Professional Documents
Culture Documents
Number
subjects
Mean
lvef(%)
Etiology
Program
duration
Adaptions due to
training
Belardinelli et al (J
Amer Coll Cardiol
1995;26:975982)
27
30
CAD-DCM
8 wk
Kavanagh et al (Heart
1996;76:4249)
30
22
CAD-DCM
52 wk
Wilson et al
(Circulation
1996;94:15671572)
Demopoulos et al
(J Am Coll Cardiol
1997;29:597603)
32
23
CAD-DCM
3 mo
16
21
CAD-DCM
12 wk
11
30
>6 mo post-MI
or CABG
36 mo
11
31
>2 yr post-MI
60 mo
12
21
CAD-DCM
4 wk
Endothelial function
22
CAD-DCM
3 mo
14
ADP/ATP, adrenaline diphosphate/triphosphate; a-v, arteriovenous; CAD, coronary artery disease; DCM, dilated cardiomyopathy; HEART RATE,
heart rate; [K+]a, arterial potassium concentration; LVEF, left ventricular ejection fraction (%); MI, myocardial infarction; mo, months; NA, noradrenaline; PCr, phosphocreatinine; QoL, quality of life; RR, relative risk; Symp, sympathetic activity; TRP, total peripheral resistance; Vagal,
vagal activity; VO2, peak oxygen consumption (mL, min-1. kg-1); wk, weeks.
EFFECTS OF TRAINING ON
POSTINFARCT REMODELING
Myocardial remodeling is a term that has
been used to describe the adaptations of the heart
during the months following an MI. These adaptations may include myocardial wall thinning,
aneurysm formation, expansion of the infarct
area, and ventricular dilatation. These responses
CHAPTER 14
severe global left ventricular dilation, left ventricular shape distortion, and scar thinning after periods
of training.15,16,137 However, subsequent controlled
trials among humans did not confirm these
findings.125,127,129,132,138-140 Giannuzzi et al138 completed a multicentric controlled trial of exercise
training in Italy. After 1 year, patients in both the
trained and control groups whose ejection fractions were equal to or less than 40% demonstrated
some degree of additional global and regional dilation. Importantly, however, training had no effect
on this response, and there was no effect in either
group among patients with ejection fractions more
than 40%. These investigators also completed a
larger randomized trial in patients with left ventricular dysfunction after an MI.137 After 6 months,
patients in the control group demonstrated
increases in both end-systolic and end-diastolic volumes, and a worsening in both wall motion abnormalities and regional dilation relative to patients
in the exercise group. The latter study was the first
to suggest that an exercise program may actually
attenuate abnormal remodeling in patients with
reduced ventricular function.
Data from Switzerland using MRI confirm that
exercise training in patients with reduced left
ventricular function following an MI is effective
in improving exercise capacity,124,127,132 and supports the recent Agency for Health Care Policy and
Research recommendations141 that this modality is a useful adjunct to medical therapy in these
patients. Training did not cause further myocardial damage (i.e., wall thinning, infarct expansion,
changes in ejection fraction, or increase in ventricular volume),124,132 nor were there any longterm changes (1-year follow-up) in these measures
assessed using MRI.127 The application of MRI to
assess the remodeling process by this group represents a significant advance in precision over previous studies.
Most recently, Giannuzzi et al129 randomized
90 patients with heart failure into a 6-month exercise program or a control group. Detailed echocardiographic measures of left ventricular size and
function revealed that patients in the trained group
actually attenuated abnormal remodeling. Left ventricular volumes increased in the control group,
but trained subjects showed reductions in left ventricular volumes, and an improvement in ejection
fraction. In addition, trained subjects demonstrated
significant improvements in peak VO2, 6-minute
walk performance, and quality of life, and fewer
hospital admissions for heart failure. This trial provided the most definitive evidence that training in
Cardiac Rehabilitation
491
ELDERLY PATIENTS
The prevalence of coronary disease increases as
the population ages; roughly 25% of individuals
equal to or older than 65 years of age have significant coronary disease. Older coronary patients are
at particularly high risk for disability. There has
been an emphasis on research funding for preventing disability in the elderly, and along with
this has come an interest in the effects of cardiac
492
effects of exercise rehabilitation on exercise capacity, return to work, or quality of life in patients
who have undergone bypass surgery is now
considerable.152-171
These studies differ considerably in terms
of design (many were retrospective), study entry
(some used preoperative exercise tolerance as the
baseline, others used postoperative exercise capacity as the baseline), and duration of follow-up.
Most previous studies only considered patients with
successful surgery that alleviated angina, whereas
our study group included approximately one third
with signs or symptoms of ischemia.
A summary of studies evaluating the effects of
cardiac rehabilitation after bypass surgery is presented in Table 14-12. The evidence would suggest
that patients who have recently undergone bypass
surgery respond to exercise training much the
same was as patients with history of MI (mean
increase in exercise tolerance 30%, with a range
of 7% to 73%). Several observations among these
studies are noteworthy. Fletcher et al157 reported
that patients who participated in a rehabilitation
program had greater exercise capacity, smoked
less, were less often rehospitalized, and were more
often fully employed compared to patients who
dropped out of their program. Similarly, Perk
et al159 demonstrated less medication use and fewer
hospitalizations in patients with history of CABG
who participated in an exercise program. Nakai
et al158 reported an improved graft patency rate at
7 weeks post-CABG among patients who exercised
(98% patency in the exercise group versus 80%
patency in the control group), as documented by
coronary angiography. In two randomized studies,
Dubach et al164,165 observed that among patients
who were randomized 1 month after surgery, control patients improved their exercise capacity to a
similar extent as patients who participated in the
1-month concentrated residential programs typical of central Europe. This finding may reflect
something unique about the spontaneous time
course of healing after bypass surgery, or that
1 month does not provide an adequate training
stimulus, or both.
