameter of 8.99 cm and an ejection fraction of 15% to 25%. Upon implantation of an LVAD, central hemodynamic function improved and the device was removed after 9 months of support. Left ventricular diastolic and systolic diameter decreased by 39.8% and more than 30%, respectively. The left atrium decreased by 21.7% and ejection fraction was maintained by the LVAD and stabilized at 20%. Four months postexplantation, a cycle ergometry graded cardiopulmonary exercise test was performed. Exercise began at 0 W and increased 25 W per 3-minute stage. RESULTS: The patient showed improvement in peak aerobic capacity when compared to pre-LVAD cardiopulmonary stress tests. Peak oxygen uptake increased from pre-LVAD measures of 11.8 mL x kg(-1) x min(-1) to 17.0 mL x kg(-1) x min(-1). Time to maximal exertion increased from 5 minutes 27 seconds to 15 minutes. CONCLUSION: Results of this case study indicate that significant improvements in native heart function leading to an increased ability to perform work is possible following a period of mechanical unloading through LVAD support.

Comparative value of NYHA functional class and quality-of-life questionnaire scores in assessing heart failure.

PURPOSE: To assess the relationships between New York Heart Association (NYHA) functional class, quality of life, aerobic capacity (peak oxygen uptake, (.)VO2), ventilatory efficiency (minute ventilation/carbon dioxide production slope, VE/(.)VCO2 slope), and brain natriuretic peptide (BNP) in creating a model for predicting peak (.)VO2). METHODS: Cardiopulmonary exercise testing was performed in 62 patients. A baseline blood sample was taken to measure the N-terminal prohormone BNP (NT-proBNP). Patients also completed the Minnesota Living with Heart Failure Questionnaire (MLHF) and the Specific Activity Questionnaire (SAQ), and NYHA functional class was determined. RESULTS: NYHA functional class correlated more strongly with SAQ score than with MLHF score. Peak (.)VO2 and VE/(.)VCO2 slope had stronger associations with NYHA functional class and SAQ score than with MLHF score. NT-proBNP plasma levels correlated more significantly with NYHA functional class and SAQ score (both P < .001) than with MLHF score. Using multiple linear regression analysis adjusted for age and sex, SAQ score, NT-proBNP, and etiology of heart failure had significant independent relationships with peak (.)VO2, explaining 63% of its variability (adjusted R(2) = 0.596). CONCLUSIONS: Cardiopulmonary exercise variables and plasma NT-proBNP are associated more with NYHA functional class and SAQ score than with MLHF score. When combined, SAQ score, NT-proBNP, and etiology of heart failure can satisfactorily predict peak oxygen uptake.

Cardiac re-synchronization therapy: effects on myocardial perfusion at rest, after vasodilation and oxygen consumption.

AIM: Cardiac resynchronization therapy (CRT) has been shown to improve haemodynamics and clinical symptoms in heart failure patients. The present study evaluated the effects of a 4-month CRT on myocardial blood flow (MBF) at rest, after vasodilation and on myocardial oxygen consumption (MVO(2)). PATIENTS, METHODS: We studied 16 patients with idiopathic dilated cardiomyopathy prior to and during CRT performed as biventricular pacing. Resting MBF and MVO(2) were determined from an (11)C-acetate PET study and vasodilator MBF from a (13)N-ammonia study. RESULTS: MBF at rest (0.55 +/- 0.10 ml/min/g), after vasodilation (1.20 +/- 0.45 ml/min/g), and MVO2 (0.082 +/- 0.014/min) did not change by mid-term CRT at a global level (0.57 +/- 0.11 ml/min/g; 1.32 +/- 0.49 ml/min/g; 0.085 +/- 0.018/min), whereas the rate pressure product (RPP) normalised MVO(2) decreased from 0.104 +/- 0.024 to 0.086 +/- 0.018/min (p = 0.02). At baseline, the regional analysis revealed significantly higher values for all parameters in the lateral wall than for those in the other walls. Under CRT the regional differences between the resting parameters equalized and all parameters showed significant lower coefficients of variation. CONCLUSION: Effects of mid-term CRT on resting MBF, vasodilator MBF and MVO(2) occur at a regional level. The resynchronization is associated with a more homogenous distribution pattern of these parameters among the myocardial walls. Substantial alterations to global MBF at rest, after vasodilation or to MVO(2) are not detectable. Regarding the RPP normalised MVO(2), there is evidence of improved ventricular efficiency through CRT.

