Razones e inconvenientes. La utilización del ejercicio físico en el sujeto sano y en el cardiópata / Reasons and drawbacks. use of hte physical exercise in the healthy subject and in the cardiac patient

El sedentarismo incrementa la mortalidad cardiovascular y es un factor de riesgo independiente para el desarrollo de coronariopatías. La práctica habitual de ejercicio aumenta la capacidad funcional y desempeña un importante papel en la Prevención Primaria y Secundaria de la cardiopatía isquémica. Los beneficios se producen en sujetos sanos y en los pacientes cardiópatas, incluyendo a los que padecen insuficiencia cardíaca. El aumento en el consumo máximo de oxígeno es consecuencia del incremento en el gasto cardíaco máximo y de la mayor extracción de O2 a nivel de la fibra muscular entrenada. El entrenamiento produce asimismo efectos positivos a nivel hemodinámico, neurohormonal, metabólico y de la función respiratoria. La mortalidad por todas las causas, incluidas las cardiológica, tiene una directa relación el entrenamiento realizado a altos niveles de gasto energético (superior a 2.000 kilocalorías a la semana).Los riesgos de la práctica habitual de ejercicio son muy bajos y pueden reducirse significativamente con una buena planificación del entrenamiento (AU)

[Cardiac rehabilitation in Spain. Preventive cardiology units]. / Rehabilitación cardíaca en España. Unidades de cardiología preventiva.

Secondary Prevention by controlling the main risk factors for atherosclerosis has proved a decrease in death rate and in damage of the obstructive arteries. The Cardiac Rehabilitation Programs are not well developed in Spain and nowadays they include less than the 2% of the feasible patients. The reasons for these are the lack of interest of many Cardiological Services and principally of the Administration which at present does not want to spend part of its budget to new loans although this new type of therapeutics has proved great benefits in the decrease of death rate and evident economical savings due to the diminution of hospital re-entries and Labour Incapacity. It is very important to notice that the 100% of the Spanish population is included in the Social Security and this would help the medical treatment of a high percentage of low risk patients, making use at the same time of the human and technological resources of the Health Centres and Municipal Gyms.

[Heart rehabilitation. Cost-effectiveness analysis]. / Rehabilitación cardíaca. Análisis de coste-efectividad.

OBJECTIVE: Heart rehabilitation programmes improve the quality of life of coronary patients and the prognosis of the illness. Implementing these therapeutic systems into practice would be easier if their economic efficiency was proven. MATERIAL AND METHODS: The expenses created by 180 survivors of a myocardial infarction have been studied at the first and sixth year after the acute episode. The survivors were divided, at random, into two groups of 90. One of them (RG) underwent a rehabilitation programme (physical training, psychological action and control guidelines of risk factors). The other (CG) served as a control. RESULTS: The profits, analyzing the direct expenses (readmissions to hospital) were of 5,074,039 ptas. the first year (CG: 19,901,578; RG: 14,827,539), and of 17,451,910 ptas. at the end of the study (CG: 54,370,249; RG: 36,918,339). Better results were obtained when reviewing the indirect expenses (derived from return to work), since the profits were of 26,000,000 ptas. after the first year (CG: 54,750,000; RG: 28,750,000) and of 209,750,000 at the sixth year (CG: 438,000,000; RG: 228,250,000). The saving per patient was of 272,437 ptas. during the first 12 months and of 2,415,220 at the end of the follow-up. CONCLUSIONS: These results justify the fact that the Public Administration and private Insurance Providers are taking into account the adequacy of implementing these therapeutic systems into practice.

[Secondary prevention and cardiac rehabilitation in Spain. Section of Preventive Cardiology]. / Prevención secundaria y rehabilitación cardíaca en España. Sección de Cardiología Preventiva.

Secondary prevention and cardiac rehabilitation constitute both a unique strategy in the prevention of coronary heart disease. Comprehensive cardiac care must be considered one of the main objectives and the Spanish cardiologists dedicate less attention to it than to other cardiological procedures. Several international recommendations on secondary prevention and cardiac rehabilitation have been published during the last years, and both strategies have shown a good cost-benefit ratio. Several measures for secondary prevention, like reducing cholesterol levels in hypercholesterolaemic patients, and the treatment with aspirin, have also shown a decrease in CHD mortality and total mortality. Cardiac rehabilitation programmes improved some sociolaboral outcomes. In spite of those facts, the Spanish cardiologists pay little attention to secondary prevention and cardiac rehabilitation, as the results of two recently distributed questionnaires show.

[Cardiac rehabilitation. Its historical evolution and current situation]. / Rehabilitación cardíaca. Evolución histórica y situación actual.