In the PERFEXT study,171 CABG patients represented a third of the total study group. Among
53 CABG patients who were randomized, 28 were
in the exercise-intervention group and 25 in the
control group. This was a unique opportunity
to evaluate the effects of CABG in rehabilitation
because the numbers were fairly high, radionuclide
changes were assessed, and, unlike many studies, it
was a controlled trial. The mean time from surgery until entry into the study was 2 years, with a
CHAPTER 14
Cardiac Rehabilitation
TA B L E 1 4 1 2 .
Summary of studies evaluating the effects of cardiac rehabilitation after bypass surgery
Investigator
Study design
No. of
subjects
Oldridge 1978
Prospective
Gohlke 1982
Waites 1983
Kappagoda 1983
Study entry
Duration
21
1 week postsurgery
32 mo
Retrospective
Retrospective
Randomized,
prospective
Retrospective
467
22
30
postsurgery
9 mo postsurgery
12 days postsurgery
5 yr
6 mo
9 mo
204
44 days postsurgery
4 mo
Randomized,
prospective
Retrospective
Prospective
53
Mean 2 yr postsurgery
1 year
54
96
30 days postsurgery
1014 days postsurgery
12 wk
1 year
147
6 wk postsurgery
1 year
28
1 mo postsurgery
3 mo
42
25 days postsurgery
4 wk
Goodman 1999
Adachi 2001
Randomized,
retrospective
Randomized,
crossover
Randomized,
prospective
Prospective
Prospective
31
57
810 wk postsurgery
2 wk postsurgery
12 wk
2 wk
Kodis 2001
Retrospective
1042
68 wk postsurgery
6 mo
Stevens 1984
Froelicher 1985
Maresh 1985
Ben-Ari 1986
Hedback 1990
Dubach 1993
Dubach 1995
REHABILITATION AFTER
PERCUTANEOUS CORONARY
INTERVENTION
The exponential growth in percutaneous transluminal coronary angioplasty (PTCA) since its first
clinical application in 1977 by Andreas Gruentzig
493
% Change in
exercise capacity
Exercise: 28%
Control: 3%
Exercise: 37%
Exercise: 25%
Exercise: 73%
Control: 29.6%
Supervised: 19%
Unsupervised: 18%
Exercise: 7.1%
Control: 2.9%
Exercise: 56%
Exercise: 81 watts
Control: 61 watts
Exercise: 32%
Control: 23%
Exercise: 16%
Control: 19%
Exercise: 11%
Control: 14%
Exercise:13%
Exercise: 42%
Control: 4%
Exercise: 21%
494
who received usual care post-PTCA without rehabilitation. They found a higher physical work
capacity and ejection fraction in the rehabilitation
group compared to controls, and lower total cholesterol, lower LDL, and higher HDL as well. There
was no difference in the rate of restenosis at 5.5
months of follow-up. Further work by this group
documented a higher return to work after their
program.176 In Japan, Kubo et al177 recently evaluated the effects of exercise training on the development of restenosis after PTCA. Single photon
emission computed tomography (SPECT) imaging was performed 1 and 13 weeks after PTCA in
18 patients who underwent exercise training and
20 controls. After the study period, the restenosis
rate was 17% in the exercise group versus 40%
among controls. Patients in the exercise group
demonstrated improvements in exercise capacity
and significantly improved SPECT redistribution
images, whereas these variables remained
unchanged among controls.
The results of the PCI versus Exercise Training
(PET) study were recently published.178 This was a
unique trial performed in Germany which will
likely have an important impact for some time.
The PET study was a randomized trial designed
to compare the effects of exercise training versus
standard PCI with stenting on clinical symptoms,
angina-free exercise capacity, myocardial perfusion,
cost-effectiveness, and frequency of a combined
clinical endpoint (cardiovascular death, stroke,
bypass surgery, angioplasty, acute MI, and worsening angina with objective evidence resulting
in hospitalization). A total of 101 male patients
younger than or equal to 70 years of age were
recruited after routine coronary angiography and
randomized to 12 months of exercise training
(20 minutes of bicycle ergometry per day) or to
PCI. Cost-efficiency was calculated as the average
expense (in U.S. dollars) needed to improve the
Canadian Cardiovascular Society class by 1 class.
The results demonstrated that exercise training
was associated with a higher event-free survival
(88% versus 70% in the PCI group) and increased
maximal oxygen uptake (+16%). To gain 1 Canadian
Cardiovascular Society class, $6956 was spent in
the PCI group versus $3429 in the training group.
Compared with PCI, the 12-month program of
regular physical exercise resulted in superior eventfree survival and exercise capacity at lower costs,
notably owing to reduced rehospitalizations and
fewer repeat revascularizations. This landmark trial
was the first to directly compare cardiac rehabilitation with an invasive intervention in a randomized
RETURN TO WORK
The presumed inability to resume gainful employment can contribute greatly to a patients loss of
self-esteem and perceived economic impotence. A
concerted effort by the medical/rehabilitation team
must be directed to allay these concerns.179 A symptom-limited exercise test, if normal, can do much to
encourage and reinstill confidence in patients to
resume their job-related activities. Conversely, an
exercise test showing a lower exercise capacity can
be used to guide a patients level of activity at work.
