Should patients with heart disease exercise in the morning or afternoon?

OBJECTIVE: To compare the cardiovascular risk of exercise in the morning and afternoon in patients with established heart disease. DESIGN: Retrospective cohort study. PATIENTS: Patients with established heart disease referred for participation in a comprehensive cardiac rehabilitation program. INTERVENTION: Supervised, submaximal exercise (1 hour three times per week) performed either in the morning (7:30 AM) or the afternoon (3 PM). MAIN OUTCOME: Documented cardiac events that occurred while patients were exercising in the rehabilitation programs. RESULTS: There were five cardiac events in 168,111 patient-hours of exercise in the morning, with an incidence of 3.0 +/- 1.3 events per 100,000 patient-hours. There were two events during the 84,491 patient-hours of exercise in the afternoon, for an incidence of 2.4 +/- 1.5 events per 100,000 patient-hours (not significant). The risk ratio of cardiac events during exercise in the morning compared with the afternoon was 1.27 (95% confidence interval, 0.25 to 6.55). CONCLUSION: In patients with coronary artery disease, the incidence of cardiac events is low during regular, submaximal exercise whether performed in the morning or the afternoon.

Cardiovascular events in the 1996 Olympic Games.

Cardiovascular events were few during the 1996 Olympic Games. On-site availability of defibrillators and well-trained medical personnel were life-saving in several instances.

Leila Denmark, MD: practicing medicine at age 100.

Leila Denmark, MD, continues to practice medicine at age 100. Her lifestyle and work ethic are an inspiration in the current era of managed care mania.

Continuous ambulatory electrocardiographic monitoring. Use in cardiac exercise programs.

In order to evaluate cardiac rate and rhythm in 20 patients with coronary atherosclerotic disease who were engaged in a medically supervised exercise program, continuous ambulatory electrocardiographic monitoring was performed during an exercise training class and the subsequent 24 hours, which included activities at work and home. Sixty-five percent (13) of the 20 patients had abnormal findings on recordings. Of the 20 patients studied, 40 percent (eight) had arrhythmias detected by ambulatory recording that had not been detected either by resting or exercise electrocardiograms. Three patients with ventricular ectopis (multiform premature ventricular beats, couplets, and begeminy) had exercise activities temporarily curtailed and therapy with antiarrhythmic drugs begun, with subsequent resolution or improvement. Two other patients (with recorded heart rates of 160 beats per minute) were instructed to carefully monitor their heart rate in order to not exceed the target maximum. We conclude that 24-hour continuous electrocardiographic monitoring is beneficial in evaluating patients in cardiac exercise programs and frequently influences the management of such patients.

Current management of severe exercise-related cardiac events.

Severe cardiac events during either exercise testing or cardiac rehabilitation are described in five patients. The three events related to exercise testing involved patients with atypical chest pain which, in retrospect, probably reflected unstable angina pectoris or coronary vasospasm (or both). Prompt coronary angiography with subsequent percutaneous transluminal coronary angioplasty was performed. Two cardiac arrests (one fatal) occurred during participation in cardiac rehabilitation programs. One was caused by primary ventricular fibrillation. Electrophysiologic testing was used in determining the efficacy of the drug. The fatality was due to an acute myocardial infarction. On-site intravenous thrombolytic therapy might prove useful in similar events in the future. Comparisons of surveys published in the 1970s with those in the 1980s show that the mortality and morbidity during exercise testing remain low and that similar rates during cardiac rehabilitation are even lower; however, these cases exemplify that emergency situations can and do arise, necessitating prompt intervention and aggressive subsequent management.

Management of casualties from the bombing at the centennial olympics.

BACKGROUND: The explosion of a bomb 75 to 100 yards away from attendees at a concert who were in the process of being evacuated from Centennial Olympic Park at approximately 1:25 AM on July 27, 1996, resulted in a multiple-casualty event involving primarily four hospitals in proximity to the blast. The purpose of this study was to review triage and care of the victims, emphasizing those with significant injuries. METHODS: Retrospective review of triage and care of injured patients. RESULTS: Ninety-six of the 111 victims of the blast were triaged in the first half hour to four hospitals within 3 miles of the bombing. Only four minor operations were performed in 61 patients evaluated at community hospitals. Ten of 35 patients evaluated at the regional trauma center underwent emergency or urgent operations, and all who were seriously injured did well. CONCLUSIONS: Although overtriage to the regional trauma center occurred, outcome was excellent in all seriously injured victims treated there.

Preparticipation physical evaluation: getting to the heart of the matter.

The cardiovascular evaluation is an important component of the preparticipation physical examination of the athlete. The history should be standardized to include questions ranging from those about chest pain and palpitations to ones about syncope. The physical examination should not be a perfunctory one, but rather a careful search for findings that might include a low grade heart murmur that accentuates with Valsalva'a maneuver (suggestive of hypertrophic cardiomyopathy, the leading cause of sudden death in a competitive athlete). The cardiovascular risks to the athlete are known. Fortunately, only a small percentage of athletes who are screened have such abnormalities. The validity of such screening remains to be proven. Recommendations are provided to make the present approach more time efficient and perhaps more cost effective.