Cardiac rehabilitation is a part of secondary prevention of cardiovascular diseases. It started as physical exercise programmes after the acceptance of the early mobilization of myocardial infarction patients. The programmes and recommendations of the World Health Organization, reported in 1964 and thereafter, expanded the development of cardiac rehabilitation and on that time, the first clinical studies were published. Later on, some randomized clinical trials were reported, but their results were not conclusive. Recently, a meta-analysis showed a reduction on mortality of 20-25% after cardiac rehabilitation programmes. The WHO Office at present, recommends the inclusion of rehabilitation programmes onto the secondary prevention measures for cardiac patients. The implementation of such programmes in our country must be considered as very necessary and beneficial.

[Rehabilitation in chronic heart failure]. / Rehabilitación en la insuficiencia cardíaca crónica.

The functional capacity of patients with chronic heart failure usually undergoes significant deterioration. Its decrease can be influenced by a low cardiac output, but is directly related to alterations at the level of the skeletal muscle. Cardiac rehabilitation programmes, which are therapeutic systems of multifactorial action (physical and psychological training, and guidelines for control of risk factors), have shown great benefits in this type of patients. There is an increase in the aerobic capacity, anaerobic threshold, O2 peak, cardiac out put and in the maximum O2 arteriovenous difference. This entails an improvement in functional capacity, which has a very positive influence on the psychological sphere. In view of the small number of cases included in the studies published, it is impossible to get to know the results at a prognosis level. The performance of physical training, which has to be carefully programmed, does not occasion more complications than when performed by low risk groups. There is no evidence proving that physical training deteriorates the ventricular function. The decrease in the ejection fraction found in some patients with very low values at the beginning of the programme could be secondary to other usual factors responsible for the negative evolution of this type of pathology.

[Cardiac rehabilitation and secondary prevention in ischemic cardiopathy]. / Rehabilitación cardíaca y prevención secundaria de la cardiopatía isquémica.

The experience gathered in the last thirty years has proved that cardiac rehabilitation improves the quality of life of the patients and contributes to their early return to work. As it consists in therapeutic systems of multifactorial action (physical training, psychological guidelines and control of risk factors), it can exert a positive influence on the prognosis through each of those actions or their sum. Despite the difficulties in the analysis of these programmes (need for a large number of patients and long follow-up periods), some studies and meta-analysis have proved that the incidence of complications and the mortality rate decrease in rehabilitated patients. Mortality goes down by 20-25% which is similar to the results obtained with perfectly accepted therapies, such a beta-blocking treatment, with the advantage that cardiac rehabilitation is cheaper and produces fewer side-effects. It goes without saying that these systems of prognosis action are complementary in a large number of patients.

[Rehabilitation in ischemic cardiopathy. Results at the level of quality of life and prognosis]. / Rehabilitación en la cardiopatía isquémica. Resultados a nivel de calidad de vida y sobre el pronóstico.

Cardiac rehabilitation programs, by means of physical, psychosocial and risk control factors, intend to improve the life style and prognosis of coronary patients. In this study, we analyzed the results obtained from 349 patients, 310 with acute myocardial infarction and 39 after coronary artery surgery. The average follow up period was 36 months and the average age was 53.9 years. The results showed that 84.3% stopped smoking, 60% returned to work after a heart attack and 51.36% after coronary artery bypass. Functional capacity improved significantly with p < 0.001. Although 50% of the patients considered themselves sexually incapacitated, the number of coitus per month is similar to that of healthy people of the same age. There were 12 new infarctions (1.28 por 100 patients per year), and 11 cardiac-related deaths (1.18 per 100 patients per year). All the deaths occurred in the group of patients with myocardial infarction, and with a significant increase in the elevation of the ST in the necrosis area, during an exercise testing, indicating extensive areas of dyskinesis. Based on these results, we have reached the conclusion that steps must be taken to reduce the high percentage of patients who leave the program. In our study this was significantly low at 21.5%.

[Inter- and intra-atrial blocks]. / Bloqueous inter e intraauriculares.

Inter and intra atrial-blocks are secondary to disorders in the conduction through the auricles of the sinusal impulse. These blocks are a consequence of important relays in the stimulation of the left auricle in respect to the right one. In these intra-atrial blocks there are two areas to auricular level, responding to different rhythms, because they are separated by a bi-directional block. In this paper we present three patients with various diseases; the first showed a persistent inter-atrial block, and the other two tanscient, intra-atrial blocks which persist through the whole acute process causing the interment of the patient in our Hospital.

[Pseudocoarctation of the aorta. Association with cardiopathy or vasculopathy]. / Pseudocoartación de la aorta. Asociación con cardiopatía o vasculopatía

Two cases of aortic pseudocoarctation were presented, the first one associated to rheumatic heart disease and the other one with an added obstruction of the left subclavian artery due to an angulation. The alterations of the subclavian arteries due to obstruction have been described very few occasions because they are usually asymptomatic. In our case there was only tiredness of the affected limb. The association of pseudocoarctation with rheumatic heart disease has been never reported, but we consider it to be just a mere coincidence. After reviewing what has been reported, we conclude that since the aortic pseudocoarctation is a benign sickness, the only thing to be done is to check these patients periodically.