Occupational evaluation and counseling
was shown to be of benefit by Dennis et al,180 who
decreased the time interval between infarction
and return to work by an average of 32% by counseling low-risk patients. Cost-benefit analysis of
these same patients revealed that total medical
costs per patient during the 6 months post-MI were
lower by $502, and their occupational income generated during this same time period was $2102
greater.181 The fact that people are working longer
into their later years, and 80% of patients younger
than 65 years of age eventually return to work after
their MIs underscores the fact that many patients
with history of MI can benefit from this type of
counseling. Engblom et al182 assessed the effects
of a rehabilitation program 5 years after CABS in
Finland. The patients who were randomized to an
exercise program after their surgery demonstrated
better physical function scores (Nottingham
Health Profile), better perception of health, and
better perception of quality of life compared to
controls. However, a greater proportion of these
patients were working only at the 3-year evaluation (not at 4 or 5 years). The Agency for Health
Care Policy and Research Guidelines on Cardiac
Rehabilitation141 summarized the results of 28
studies, and the results of the effects of rehabilitation on return to work were mixed. Return to work
is a complex issue that is influenced by social and
political factors, economic incentives or disincentives to resume working, employer attitudes, and
preillness employment status of the patient.141 Few
of these factors have been considered in studies on
the effects of rehabilitation on return to work, and
this remains an area in need of further study.
CHAPTER 14
RISK-FACTOR MODIFICATION
Given the recurrence rate of reinfarction and
overall cardiovascular mortality in survivors
of MI, theoretical benefits of risk factor modification in this high-risk population could be very
significant.183 There have been numerous efforts
to assess the effects of controlled, multifactorial
risk-factor reduction programs on cardiovascular
risk. Exercise training programs alone have inconsistent effects on smoking cessation, lipids, and
body weight.141 However, multifactorial programs
including exercise, lipid-lowering therapy, dietary
education and counseling, and other interventions
have been demonstrated to be effective (Fig. 14-2).
As part of a WHO study, Kallio et al33 performed a
multifactorial intervention combined with cardiac rehabilitation in patients with history of MI
Cardiac Rehabilitation
495
25
Exercise only
Multifactorial
22
20
15
13
10
7
0
Significant
benefit
FIGURE 142
Changes in lipid levels in 18 randomized controlled trials of cardiac rehabilitation by intervention
strategy-exercise only versus multifactorial intervention. (From Agency
for Health Care Policy and Research,
Guidelines for Cardiac
Rehabilitation, 1995).
No difference
496
PREDICTING OUTCOME IN
CARDIAC REHABILITATION
PATIENTS
Cardiac rehabilitation programs can be expensive
and may be difficult to provide to some patients
due to financial reasons, lack of insurance, distance
to the hospital or rehabilitation facility, comorbidities, or other reasons. If a patients likelihood
of improving work capacity could be predicted on
Heidelberg
Schuler 1992
Study population
Length
Intervention
Result (% of sample)
62 (No LM CAD, no
bypass, no
hypercholesterolemia)
1 yr
36 (CAD, stable
symptoms)
1 yr
Progressionintervention (10%)
Control (45%)
No change-intervention (62%)
Control (49%)
Regression-intervention (28%)
Control (6%)
Progression-intervention (28%)
Lifestyle Heart
Trial
Ornish et al 1990
1 yr
Diet (low-fat,
vegetarian) smoking
cessation, stress
management training,
exercise
Lifestyle Heart
Trial
Ornish et al 1998
35 (moderate to severe
CHD, 20 intervention and
20 control)
1 yr and
5 yr
Diet (low-fat,
vegetarian) smoking
cessation, stress
management training
exercise
Schuler et al 1992
1 yr
Low-fat and
cholesterol exercise
>3 hr/week
Schuler et al 1992
1 yr
SCRIP
Haskell 1994
300 (angiographically
detectable
atherosclerosis,
41 females)
4 yr
Bellardinelli 2001
118 randomized to
exercise or control
6 mo
Low-fat and
cholesterol diet,
exercise, weight loss,
smoking
less/cessation, niacin,
lovastatin,
gemfibrozil, probucol
Exercise training
Hambrecht 2004
1 year
Exercise training
Control (33%)
No change-intervention (33%)
Control (61%)
Regression-intervention (39%)
Control (6%)
Progression-intervention (18%)
Control (53%)
No change-intervention (0%)
Control (5.3%)
Regression-intervention (82%)
Control (42.7%)
1 yr (relative change)
Progression-intervention (5.4%)
Control (0%)
Regression-intervention (0%)
Control (4.5%)
5 yr (relative change)
Progression-intervention (27.7%)
Control (0%)
Regression-intervention (0%)
Control (7.9%)
Regression-intervention (38.9%)
Control (5.6%)
No change-intervention (33%)
Control (61%)
Progression-intervention (27.8%)
Control (33%)
Progression-intervention (23%)
Control (43%)
Regression-intervention (32%)
Control (17%)
No change-intervention (45%)
Control (35%)
New lesions-intervention (15%)
Control (14%)
New occlusionsintervention (10%)
Control (14%)
Progression-intervention (50.4%)
Control (49.6%)
Regression-intervention (21%)
Control (10%)
498
CHAPTER 14
Cardiac Rehabilitation
499
From the AHA and AACVPR: Scientific Statement on Core Components of Cardiac Rehabilitation/Secondary Prevention Programs. Circulation
2000;102:10691073.
500
CHAPTER 14
Cardiac Rehabilitation
501
has never been an integral part of medical education, efforts must be made to convince current
practitioners and medical students about the benefits to patients.
