To determine how frequently the National Cholesterol Education Program (NCEP) goal of a low-density lipoprotein (LDL) cholesterol level of 100 mg/dL or less is achieved in clinical practice in ...patients with coronary artery disease and what fraction of patients can achieve this goal without drug therapy. We examined the results of lipid management in 152 consecutive patients who had completed cardiac rehabilitation after an acute coronary event. Patients were randomized to follow-up by specially trained nurses or by preventive cardiologists, and they were not receiving lipid-lowering drugs at the start of the study. Patients were given aggressive diet and exercise recommendations and lipid-lowering drugs in accordance with NCEP guidelines. Follow-up was continued for a mean of 526 days after the first lipid assessment subsequent to the coronary event. Multiple logistic regression analysis was used to identify independent predictors of a final LDL cholesterol level of 100 mg/dL or less. Of the study group, 39% achieved the NCEP goal LDL cholesterol level of 100 mg/dL or less. Characteristics of the patients with LDL cholesterol levels of 100 mg/dL or less in comparison with those with LDL cholesterol levels of more than 100 mg/dL included a greater frequency of drug therapy (65% versus 38%), more rigorous dietary compliance, longer follow-up (586 +/- 317 days versus 493 +/- 264 days), more favorable weight change (-0.3 +/- 4.9 kg versus +1.7 +/- 5.0 kg), and more extensive weekly exercise (183 +/- 118 minutes versus 127 +/- 107 minutes). The registered nurses managed the lipids of these patients as effectively as did the preventive cardiologists. Appropriate drug therapy was the most important factor in achieving an LDL cholesterol level of 100 mg/dL or less, but 35% of patients attaining this NCEP goal were not receiving drug therapy. Exercise, dietary compliance, and weight loss were also important factors.
Cardiovascular rehabilitation is defined as the process of development and maintenance of a desirable level of physical, social, and psychologic functioning after the onset of a cardiovascular ...illness. Patient education, counseling, nutritional guidance, and exercise training play prominent roles in the process of rehabilitation. Benefits from cardiac rehabilitation include improved exercise capacity and decreased symptoms of angina pectoris, dyspnea, claudication, and fatigue. Recent pooled data regarding exercise training after myocardial infarction demonstrated a 20 to 25% reduction in mortality and major cardiac events. Exercise training may result in an improvement in systemic oxygen transport, a reduction in the myocardial oxygen requirement for a given amount of external work, and a decrease in the extent of myocardial ischemia during physical activity. The efficacy of modification of risk factors in reducing the progression of coronary artery disease and future morbidity and mortality has been established. Herein we review the history, current practice and results, and future challenges of cardiovascular rehabilitation.
Regional wall dynamics of the left ventricle before and after sublingual administration of 0.6 mg of nitroglycerin were determined from left ventricular angiograms in 27 patients undergoing coronary ...arteriography. Regional wall dynamics were quantitatively measured from 60/sec determinations of wall thickness and derived peak rate of systolic wall thickening (peak dTw/dt) in selected sites of the left ventricle. A total of 70 regions were studied. Analysis of the same segment before and after administration of nitroglycerin revealed that the mean change in peak dTw/dt was +1.97 cm/sec in segments with an initial peak dTw/dt of less than 5 cm/sec, in contrast to a change of +0.66 cm/sec in segments with an initial control value of 5 cm/sec or greater. Akinetic or dyskinetic areas did not show improvements after nitroglycerin. In 11 left ventriculograms, an area that was initially hypokinetic manifested an increase in rate of wall thickening after nitroglycerin. The mean increase in peak dTw/dt in anterior segments with electrocardiographic evidence of myocardial infarction was 0.18 cm/sec (P less than 0.05) after nitroglycerin, compared with a mean change of 1.33 cm/sec in anterior segments without such evidence. This study presents evidence for a regional myocardial response to nitroglycerin with differing responses within the same ventricle apparently depending upon the functional state of the underlying myocardium.
In order to test the safety of hot tub use for persons with heart disease, 15 men with clinically stable coronary artery disease underwent 15 minutes of immersion in a hot tube at 40 degrees C. On ...another day, they exercised on a cycle ergometer for 15 minutes; target heart rate was determined by standard methods. Tympanic temperature, skin temperature, electrocardiographic findings, blood pressure, plasma catecholamines, subjective comfort, and cardiovascular symptoms were monitored. The peak heart rate was significantly lower during the hot tub session versus the exercise session (85 +/- 14 versus 112 +/- 19 beats/min), as were the systolic (106 +/- 15 versus 170 +/- 21 mm Hg) and diastolic (61 +/- 6 versus 83 +/- 8 mm Hg) blood pressure measurements (P < 0.01). Tympanic temperature increased by a mean of 0.6 +/- 0.3 degrees C during immersion and 0.1 +/- 0.1 degrees C during exercise. No ischemic electrocardiographic changes or clinical complications occurred. Simple ventricular ectopic activity and "just noticeable" chest pain were more frequent during exercise than during immersion. Plasma norepinephrine increased during exercise but not during immersion. These data suggest that hot tub use within these time and temperature constraints should be safe for men with stable heart disease who can follow an exercise regimen at home.
In a retrospective analysis, 63 participants in a cardiac rehabilitation-preventive cardiology program were identified as having low blood concentrations (mean, 34 mg/dl) of high-density lipoprotein ...cholesterol (HDL-C) and a mean total cholesterol level of 223 mg/dl after 3 months of hygienic measures (aerobic exercise, avoidance of tobacco, diet, and weight loss) designed to increase the HDL-C level. These patients (treatment group) were treated with low-dose, time-release nicotinic acid (mean, 1,297 mg/day) for a mean duration of 7.4 months. All subjects were able to take the drug without intolerable side effects. Fifty-four patients similar to those in the treatment group participated in the same program but were not treated with nicotinic acid (control group). Exercise, diet, body weight, and smoking remained stable throughout the period of observation. For the treatment group, HDL-C levels increased a mean of 18% (+6 mg/dl), total cholesterol concentrations decreased 9% (-20 mg/dl), the ratio of total cholesterol to HDL-C decreased 25% (from 6.8 to 5.1), low-density lipoprotein cholesterol levels decreased 13% (-20 mg/dl), and triglyceride levels decreased 20% (from 165 mg/dl to 132 mg/dl). Aspartate aminotransferase and uric acid concentrations were minimally increased after treatment, and the blood glucose level was unchanged. In the control group, HDL-C levels increased a mean of 8% (+3 mg/dl) and the other blood lipid variables were not improved after a mean of 8.3 additional months of diet and exercise.
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