The athlete's heart syndrome.

The athlete's heart is a benign condition, associated with physiologic alterations that can be detected on physical and laboratory examination. Echocardiography is a particularly useful technique is quantitating cardiac adaptation to exercise training and in screening for cardiovascular disorders that can be deleterious to the athlete. Cardiomyopathies are common causes of sudden death in young athletes, and myocarditis in physically-active young military recruits. Coronary disease is usually implicated in middle-aged athletes such as distance runners. Recent well-publicized deaths in several athletes have focused more attention on the need to detect Marfan's syndrome and cocaine use. Published guidelines such as the 16th Bethesda Conference and recent medical advances like new antihypertensive and antiarrhythmic drugs assist the clinician in counseling and managing athletes with cardiovascular disorders.

Cardiac rehabilitation in Germany.

The concept of cardiac reconditioning centers for the prevention and rehabilitation of coronary patients has been tremendously successful in Germany over the past 20 years. At least 40 such centers are located throughout the country. Physicians, nurses, and physical therapists work closely together in the various facets of the rehabilitation process. The financial backing for these facilities is primarily through governmental and regional insurance companies, whose officials are apparently convinced that in the long run supporting preventive measures is financially sound. Objective data supporting their convictions come from studies such as that of Brusis, who showed that such as that of 1,500 employees was diminished by nearly 70 percent during a two-year period after cardiac reconditioning, as compared to a similar time period before the rehabilitation experience. Subjective benefits, which are extremely difficult to quantitate in meaningful terms, were nonetheless expressed by nearly all the patients with whom I conversed. Perhaps they have experienced the same feelings that Mark Twain did when he observed that "all frets and worries and chafings sank to sleep in the presence of the benignant serenity of the Alps; the Great Spirit of the Mountains breathed his own peace upon their hurt minds and sore hearts and healed them."

Jeremiah Stamler.

Jeremiah Stamler has had a major impact on the primary and secondary prevention of cardiovascular disease. His work began in the animal experimental laboratory and shifted to large-scale epidemiologic studies and clinical trials, resulting in nearly 800 contributions to the world medical literature. His influence is felt, not only through these publications and his innumerable lectures, but also... "through the hundreds of young people he has helped train (in the U.S. and abroad), and through the leadership role he has played locally, nationally, and internationally in preventive cardiology... The spirit imbuing the work of Dr. Stamler is a deep concern for human welfare, for the prevention of unnecessary disease, and for the prolongation of healthy life. This same spirit has made his name synonymous also with preservation of civil liberties, international cooperation among scientists of all countries, and efforts to avoid the catastrophe of nuclear holocaust." According to Dr. Geoffrey Rose, Dr. Stamler "... confronted the most devastating health problem of Western Society, cardiovascular disease. He espoused the belief that diet holds the key to its control at a time when that belief was widely considered to be false and its proponents a little crazy. That is now accepted wisdom, and the fact that in many countries at last the problem is in decline is due to this man more than to any other."

Nicolai S. Korotkoff (1874-1920).

As a 31-year-old surgeon, with special interest in vascular disease, Korotkoff discovered the sounds of the blood pressure in 1905 while working on his doctoral thesis. After publication of the latter, he wrote nothing further about his remarkable discovery. As is often the case, others picked up on it, however, and the technique of measuring arterial blood pressure changed from one of touch to one of hearing. If not for Nicolai Korotkoff's astute observation, writes Dock, "we might still be unable to estimate diastolic pressure without trauma or use of complex devices."

Exercise and coronary heart disease: role in primary prevention.

Physical fitness programs for healthy people have gained popularity throughout the world. Available scientific studies, none of which is ideal, suggest that those engaged in vigorous activity at work or in leisure hours have a reduced risk of coronary events. The possible mechanisms for this have been reviewed. A balanced exercise program (including endurance, flexibility, and strength activities) should be prescribed on an individual basis, after appropriate baseline testing. Target heart rates should be assigned. Risks and precautions should be discussed.

Eight steps to inpatient cardiac rehabilitation: the team effort-methodology and preliminary results.

The effects of a team approach in cardiac rehabilitation were investigated in 89 postmyocardial infarction patients. Team members followed an eight-step protocol in caring for the patients during the hospitalization phase. Risk factor modification data were collected at a mean time of 13.5 months after hospitalization. The investigated parameters included work, dietary and exercise habits, body weight, high blood pressure and cigarette smoking. Fifty-six per cent (42 of 75) of the survival group were actively working, 66 per cent (49 of 75) were adhering to a fat-controlled diet, 77 per cent (58 of 75) continued an exercise regime, 70 per cent (40 of 57) lost excess body weight, 91 per cent (21 of 23) had their blood pressure controlled and 60 per cent (27 of 45) stopped smoking cigarettes. It is concluded that an in-hospital team approach in rehabilitation of postmyocardial infarction patients is beneficial in long-term risk factor modification.