Expand Utilization
Although less than 20% of all eligible cardiac
patients are referred to cardiac rehabilitation programs, 100% of all eligible patients could benefit
from some form of cardiac rehabilitation. One reason for this discrepancy may be a physician belief
system that fails to incorporate secondary prevention (e.g., cardiac rehabilitation) into the patients
treatment plan. Physicians should become more
familiar with alternatives to their current practice
and utilize other healthcare professionals to efficiently and economically extend their capacity to
treat their patients. Ideally, specialists who would
determine their needs and individualize a program would see every patient at a rehabilitation
center. All of the modalities of rehabilitation would
be considered (home-based to monitored groups)
without outside pressures to enter patients into
expensive approaches. In addition, eligibility should
be expanded to the elderly, patients with CHF, and
those patients in need of post-surgical intervention. In some circumstances, all the rehabilitation
needed or available might be counseling by a primary care physician. Patients who are more successful in changing their lifestyle behaviors report
that the physicians recommendation had a strong
influence on their willingness to change. Physicians
who are confident and have good counseling skills
are often effective in changing the behavior of
their patients. Physicians with good personal
health habits and positive health beliefs are also
more likely to have a positive influence on their
patients lifestyles. It has even been suggested that
the traditional physical examination in apparently
502
Document Cost-Efficacy
Like all clinical interventions today, cardiac rehabilitation programs must demonstrate to hospital administrators that they are cost effective.
Although such documentation is likely to exist for
many, if not most, programs, few have made the
effort to publish such data. There has been a proliferation of research methodologies in recent years
that consider alternative ways of conducting economic evaluation of healthcare.213 Although this
has added some uncertainty of approach, standardization is coming and decision makers are beginning to consider these findings as they reformulate
the scope of their health insurance coverage.
Importantly, recent studies clearly demonstrate
that cardiac rehabilitation is cost-effective.
Oldridge et al214 performed an economic evaluation of patients 1 year after randomization to
either an 8-week rehabilitation intervention or
usual care and revealed that cardiac rehabilitation
is an efficient use of healthcare resources. Ades et
al215 presented the results of a 3-year economic
evaluation of patients undergoing 12 weeks of
rehabilitation, which revealed that per capita
hospitalization charges for rehabilitation participants were $739 lower than for nonparticipants.
Bondestam et al216 described the effects of early
rehabilitation that relied totally upon the primary
healthcare system on consumption of medical care
resources during the first year after acute MI in
patients 65 years of age or older. Patients from
one primary healthcare district were assigned to a
rehabilitation program, whereas patients from a
neighboring district constituted a control group.
The rehabilitation measures were initiated very
early after the infarction with individual counseling
in the home of the patient and later in the local
health center, where 21% of the patients also joined
a low-intensity exercise group. During the first
3 months there was a significantly lower incidence
of rehospitalization in the intervention group,
expressed both in terms of percentage of patients
and days of rehospitalization. Visits to the emergency department without rehospitalization also
were significantly lower in the intervention group.
After 12 months the differences still remained, with
the exception of no intergroup difference in followup relative to days of rehospitalization. In the
matched groups the same result was seen. Although
readmissions and emergency department visits
generally were well justified in the intervention
group, vague symptoms dominated among the controls. Levin et al217 presented the results of an economic evaluation of patients followed-up for 5 years
after rehabilitation intervention or usual care that
demonstrated that mean patient costs were $8800
lower in the rehabilitation group. These cost-savings
associated with rehabilitation compare favorably to
the cost-effectiveness of other preventive measures,
with the exception of smoking cessation.218
SUMMARY
Cardiac rehabilitation has been going through the
same dramatic changes as the entire healthcare
system. However, its principles have become part
of good medical practice. The outcome for nearly all
clinical interventions carried out for cardiovascular
disease can be improved by lifestyle intervention,
and cardiac rehabilitation has been an important medium for these lifestyle changes. A major
challenge that remains is providing rehabilitation services to a greater proportion of eligible
patients. The emphasis on the health benefits of
physical activity, rather than physical fitness and
the reduction of iatrogenic deconditioning, have
decreased the emphasis on exercise prescription
and the phased approach. Cardiac rehabilitation is
CHAPTER 14
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index
A
Absolute spatial vector velocity (ASVV), in Sunnyside
biomedical exercise electrocardiography program, 8485
as transformation function, 65
formula for, 66
mathematical constructs, 68t, 85
ACC/AHA exercise testing guidelines. See American College
of Cardiology (ACC)/American Heart Association (AHA)
exercise testing guidelines.
ACE (Angiotensin-converting enzyme), during
transplantation, 334
Activity, progressive, during cardiac rehabilitation, 465467
Activity counseling, after myocardial infarction, 324
Adenosine, in nuclear perfusion imaging, 35
Adenosine diphosphate, 2
Adenosine triphosphate, production of, for muscular
contraction, 23
Aerobic capacity, after myocardial infarction, spontaneous
improvement in, 478
Aerobic exercise program, features of, 419
hemodynamic consequences of, 420, 420t
metabolic consequences of, 420, 420t
morphologic consequences of, 420, 420t
Aerobic training, maximal oxygen uptake in, 93
Afterload, 5, 6
Age, definition of, in multivariable analysis, 224
effect of, on athletic sudden death, 452453
on heart rate, 45
on maximal heart rate, 109112, 110t, 111
maximal heart rate vs., 101, 103
in United States Air Force School of Aerospace Medicine
(USAFSAM) study of, 111112, 112
metabolic equivalent vs., 101102, 102
nomograms for, effect on exercise capacity and, 100101,
101, 102
predicting metabolic equivalents, 102104, 105t
relationship to maximal oxygen uptake, 55, 56, 95, 95
vs. disease effects on, maximal cardiac output, 107108
maximal heart rate and, 109
Note: Page numbers in italics refer to illustrations; page numbers followed by the letter t refer to tables.
