Long-term Cardiac Maintenance Programming: A SINGLE-SITE ANALYSIS OF MORE THAN 200 PARTICIPANTS.

PURPOSE: Greater than 65% of all cardiac mortality is related to coronary artery disease (CAD). Cardiac rehabilitation (CR) aims to reduce cardiovascular risk and number of hospital readmissions. Cardiac maintenance programs (CMPs) are designed to sustain or improve health after completing early CR. Although CMPs are supported by most national health guidelines, few long-term studies on these diverse programs have been performed. METHODS: This was a retrospective repeated-measures analysis with case-controlled subanalysis. Within-subject differences for CMP participants were examined between enrollment and last clinical visit. Assessments included medical history, anthropometry, blood analysis, and cardiopulmonary exercise testing. A subset of 20 CMP participants were compared with 20 patients with CAD who chose not to participate in CMP, matched for age, sex, and follow-up duration. RESULTS: A total of 207 patients (60 ± 9 yr, 16% female) were included for the primary analyses. Average follow-up was 6.3 ± 4.8 yr (range 4-20 yr). CMP participants reduced peak workload (1.76 ± 0.56 to 1.60 ± 0.58 W/kg; P < .001) and aerobic capacity (26.1 ± 6.2 to 24.6 ± 7.1 mL/kg/min; P = .003). High-density lipoprotein-cholesterol increased significantly (48 ± 12 to 51 ± 14 mg/dL; P < .001), whereas all other metabolic risk factors remained unaffected. Matched controls had higher functional capacity (2.35 ± 0.81 vs 1.56 ± 0.52 W/kg; P < .001) and lower body mass index (25.3 ± 3.6 vs 28.6 ± 3.9 kg/m2) at baseline, but no significant differences with respect to long-term efficacy were observed. CONCLUSIONS: Long-term participation in CMP did not result in maintaining functional capacity or cardiovascular risk profile in patients with CAD. However, compared with matched nonparticipants, CMP participants (are more deconditioned at baseline) but do not seem to deteriorate as quickly.

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in the Evolution of Cardiac Rehabilitation.

The maturing of a clinical discipline necessitates the ability to document scientific advancements and state-of-the-art reviews with a focus on clinical practice. Such was the case for the field of cardiac rehabilitation in 1981. Whereas a growing body of literature was demonstrating benefits of exercise in cardiac patients with regard to clinical, psychologic, and quality-of-life outcomes,, there were still concerns about the safety of exercise and whether it could be widely adapted in clinical care. Since this was a time period when searches of online databases such as PubMed had not yet been established (began in 1996), there was a great value of concentrating much of the cardiac rehabilitation literature in a single journal.This commentary describes the conceptualization and implementation of the Journal of Cardiopulmonary Rehabilitation and Prevention from 1981 to the present and its acceptance as the official journal of the American Association of Cardiovascular and Pulmonary Rehabilitation and later the Canadian Association of Cardiac Rehabilitation. The commentary also highlights the journal's inclusion in Index Medicus in 1995, its receipt of an impact factor from International Scientific Indexing in 2007, and its publication of many important scientific statements, often in collaboration with major scientific organizations such as the American Heart Association and the American College of Cardiology.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative.

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Pulmonary Disease: Review of Selected Guidelines: AN OFFICIAL STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION.

Chronic obstructive pulmonary disease (COPD) is associated with disabling dyspnea, skeletal muscle dysfunction, and significant morbidity and mortality. Current guidelines recommend pulmonary rehabilitation (PR) to improve dyspnea, functional capacity, and quality of life. Translating exercise science into safe and effective exercise training requires interpretation and use of multiple guidelines and recommendations. The purpose of this statement is to summarize for clinicians 3 current chronic obstructive pulmonary disease guidelines for exercise that may be used to develop exercise prescriptions in the PR setting. The 3 guidelines have been published by the American College of Sports Medicine, the American Thoracic Society/European Respiratory Society, and the American Association of Cardiovascular and Pulmonary Rehabilitation. In addition to summarizing these 3 guidelines, this statement describes clinical applications, explores areas of uncertainty, and suggests strategies for providing effective exercise training, given the diversity of guidelines and patient complexity.