Sexual activity in exercising patients after myocardial infarction and revascularization.

In order to evaluate the effects of exercise training on coital habits after myocardial infarction and revascularization, questionnaires were mailed to 130 patients enrolled in a gymnasium exercise program. Of 87 (67%) responding, 68 had experienced myocardial infarction and 19 had undergone myocardial revascularization. The postinfarction group significantly decreased their frequency of coitus after infarction by 28%; the revascularization group, however, decreased activity by only 10%. The myocardial infarction group waited 9.4 weeks after infarction to resume sexual intercourse, while the revascularization group waited a mean of only 5.7 weeks. These data suggest that physically trained post-myocardial infarction patients decrease frequency of coitus significantly more than physically trained patients with myocardial revascularization. The overall decrease, however, is notably less than that reported in nontrained post-myocardial infarction patients and suggests a "bedroom benefit" of medically supervised exercise in selected patients after infarction or revascularization.

Cardiovascular aspects of running.

Running is an excellent means of conditioning the cardiovascular system. It is a highly aerobic activity that utilizes both fatty acids and carbohydrates for energy. The typical runner tends to have a slow resting pulse rate and a high maximal oxygen consumption. Echocardiographic studies show that distance runners have larger, thicker left ventricles than do sedentary controls; their hearts are more efficient than those of sedentary people, pumping a larger volume per beat. Physiologic findings on examination of well-trained runners can sometimes be confused with pathologic entities. The "athlete's heart," once believed to be an abnormal condition, is now recognized as representing a highly efficient organ. Runners are not immune to organic heart disease. Careful physical examination of the cardiovascular system, the resting EKG, and echocardiography are useful ways to screen young competitive athletes for cardiomyopathy, the leading cause of sudden death in this age group. Treadmill testing is often used as a screening test in middle-aged and older runners for underlying coronary atherosclerotic heart disease, the leading cause of sudden exercise-related death in this age category. Radionuclide exercise scans and, on occasion, coronary angiography will be of use when the diagnosis of coronary disease is still in doubt. Distance running has positive effects on a host of coronary risk factors, which may help to explain why chronic endurance exercise is associated with lower coronary death rates.

Marfan's Syndrome: Detection and Management.

In brief: Marian's syndrome has gained increased attention and interest recently, more so since the death of volleyball star Flo Hyman last January. The disorder was first described by French pediatrician Antoine Bernard-Jean Marfan in 1896, although it may not have been the same syndrome as we know it today. Current thought suggests a defect in collagen-the fibrous material found in bones, joints, eyes, heart, and blood vessels. Positive diagnosis requires the presence of at least two of four major features: a positive family history and ocular, cardiac, and skeletal abnormalities. This article reviews the disease and discusses methods of detection and management.

Cardiac Rehabilitation in the Mid-1980s.

In brief: The cardiac rehabilitation program al Georgia Baptist Medical Center in Atlanta, one of more than 700 such programs in the United States, gives an idea of the state of the art. The program consists of training and supervision in exercise, nutrition, and stress management. Inpatient care involves aggressive treatment, early mobilization, and predischarge treadmill testing. Immediately after discharge, patients follow either a prescribed norne exercise regimen or a telemetry-monitored program in the hospital gymnasium. Late-postdischarge patients perform various aerobic exercise routines at least three times a week. Home exercise programs clearly improve cardiorespiratory fitness and save money. Although it is not" yet clear that such Programs reduce mortality, the evidence Joints in that direction.

Is It Angina?

In brief Most chest pain in athletes is brief noncardiac, and it resolves spontaneously or with appropriately directed treatment. But when the patient's medical history suggests angina pectoris, accurate diagnosis of cardiac disease is imperative. If cardiac examination suggests an organic heart murmur in conjunction with angina, or a resting ECG reveals inappropriate left ventricular hypertrophy, Q waves, or repolarization variations, echocardiography should be done to detect hypertrophic cardiomyopathy. A standard exercise ECG is also valuable, though a thallium stress scan may be necessary to exclude a false-positive treadmill test. If these tests are inconclusive, medication trials and other diagnostic tests can help determine the athlete's source of pain.

An irregular pulse in a skydiver.

A 29-year-old man was referred to a cardiologist after an irregular heartbeat was found on a preemployment physical examination. He had no cardiac or pulmonary symptoms.

Can this college athlete compete?

A 20-year-old male college sprinter and hurdler was seen for a cardiology assessment because a preseason cardiac evaluation revealed a heart murmur dating back to early childhood. He was asymptomatic.