509
510
Index
B
Bags, Douglas, in gas exchange measurement, 46
Balke protocol, 21t
oxygen uptake slopes in, vs. work rate in, 23t, 44t
Balloon(s), weather, in gas exchange measurement, 46
Baltimore Longitudinal Study of Aging, 147, 366
Baseline wander, cubic spine filter effect on, 65, 67
in computerized electrocardiographic analysis, reduction
of, 65, 67, 86
Bayes Theorem, 73, 196
formula for, 197
nomograms for, 197
sensitivity and specificity of, 198199
vs. multivariate diagnostic techniques, 234
Beat(s), in computerized electrocardiographic analysis,
alignment of, 86
averaging of, 68, 68, 83
classification of, 68
extraction of, 86
Bed rest, during cardiac rehabilitation, 462t, 464, 465
effect of, on maximal heart rate (HRmax), 111112
recommendations for, after acute myocardial infarction,
461
Bernoullis law, 46
Beta-blockers, during exercise testing, 14, 205206, 310
during exercise training, 484486, 487t
effect of, on computerized electrocardiographic analysis,
8485
on maximal oxygen uptake, 411
on multivariable analysis, 205206, 233
on QRS score, 73
on ST-segment, 205206
for atrial fibrillation, 410412
for myocardial infarction, 471
Bicycle ergometry, protocol(s) for, 2022, 21t
oxygen uptake slopes in, vs. work rate in, 23t
regression equations for, 57
supine, cardiac output changes during, 482t
physiologic response to, 115
stroke volume changes during, 482t
vs. upright, 19
vs. Bruce protocol, maximal ST/HR slope in, 74
vs. treadmill testing, 17, 19
maximal oxygen uptake in, 22
Index
C
Cable(s), in exercise testing, 25
CABS (coronary artery bypass surgery). See Coronary artery
bypass surgery (CABS).
Calcification, atherosclerotic, 371
of coronary arteries. See Coronary artery calcification.
Calcium, role of, in muscular contraction, 2
Calcium channel blockers, effect of, on exercise testing, 222
Calibration, in multivariable analysis, 223
Capillaries, changes in, from chronic exercise, 421
Capillary blush, for maximal heart rate determination, 108
Carbohydrate(s), as energy source in muscular contraction, 3
Carbon dioxide, production of, formula for, 49t
ventilatory equivalents of, 5051
Cardiac arrest, exertion-related, during cardiac
rehabilitation, 478
Cardiac catheterization, in prediction of coronary artery
disease, 266
Cardiac death, as cardiac endpoint, 259
noninvasive testing for, predictive value of, 317t
summary odds ratio for, 317322, 318t, 319, 320
Cardiac dyspnea, vs. pulmonary dyspnea, 20
Cardiac endpoints, prediction of, in coronary artery disease,
252257, 257t258t, 261
Cardiac fluoroscopy, of coronary artery calcifications, 372
Cardiac function, exercise capacity and, 9699, 98
Cardiac output, changes in, during supine bicycle exercise, 482t
determinants of, 49
511
512
Index
Index
513
Dalhousie square, 26
DASI (Duke Activity Status Index), 96, 97t
Death, cardiac, as cardiac endpoint, 241
noninvasive testing for, 317t
summary odds ratio for, 317322, 318t, 319, 320
cardiovascular, spectrum of, 260
exertion-related. See Sudden death.
from exercise-induced hypotension, 119
from myocardial infarction, 291
reduction of, animal studies of, 421t
through cardiac rehabilitation, 502
related to physical activity, 435
sudden. See Sudden death.
Dekers (Rotterdam) studies, of computerized
electrocardiographic analysis, 80
Detrano (Cleveland Clinic) studies, of computerized
electrocardiographic analysis, 80
Detry (Belgium) studies, of computerized
electrocardiographic analysis, 80
Diabetes, definition of, in multivariable analysis, 224
silent ischemia with, 160163
in prognostic studies, 278
514
Index
Index
515
516
Index
F
Face masks, in gas exchange measurement, 46
FAI (Functional aerobic impairment), nomograms for, 5758
Family history, of coronary artery disease, definition of, 224
Fasting glucose, aerobic exercise program effect on, 420
Fast-twitch (Type II) muscle fibers, 34
Feinsteins methodologic standards, for studies of diagnostic
test performance, 213215
Fibrinolytic system, aerobic exercise program effect on, 420
Fiducial point, identification of, in computerized
electrocardiographic analysis, 69
Filling pressure, 6
Filter(s), for absolute spatial vector velocity curve, 85
for noise reduction, 65
notched, 66
source consistency, 67
time-varying, 67
Flecainide, associated with exercise-induced ventricular
tachycardia, 206
effect of, on multivariable analysis, 206
Fleisch pneumotacometer(s), in gas exchange measurement,
46
Flowmeter(s), in gas exchange measurement, 46
Fluoroscopy, cardiac, of coronary artery calcification, 372
Force, definition of, 2
Framingham offspring study, 177, 323, 439
Framingham score, 382
Frank lead system, 28, 64
computerized study of, in angina, 70
vs. bipolar lead system, in ST-segment depression, 70
Frank-Starling mechanism, 6, 329
Free fatty acids, as energy source in muscular contraction, 2
Functional aerobic impairment nomogram(s) for, 5758
Functional classification, exercise capacity vs., 9396, 95
questionnaire assessment in, 96, 96t, 97t
G
Gas exchange, 4159
and exercise capacity, 101102, 103104
breathing reserve and, 52
carbon dioxide production and, 50
formulas for, 49t
instrumentation for, 4347
maximal oxygen uptake and, 4748
minute ventilation and, 4850
normal values for, 5658
oxygen kinetics and, 5455
Index
H
Handrails, holding onto, in treadmill testing, 1415
HDL (high-density lipoprotein), aerobic exercise program
effect on, 420
cardiac rehabilitation effect on, 495
exercise training effect on, 434
Heart failure, chronic, blood flow in, 8
outcomes prediction of, through gas exchange, 4748
VD/VT (ventilatory dead space to tidal volume ratio) in,
5152, 51
cardiac transplantation, treatment for severe, 330
congestive. See Congestive heart failure.
