A new model for risk stratification and delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease.

This model for risk stratification includes variables that classify patients for Risk of Event similar to current models of risk stratification, as well as variables that stratify patients for Risk of Progression of Atherosclerosis by established risk factors. Categories of risk are established using accepted data from the literature for each risk factor that targets regression or plaque stabilization as the goal for Low Risk. A case-rate charging system and the proposed removal of time restrictions for length of cardiovascular rehabilitation fit neatly into the present climate for health care. Health maintenance organizations will be seeking programs that use similar models to address cost issues inherent in cardiovascular rehabilitation programs under current fee-for-service models. Improved outcomes will also be targets for these programs and case-management lends itself to disease management, thus, improved outcomes. Tracking outcomes becomes even more important to both the provider and the insurer because results drive referrals. Likewise, removal of the time restriction for cardiovascular rehabilitation allows programs to individualize care and to target risk factors that are not only most deleterious, but also where patients show readiness for change. The changing environment of health care virtually mandates change in cardiovascular rehabilitation. It is imperative that programs manage the disease process, are effective in achieving outcomes that affect both patient function and the disease process, and are cost effective. This model for risk stratification and delivery of services addresses these requirements and provides a beginning for implementing these changes in cardiovascular rehabilitation.

The feasibility of conducting strength and flexibility programs for elderly nursing home residents with dementia.

A strength and flexibility training program was designed to determine the feasibility of conducting such a program with elderly nursing home residents with dementia. Training sessions included a warm-up and cool-down to improve flexibility, and a variety of strength exercises using Therabands to improve strength. Ten subjects met three times per week for 20 minutes each session. Throughout the program, the number of repetitions and the resistance of the Therabands was increased. At the end of the 11-week training program, improvements occurred in strength and flexibility. We conclude that this strength training program is feasible to conduct for elderly persons with dementia.

Pediatric cardiac rehabilitation.

Sixteen patients participated in a Pediatric/Young Adult Cardiac Rehabilitation Program that included exercise training, education about cardiovascular diseases, dietary counseling, and counseling on stress management. Seven patients completed the program, and complete data were available on six. The subjects demonstrated significant changes in their hemodynamics and exercise tolerance after completing the program. Resting blood pressure decreased by 7%, from 119 +/- 12 to 111 +/- 10 mm Hg; peak oxygen consumption increased by 20%, from 31.9 +/- 4.3 mL/kg of body weight per minute to 38.4 +/- 6.0 mL/kg of body weight per minute; and exercise treadmill time increased by 21%, from 8.5 +/- 1.4 to 10.3 +/- 1.0 minutes. No complications occurred during exercise training or testing. Supervised exercise training at moderate intensity is safe and produces significant and beneficial changes in hemodynamics and exercise time in children with cardiac disease.

Exercise capacity during the first year after cardiac transplantation.

Few data are available examining the influence of perioperative clinical parameters on exercise capacity after cardiac transplantation. Accordingly, 40 patients were studied by metabolic exercise testing early (1 to 3 months) and late (6 to 12 months) after cardiac transplantation. Various clinical parameters, including congestive heart failure class, length of hospital stay, age, cold ischemic time and histologic evidence of rejection were correlated with exercise capacity after transplantation. As expected, peak exercise capacity correlated inversely with both age and length of hospital stay. There was no correlation with preoperative congestive heart failure class or heart rate at rest. Interestingly, there was a statistically significant correlation between cold ischemic time and exercise capacity after transplantation. In addition, increased episodes of rejection during the first 6 months after transplantation resulted in statistically lower exercise capacity at 6 to 12 months after the operation. Thus, ischemic damage during transport of the donor organs and subclinical damage during early rejection may affect clinical status after heart transplantation and may only be apparent during increased physical demand such as exercise.