Cardiometabolic risk clustering in spinal cord injury: results of exploratory factor analysis.

BACKGROUND: Evidence suggests an elevated prevalence of cardiometabolic risks among persons with spinal cord injury (SCI); however, the unique clustering of risk factors in this population has not been fully explored. OBJECTIVE: The purpose of this study was to describe unique clustering of cardiometabolic risk factors differentiated by level of injury. METHODS: One hundred twenty-one subjects (mean 37 ± 12 years; range, 18-73) with chronic C5 to T12 motor complete SCI were studied. Assessments included medical histories, anthropometrics and blood pressure, and fasting serum lipids, glucose, insulin, and hemoglobin A1c (HbA1c). RESULTS: The most common cardiometabolic risk factors were overweight/obesity, high levels of low-density lipoprotein (LDL-C), and low levels of high-density lipoprotein (HDL-C). Risk clustering was found in 76.9% of the population. Exploratory principal component factor analysis using varimax rotation revealed a 3-factor model in persons with paraplegia (65.4% variance) and a 4-factor solution in persons with tetraplegia (73.3% variance). The differences between groups were emphasized by the varied composition of the extracted factors: Lipid Profile A (total cholesterol [TC] and LDL-C), Body Mass-Hypertension Profile (body mass index [BMI], systolic blood pressure [SBP], and fasting insulin [FI]); Glycemic Profile (fasting glucose and HbA1c), and Lipid Profile B (TG and HDL-C). BMI and SBP formed a separate factor only in persons with tetraplegia. CONCLUSIONS: Although the majority of the population with SCI has risk clustering, the composition of the risk clusters may be dependent on level of injury, based on a factor analysis group comparison. This is clinically plausible and relevant as tetraplegics tend to be hypo- to normotensive and more sedentary, resulting in lower HDL-C and a greater propensity toward impaired carbohydrate metabolism.

Three 15-min bouts of moderate postmeal walking significantly improves 24-h glycemic control in older people at risk for impaired glucose tolerance.

OBJECTIVE: The purpose of this study was to compare the effectiveness of three 15-min bouts of postmeal walking with 45 min of sustained walking on 24-h glycemic control in older persons at risk for glucose intolerance. RESEARCH DESIGN AND METHODS: Inactive older (≥60 years of age) participants (N=10) were recruited from the community and were nonsmoking, with a BMI<35 kg/m2 and a fasting blood glucose concentration between 105 and 125 mg dL(-1). Participants completed three randomly ordered exercise protocols spaced 4 weeks apart. Each protocol comprised a 48-h stay in a whole-room calorimeter, with the first day serving as the control day. On the second day, participants engaged in either 1) postmeal walking for 15 min or 45 min of sustained walking performed at 2) 10:30 a.m. or 3) 4:30 p.m. All walking was on a treadmill at an absolute intensity of 3 METs. Interstitial glucose concentrations were determined over 48 h with a continuous glucose monitor. Substrate utilization was measured continuously by respiratory exchange (VCO2/VO2). RESULTS: Both sustained morning walking (127±23 vs. 118±14 mg dL(-1)) and postmeal walking (129±24 vs. 116±13 mg dL(-1)) significantly improved 24-h glycemic control relative to the control day (P<0.05). Moreover, postmeal walking was significantly (P<0.01) more effective than 45 min of sustained morning or afternoon walking in lowering 3-h postdinner glucose between the control and experimental day. CONCLUSIONS: Short, intermittent bouts of postmeal walking appear to be an effective way to control postprandial hyperglycemia in older people.

Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation.

Aerobic exercise intensity prescription is a key issue in cardiac rehabilitation, being directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exercise. This joint position statement aims to provide professionals with up-to-date information regarding the identification of different exercise intensity domains, the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training, the effects of the use of different exercise protocols on exercise intensity prescription and the indications for recommended exercise training prescription in specific cardiac patients' groups. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and ramp incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This may allow a shift from a 'range-based' to a 'threshold-based' aerobic exercise intensity prescription, which, combined with thorough clinical evaluation and exercise-related risk assessment, could maximize the benefits obtainable by the use of aerobic exercise training in cardiac rehabilitation.