exercise testing, role of, for decision-making in, 330
cardiopulmonary, for decision-making in, 333, 334336
oxygen uptake in, during ramp vs. Bruce protocol(s), 22, 24
prevalence in, 330
prognosis in, 330, 334336
Heart rate, aerobic exercise program effect on, 419
impairment of, 112113
normal, 121
response to exercise, influences on, 45
resting, aerobic exercise program effect on, 420
Heart rate reserve, 424
Heat cramps, 452
Heat exhaustion, 452
Heat injury, 452
Heat stroke, 452
avoidance of, 454
Hematuria, in runners, 454
Hemoglobin, arterial, during exercise, 89
High blood pressure, definition of, in multivariable analysis,
224
evaluation of, 406
exercise training effect on, 433
High-density lipoproteins (HDLs), aerobic exercise program
effect on, 420
cardiac rehabilitation effect on, 495
Hollenberg treadmill exercise score, 73
Holter monitoring, treadmill testing vs., in prognostic
studies, 282
Home-based model, of cardiac rehabilitation, 500
HRmax (maximal heart rate). See Maximal heart rate
(HRmax).
517
I
Incremental averaging, in computerized electrocardiographic
analysis, 67
Individualized exercise intensity, 423
Individualized exercise program, evaluation for, 415
Infarction, myocardial. See Myocardial infarction.
Informed consent, for exercise testing, 15
Insulin sensitivity, aerobic exercise program effect on, 420
Intraclass correlation coefficient, definition of, 182
Ischemia, computer-derived criteria for, 7074, 71, 72t
differentiation from left ventricular dysfunction, during
exercise testing, 1
dobutamine echocardiography in, 35
echocardiographic exercise testing in, 35
exercise test responses due to, 250
nuclear perfusion imaging in, 35
silent. See Silent ischemia.
ST-segment normalization in, 140142
ST-segment shift in, 155
transient, in exertion-related cardiac arrest, 453
wall motion abnormality vs., 138140, 141142
Isometric exercise, dangers of, 424
definition of, 17, 419
Isometric work, 467
Isonitrile (Sestimibi) nuclear perfusion imaging, with
exercise testing, 35
Isotonic exercise, definition of, 419
J
J junction, alterations in, during maximal treadmill exercise,
128
Joggers, coronary atherosclerosis in, 448449
Junctional ST-segment depression, exercise-induced changes
in, 134
K
Kaplan-Meier survival curve, for Veterans Affairs prognostic
score, 261
Karvonen formula, 426\4
Krebs cycle, 3
L
Lactate, accumulation of, 52
as determinant of endurance performance, 3
Lactate shuttle, 52
Law of Laplace, 33
LBBB (left bundle branch block), 206207
exercise-induced, 207
518
Index
M
Malignant ventricular arrhythmia(s), evaluation of, 408
Mapping, body surface, in electrocardiography (ECG), 3233
in normal patients, 32
Marathon runners, coronary atherosclerosis in, 448450
Marquette Electronics, computerized exercise systems of, 89
Masks, face, in gas exchange measurement, 46
Mason-Likar lead systems, 2627, 27, 77
Maximal cardiac output, age vs. disease effects on, 107108
Maximal effort, measures of, 114115, 115t
Maximal exercise testing, in atrial fibrillation, 410, 410t
Maximal heart rate (HRmax), age effects on, 109111, 110t, 111
age vs. disease effects on, 109
altitude effects on, 112
bed rest effects on, 111
during arm ergometry, gender differences in, 18, 18t
during bicycle ergometry, 19
during dynamic exercise, 108109, 109t
factors limiting, 108109, 109t
motivation effects on, 112
recording methods for, 108
vs. age, 101, 102
Maximal oxygen uptake (VO2 max), aerobic exercise program
effect on, 419
age factors in, 54, 56, 9596, 95
beta-adrenergic blockade effect on, 411
determinants of, 5, 49
during arm ergometry, gender differences in, 18
during bicycle ergometry, 19
during treadmill testing, vs. bicycle ergometry, 19
measured, nomograms of, 104
resting ejection fraction vs., 98, 98
minimal level of, for physical fitness, 95, 411
in aerobic training, 95
of normal sedentary adults, 95
peak, 48
resting ejection fraction vs., 98, 98
Maximal ramp exercise test, thirty-second moving averages
in, 4647, 48t
Maximal ST/HR slope, in computerized electrocardiographic
analysis, 74
bicycle ergometer vs. Bruce protocol, 74
Maximal testing, vs. submaximal testing, in asymptomatic
screening, 363
Maximal treadmill testing, in PERFEXT, 480, 482t
waveform alterations in, 128, 129
Maximal voluntary ventilation (MVV), 52
McHenry protocol, 21
Mean, trimmed, 87
Measured maximal oxygen uptake, nomograms of, 104
resting ejection fraction vs., 98, 98
Medication(s), effect of, on exercise testing, 14
on exercise-induced ST-segment depression, 149
on multivariable analysis, 205, 233
Men. See Gender.