Implante de desfibrilador: a propósito de um limiar de desfibrilação elevado / Defibrillator implant: aiming at a high defibrillator threshold

Este artigo tem por finalidade orientar a conduta nos casos de pacientes com taquicardia ventricular sustentada e disfunção grave, encaminhados para implante de desfibrilador, situação cada vez mais frequente. Discute-se a possibilidade de utilizar alternativas cirúrgicas para solucionar situações em que os limiares de desfibrilação permanecem altos durante os testes realizados no momento do implante

Treatment of extensive ischemic cardiomyopathy: quality of life following two different surgical strategies.

OBJECTIVE: To review outcomes and quality of life following two surgical strategies for severe left ventricular dysfunction due to ischemic dilated cardiomyopathy. METHODS: Hospital and follow-up records of 111 patients with extensive ischemic cardiomyopathy (mean age 57.3+/-8.4) referring to our institution between January 1996 and December 2003 were reviewed. Group A included 42 patients (mean age 62.4+/-7.9) with morphological and functional cardiac parameters allowing for ventricular restoration (including endoventricular circular patch plasty, coronary artery by-pass grafting, and, when needed, mitral surgery). Group B included 69 patients (mean age 54.3+/-7.2), undergoing cardiac transplantation. Hospital mortality, treatment-related late mortality, incidence of cardiac events, freedom from cardiac failure, freedom from hospital re-admission, functional recovery at follow-up (3075.2pts/months; 100% complete) and quality of life (WHOQOL test) were assessed. RESULTS: Hospital mortality was 19% in group A and 8.7% in group B (P=0.143). No treatment-related late deaths were observed in group A, while six deaths (9.5%) occurred in group B (P=0.063). Incidence of cardiac events was comparable. At 60 months, freedom from cardiac failure was 93.5+/-0.04 and 86.2+/-0.05%, respectively (P=0.23), freedom from hospital re-admission was 93.5+/-0.04 and 61.3+/-0.07% (P=0.002). Exertion dyspnea was present in 40% patients in group A versus 13% in group B (P=0.006). WHOQOL test showed a satisfying quality of life in both groups, although patients undergoing restoration reached higher scores in the psychological and social domains. CONCLUSIONS: Selected patients with ischemic cardiomyopathy, potentially eligible for transplantation, can be managed by ventricular restoration. In those patients post-operative quality of life is satisfactory, with comparable survival and low risk of re-hospitalization.

[Long survival with chronic ventricular fibrillation under support of uni-left-ventricular assist system].

Few minutes of suspended malignant ventricular arrhythmia may be permitted for the patient with left ventricular assist system (LVAS). However, longer and continuous ventricular arrhythmia, especially ventricular fibrillation (Vf), may induce the low output of LVAS, which leads circulatory collapse immediately. Our presenting case is a female dilated cardiomyopathy patient who has been supported with LVAS. Four months after the LVAS installation, her electrocardiogram has changed to Vf without any symptoms. Her ventricular function has never recovered, even ventricular tachycardia. She has been a candidate of heart transplantation for more than 19 months with this rare hemodynamic condition (LVAS+Vf), like the Fontan circulation. Her performance status is limited due to deceasing of the LVAS flow, which caused by the change of her position: 2.5-2.9 l/min (lie down) to 2.0 l/min (rise). Her peak VO2/W is 6.9 ml/min/kg measured by the cardio-pulmonary exercise test. However, she has developed her general status by doing rehabilitation program and is able to walk for more than 100-150 meters.