Cardiac rehabilitation and cardiovascular disability: role in assessment and improving functional capacity: a position statement from the American Association of Cardiovascular and Pulmonary Rehabilitation.

The Social Security Administration (SSA) oversees the disability determination process and the payment of disability benefits to Americans. According to recent SSA data, approximately 900 000 persons are receiving cardiovascular disability payments and about 145 000 adult claims for cardiovascular disability are processed by the SSA annually. An objective and comprehensive examination of functional capacity is an important part of the disability assessment process. This statement reviews various protocols for disability assessment of aerobic capacity, muscle function, and the physical requirements of job tasks. Cardiac rehabilitation programs are ideal settings for conducting comprehensive disability assessments of functional capacity in persons with cardiovascular disease. In addition, exercise training provided by cardiac rehabilitation programs can increase functional capacity in most patients.

Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation.

Aerobic exercise intensity prescription is a key issue in cardiac rehabilitation, being directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exercise. This joint position statement aims to provide professionals with up-to-date information regarding the identification of different exercise intensity domains, the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training, the effects of the use of different exercise protocols on exercise intensity prescription and the indications for recommended exercise training prescription in specific cardiac patients' groups. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and ramp incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This may allow a shift from a 'range-based' to a 'threshold-based' aerobic exercise intensity prescription, which, combined with thorough clinical evaluation and exercise-related risk assessment, could maximize the benefits obtainable by the use of aerobic exercise training in cardiac rehabilitation.

Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation.

Cardiac rehabilitation/secondary prevention (CR/SP) services are typically delivered by a multidisciplinary team of health care professionals. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that to provide high-quality services, it is important for these health care professionals to possess certain core competencies. This update to the previous statement identifies 10 areas of core competencies for CR/SP health care professionals and identifies specific knowledge and skills for each core competency. These core competency areas are consistent with the current list of core components for CR/SP programs published by the AACVPR and the American Heart Association and include comprehensive cardiovascular patient assessment; management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues.

Cardiometabolic risk in community-dwelling persons with chronic spinal cord injury.

PURPOSE: The purpose of this study was to describe cardiometabolic risk factors and risk clustering in people with spinal cord injury (SCI). METHODS: This was a cross-sectional study of 121 subjects aged 18 to 73 years (mean, 37 ± 12 years) with chronic, motor complete SCI between C5 and T12. Assessments included demographic, social, and medical history; physical, anthropometric, and blood pressure assessments; fasting serum assays including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides, and hemoglobin A1c; calculated low-density lipoprotein cholesterol (LDL-C); and an oral glucose tolerance test. Framingham risk scores (FRSs) for each subject were calculated on the basis of Third National Cholesterol Education Program Adult Treatment Panel algorithm. RESULTS: According to FRSs, 90.1%, 8.3%, and 1.7% were classified in the low-, medium-, and high-risk groups, respectively. The most prevalent cardiometabolic risk factors were overweight/obesity (74%), elevated LDL-C (64%), low HDL-C (53%), elevated systolic blood pressure (SBP, 33%), and elevated TC (30%). Stratification by level of injury demonstrated significant differences between paraplegic and tetraplegic participants in SBP (120 vs 99 mm Hg, P = .0001), 2-hour glucose (101.37 vs 137.93 mg/dL, P = .0001), and 2-hour insulin (47.45 vs 94.36 µIU/mL, P = .024). In addition, triglycerides, fasting insulin, body mass index, LDL-C, hemoglobin A1c, and insulin resistance were significantly associated with FRS. CONCLUSIONS: Ten percent of young people with SCI are at moderate to high risk for long-term hard cardiac events. Overweight/obesity, LDL-C, HDL-C, SBP, and TC were the most prevalent risk factors. Carbohydrate metabolism is preferentially affected in persons suffering from tetraplegia, indicating a need for impairment-specific risk assessment.