Metabolic equivalent(s), definition of, 2, 93, 100
prediction of, from age, 104, 105t
vs. age, 102, 102
Minute ventilation (VE), definition of, 48, 50
formula for, 49t
Index
519
N
N (newton), 2
National Exercise and Heart Disease Project (NEHDP), 471
National Institutes of Health (NIH) report on Physical
Activity and Health, 447
Naughton treadmill protocol, vs. Bruce treadmill protocol,
for post-myocardial exercise testing, 294
Nearest-neighbor procedure, 312
NEHPD (National Exercise and Heart Disease Project), 471
New Zealand studies, of exercise testing prognostic value, 304
Newton (N), 2
Newton meter (Nm), 2
Nitrates, long-acting, evaluation of, in exercise testing, 389391
resting systolic blood pressure changes correlated with
exercise capacity, 391
Nm (newton meter), 2
Noise, causes of, during computerized electrocardiography, 65t
definition of, 64
Gaussian distribution of, 87
reduction of, during computerized electrocardiography,
6465
absolute spatial vector velocity curve filtering, 8586
during electrocardiography, 16
during exercise testing, through skin preparation, 25
Nomogram(s), for Bayess Theorem, 197
for Duke Treadmill Score, 255
for exercise capacity, 100107, 101104, 105107t
in normal patients, 101102, 103104, 107t
for functional aerobic impairment, 5758
Noncardiac surgery, cardiac risk stratification by, 402t
patient selection for, 402
with coronary artery disease, 400t
preoperative risk assessment of, ambulatory
electrocardiography monitoring in, 403404
clinical predictors of, 402t, 404405
dobutamine stress echocardiography in, 403
indications for coronary angiography in, 405
myocardial ischemia and exercise capacity in, 402403
myocardial perfusion imaging in, 403
nonexercise stress testing in, 403
recommendations for, 405406
test selection in, 404
520
Index
O
Orthopedic injuries, in athletes, 454
Overfitting, in multivariable analysis, 222
Oxidative phosphorylation, role of, in muscular
contraction, 3
Oxygen, arterial, determinants of, 89
in pulmonary disease, 8
venous, determinants of, 9
ventilatory equivalents of, 5051, 51
Oxygen consumption, myocardial, estimation
of, 121122
Oxygen kinetics, measurement of, 44t, 5455
Oxygen pulse, definition of, 50
ventilatory equivalents and, 5051
Oxygen uptake (VO2), breathing reserve and, 52
carbon dioxide production and, 50
factors affecting, 42, 43t
formula for, 45, 49t
in chronic heart failure, during ramp vs. Bruce protocol(s),
2223, 24
in coronary artery disease, vs. normal patients, 42, 43
instrumentation for, 4547
in data sampling, variability in, 4647, 47, 48t
in expired ventilation collection, 46
maximal. See Maximal oxygen uptake (VO2 max).
minute ventilation and, 4850
myocardial, 1, 2t
oxygen pulse and, 50
plateau in, 55
prediction of, 4145
respiratory exchange ratio and, 50
slopes of, vs. work rate, 2223, 23t, 43, 44t
ventilatory threshold and, 5253, 53
vs. treadmill time, 45, 45t
Oxygen uptake drift, 43
Oxygen uptake lag, 43
P
Paroxysmal supraventricular tachycardia (PSVT), ST-segment
depression in, 179180
Patient(s), inclusion of, in cardiac rehabilitation, 500
Patient history, role of, in exercise testing, 1213
Patient instruction, for exercise testing, 14
Peak maximal oxygen uptake (VO2max), 47
cut points for, 341
with EF, 336
role of, in HF patients, 335
with plasma biomarkers, in predicting risk, 343
vs. hemodynamic variables, 341343
Index
Q
Q wave, effect on ST-segment shifts, 295
exercise-induced changes in, 128
respiration effect on, 30
standing effect on, 31
Q wave anterior myocardial infarction, 463
Q wave inferior myocardial infarction, 463
QRS axis, computer analysis of, 29, 30t
QRS complex, misalignment of, 67
QRS score, beta blockade effect on, 73
QUEST, 89
QUEXTA studies, 231
of computerized electrocardiographic analysis, 8081
Quinton Instruments, computerized exercise systems of, 89
R
R wave, changes in, 204205
effect of, on exercise-induced ST-segment depression, 148
exercise-induced changes in, 131132, 133
Radionuclide ventriculography, 67, 7t
assessment of coronary patients by, after exercise training,
479
vs. exercise electrocardiography, in ST/HR slope, 74
Radionuclide ventriculography (RNV), prognostic
applications of, in coronary artery disease, 267
Ramp exercise test, maximal, thirty-second moving averages
in, 4647, 48t
oxygen uptake in, during chronic heart failure, 2223, 24
oxygen uptake slopes in, vs. work rate in, 23t, 44t
Ramp protocols, 22, 24
Receiver operating characteristic curve (ROC), calculation of,
192t
definition of, 194195, 195
Recorders, paper, for electrocardiography, 1617
with inadequate frequency response, exercise-induced
ST-segment depression and, 155
Recovery, ST-segment depression during, 143146, 145t
Recursive partitioning, 312
Regression equation(s), 5657
Rehabilitation. See Cardiac rehabilitation.