Can serum NT-proBNP detect changes of functional capacity in patients with chronic heart failure?

Recently, in a cross-sectional study, a correlation of moderate degree was documented between serum BNP (brain natriuretic peptide) and exercise capacity in patients with chronic heart failure (CHF). However, it remains unknown if BNP, which increases in response to high myocardial wall stress, is sufficiently sensitive for changes in exercise capacity during clinical follow-up. To elucidate this, 42 CHF patients were recruited and randomized into a training (T; 58 +/- 10 years; n = 14 NYHA II; n = 5 NYHA III) and a control group (CO; 54 +/- 9, n = 17 NYHA II; n = 6 NYHA III). T carried out 12 weeks of endurance training on a cycle ergometer (4 sessions per week, 45 min duration). Venous blood sampling and cycle ergometry with simultaneous gas exchange measurements were carried out prior to and after the experimental phase. Due to its superior stability during laboratory procedures, NTproBNP was determined instead of BNP. Both proteins are secreted in equimolar amounts and share an identical diagnostic meaning. In both groups, NT-proBNP decreased slightly (T: from 1092 +/- 980 to 805 +/- 724 pg x ml(-1); CO: from 1075 +/- 1068 to 857 +/- 1138 pg x ml(-1); T vs CO: p = 0.65). Anaerobic threshold (AT) as a measure of exercise capacity went up in T (from 0.96 +/- 0.17 to 1.10 +/- 0.22 l x min(-1)) but remained almost constant in CO (pre: 1.02 +/- 0.27; post: 1.00 +/- 0.27 l x min(-1); T vs CO: p < 0.001). The correlation between changes in NT-proBNP and changes in AT remained insignificant (r = 0.02, p = 0.89)-even if only T was considered (r = 0.09, p = 0.72). Improved exercise capacity in CHF patients due to 3 months of endurance training is not reflected in the course of NT-proBNP. These findings are inconsistent with a sufficient sensitivity of this parameter to detect changes in exercise capacity during clinical follow-up. Changes in NT-proBNP beyond its spontaneous variability are more likely to be detected following therapeutical interventions which aim more clearly at the myocardium. In determining alterations of functional capacity ergometric testing cannot be replaced by serial determinations of NT-proBNP.

Cardiac rehabilitation in patients with implantable defibrillators. Feasibility and complications.

OBJECTIVE: We examined patients with implantable cardioverter defibrillators (ICD) in order to demonstrate their safe participation in a standard rehabilitation program. DESIGN: Prospective cohort study of a consecutive series of patients after ICD implantation. Setting Inpatient rehabilitation center. PATIENTS AND METHODS: A total of 118 patients (73.7% male, mean age 60+/-11 years) took part for 23 +/- 4 days in a standard inpatient rehabilitation program including physical activity, psychological care, heart function seminars, and resuscitation exercises with family members. The following noninvasive tests were performed: symptomlimited exercise testing, two-dimensional echocardiography, Holter monitoring, telemetric ICD interrogation, optional fluoroscopy or X-ray examination of the thorax, and (in some patients) defibrillation threshold testing. RESULTS: Out of 118 patients 101 patients (85.6%) participated in regular ergometer training during which the initial workload of 23 +/- 11 Watts could be increased to 45 +/- 18 Watts. An individual conditioning program was assigned to 15% (n = 17) patients, thereby enabling the inclusion of all patients in the rehabilitation process. Under these conditions 12 patients (10%) experienced ICD malfunctions requiring therapy. As a consequence of all cardiac function tests, ICD reprogramming was necessary in 26 patients (22.1%). CONCLUSION: Following ICD implantation, patients may participate in a standard rehabilitation program without serious complications and with a significant increase in physical capacity. However, ICD malfunction occurs in approximately 10% of patients. Additional tests performed by skilled medical staff and appropriate technical equipment allows the ICD program to be optimized.