Reperfusion, prognostic effect of post-myocardial infarction
exercise testing, 322324
Repolarization, atrial, exercise-induced ST-segment
depression and, 153154
RER (respiratory exchange ratio), definition of, 50, 115
production of, formula for, 49t
Respiration, effect of, on Q wave, 30
on vectorcardiographic lead systems, in exercise
testing, 30
521
S
S wave, exercise-induced changes in, 128, 133
Safety, during exercise testing, 1213
during early post myocardial infarction, 293
Sampling, in gas exchange, 4647, 47, 48t
SAS (specific activity scale) of Goldman, 96t
Schiller, computerized exercise systems of, 8990
Screening, asymptomatic. See Asymptomatic screening.
criteria for, procedure selection, 351
definition of, 351
efficacy of, 351
for athletes, 452
guidelines for, performance of, 351
Holter study of, 367, 367t
of apparently healthy individuals. See Asymptomatic
screening.
Seattle Heart Watch study, ST-elevation and, 138
Sensitivity, 210
calculation of, 192t
definition of, 191
Serum phosphorus, alterations in, during exercise, 128130
Serum potassium, alterations in, during exercise, 130
Serum triglycerides, aerobic exercise program effect on, 420
cardiac rehabilitation effect on, 494, 495
522
Index
T
T wave, exercise-induced changes in, 128
inversion of, pseudo-normalization of, during exercise
testing, 142
Tachycardia, definition of, 297
TES (treadmill exercise score), definition of, 72t
Hollenberg, 73
Thallium nuclear perfusion imaging, with exercise
testing, 35
Index
U
U wave, exercise-induced changes in, 133
UCSD (University of California, San Diego) electrode(s),
placement of, in exercise testing, 2729, 28
UCSD (University of California, San Diego) lead systems,
2829, 28
UCSD (University of California, San Diego) R-wave study,
129, 132133
UCSD SCOR studies, of exercise testing prognostic value,
305306
United States Air Force School of Aerospace Medicine
(USAFSAM), protocol, 21
University of California, San Diego (UCSD) electrode(s),
placement of, in exercise testing, 2729, 28
University of California, San Diego (UCSD) lead systems,
2829, 28
University of California, San Diego (UCSD) R-wave study,
129, 132133
Upsloping ST-segment, depression of, 204
U.S. Army Cardiovascular Screening Program, 380
USAFMC Normal Aircrewmen study, 128
USAFSAM, asymptomatic screening, 369
USAFSAM (United States Air Force School of Aerospace
Medicine). See United States Air Force School of
Aerospace Medicine (USAFSAM).
USAFSAM study, serial electrocardiography screening, of
asymptomatic individuals, 358
523
V
Valvular disease, quantitation of, through exercise testing, 20
Valvular heart disease, ACC/AHA guidelines for, exercise
testing in, 412
evaluation of, 412415
aortic stenosis, 412413
Valvular stenosis, exercise testing in, 413
Variant angina, 134135, 135t
VASQ (Veterans Specific Activity Questionnaire), 96, 97t
VCG (vectorcardiographic) lead systems, 26
respiration effect on, 30
sitting effect on, 30
VD/VT (ventilatory dead space to tidal volume ratio), 5152, 51
VE/CO2, 5051
Vector leads, bipolar leads vs., in computerized
electrocardiographic analysis, 73
Vectorcardiographic (VCG) lead systems, 26
respiration effect on, 30
sitting effect on, 30
Veins, oxygen content of, determinants of, 89
Venous pressure, determinants of, 6
Ventilation perfusion ratio, definition of, 48
Ventilatory dead space to tidal volume ratio (VD/VT), 51, 51
Ventilatory gas exchange. See Gas exchange.
to predict outcomes, in Chronic Heart Failure, 331t333t
Ventilatory oxygen uptake (VO2), 1, 2t
and exercise capacity, 101102
in exercise prescription, for cardiac rehabilitation, 467
Ventilatory threshold, exercise program effect on, 483
Ventilatory threshold (VT), 5253, 53
Ventricle(s), exercise training effect on, 425432, 426t431t
left. See Left ventricular entries.
Ventricular aneurysm, ST-elevation and, 137
Ventricular arrhythmia(s), exercise-induced, evaluation of,
408409
Ventricular compliance, 6
Ventricular damage, 329
Ventricular fibrillation threshold, changes in, from chronic
exercise, 422423
Ventricular filling, determinants of, 6
Ventricular function, after myocardial infarction,
spontaneous improvement in, 479
exercise capacity and, 98
Ventricular tachycardia, during exercise testing, 178179
Baltimore Aging Study, 179
Long Beach Veterans Affairs Medical Center study,
153155, 154
exercise-induced, evaluation of, 409
Ventricular volume, as response to exercise, 78, 7t
radionuclide studies of, 7
Veterans Affairs Medical CentersHungarian Heart Institute
studies, of computerized electrocardiographic analysis,
8185
beta-blocker effect on, 8485
computer analysis of, 81
leads of, 83
population characteristics of, 81, 82t
post-exercise test results, 8182, 82t
R wave adjustment in, 84
recovery measurements for, 83
resting electrocardiography effect on, 8485
ST criteria for, 8283, 82t, 84
Veterans Affairs score, equation for, 262
Kaplan-Meier survival curve in, 261
ROC curve in, 262
Veterans Specific Activity Questionnaire (VASQ), 97, 97t
524
Index
W
Wall motion, abnormality of, vs. ischemia, 138140, 141142
averaging of, of electrocardiogram signals, during exercise
testing, 16
recognition of, in computerized electrocardiographic
analysis, 69
Weather balloons, in gas exchange measurement, 46
Weight, body, exercise training effect on, 434
White collar rhabdomyolysis, 454
WHO (World Health Organization), definition of
cardiac rehabilitation, 467