[Ambulatory long-term management of a left ventricular assist device. Current modality in terminal heart failure]. / Ambulante Langzeitbetreuung mit einem Linksherzunterstützungssystem. Eine zeitgemässe Modalität in der Behandlung der terminalen Herzinsuffizienz.

We report about the first use and successful outpatient therapy with an implantable pulsatile left ventricular assist device (LVAD, Novacor) in a patient with a combined dilative and ischemic cardiomyopathy in Switzerland. The patient, a 51 year old man (112 kg, 191 cm, blood type A) developed end-stage heart failure (New York Heart Association class (NYHA) IV) while he was awaiting orthotopic heart transplantation. Due to his profession as an independent graphic-designer the patient was afraid of a long-term temporary disablement with consecutive bankruptcy. Therefore we decided and performed the implantation of a Novacor-LVAD as a bridge to transplantation with the possibility to outpatient therapy in a favourable course. The patient was supported by the device for more than five months. His cardiac functional status returned to NYHA class I, and the patient was discharged 5 weeks after implantation. He returned into his normal life and started working at 100% again. Furthermore the LVAD enabled the patient to participate in almost all activities. Five months (151 days) after implantation a donor organ became available and the patient underwent orthotopic heart transplantation. The use and successful outpatient therapy with an implantable pulsatile left ventricular assist device in our patient has proved to be save, reliable, life-saving, quality of life improving and could be an important alternative for the economic burden in heart failure therapy.

[Cardiac rehabilitation in Austria. A need to treat analysis]. / Kardiologische Rehabilitation in Osterreich. Eine Bedarfsanalyse.

The aim of this analysis is to survey the general demand and current supply of cardiac rehabilitation in Austria on the basis of best evidence practice and to produce recommendations for a cost-effective structure of the entire cardiac rehabilitation system. Following the standards of indication of the Austrian Society of Cardiology an analysis of demand of cardiac rehabilitation has been carried out and juxtaposed with the current supply of facilities for cardiac rehabilitation. According to hospitalizations in the year 2000, 11,630 patients per annum would require inpatient phase II rehabilitation, 6,270 patients institutional based outpatient phase II rehabilitation and 14,319 patients institutional based phase III rehabilitation. In the year 2000, 14,746 patients received treatment in the 9 Austrian inpatient cardiac rehabilitation centres. This number is compared with an annual demand of 11,630 admissions for phase-II treatment. It follows that an equilibrium can be argued for the supply of and demand for inpatient cardiac rehabilitation in Austria. At present, 10 approved institutions in Austria offer outpatient cardiac rehabilitation services. The maximum number of positions for treatment per institution is currently 200-250. Consequently, maximally 2,000-2,500 patients per annum can be treated. In comparison, there exists a calculated demand for 6,270 patients in institutional based outpatient phase II rehabilitation and 14,319 patients in institutional based phase III rehabilitation. Altogether this amounts to a demand for 20,588 positions for treatment per annum. In Austria, the expenditures for inpatient phase II rehabilitation of a patient given an average duration of stay of 28 days, are [symbol: see text] 4,774.-. Presuming 100% compliance, the institutional based outpatient phase II rehabilitation program costs [symbol: see text] 2,760.- per patient. The costs for institutional based phase III rehabilitation services are [symbol: see text] 2,990.- per patient. This number is accompanied by a potential effective reduction of risks for the patients and a potential effective reduction of costs for the carrier as the number of rehospitalizations and recurrent procedures would decrease significantly. At present, the supply of cardiac rehabilitation in Austria is sufficient for inpatient phase II, but insufficient for the institutional based outpatient phase II and mainly phase III. Thus, a striking asymmetry exists between supply and demand. In view of the enduring effects of institutional based phase III rehabilitation, the individual and social use and finally the expected efficiency in terms of costs, this program should at least be offered without limits to all eligible patients.