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Cardiac rehabilitation (CR) can reduce cardiovascular mortality and morbidity in coronary artery disease. Long coronary artery lesions may be associated with adverse outcomes after drug-eluting stent (DES) implantation. The purpose of this study was to evaluate angiographic outcomes after a comprehensive CR program in patients with DESs for long coronary artery lesions. A total of 576 patients treated with DESs for long (≥25 mm) coronary lesions were enrolled in this prospective CR registry. Comprehensive CR programs were successfully performed in 288 patients (50%). The primary end point was in-stent late luminal loss at the 9-month angiographic follow-up. There were few significant differences between the CR and non-CR groups in terms of baseline characteristics, including clinical, angiographic, and procedural variables. The rate of in-stent late luminal loss in the CR group was 35% less than in the usual care group (0.19 ± 0.33 mm in CR vs 0.29 ± 0.45 mm in non-CR, difference 0.08 mm, 95% confidence interval 0.01 to 0.16, p = 0.02) at the 9-month follow-up. After propensity-matched analysis (224 pairs), the results were consistent (0.18 ± 0.31 mm in CR vs 0.28 ± 0.41 mm in non-CR, difference 0.10 mm, 95% confidence interval 0.02 to 0.18, p = 0.02). The CR group showed a significant improvement in the overall risk profile compared with the non-CR group, including current smoking, biochemical profiles, depression, obesity, and exercise capacity. In conclusion, the comprehensive CR program significantly reduced late luminal loss after DES implantation for long coronary lesions. This may be associated with significant improvements in exercise capacity and overall risk profile., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Familial hypercholesterolemia (FH) is a frequently undiagnosed genetic disease characterized by substantial elevations of low-density lipoprotein cholesterol (LDL-C). The prevalence of heterozygous FH (HeFH) in the general population is 1:500 inhabitants, while the prevalence of homozygous FH (HoFH) is 1:1,000,000. If FH is not identified and aggressively treated at an early age, affected individuals have a 20-fold increased lifetime risk of coronary heart disease compared with the general population. This narrative review provide a concise overview of recommendations for diagnosis and treatment of adults and children with FH, and discuss the utility of considering FH as a comorbidity at the entry of cardiac rehabilitation programmes.

Background: In patients with coronary heart disease, both arterial stiffness and wave reflections are increased and predict unfavorable cardiovascular events. Cardiac rehabilitation has the goal to reduce risk factors and slow the progression of the disease. The aim of this study was to prospectively determine the impact of an ambulatory cardiac rehabilitation program on pulsatile hemodynamics., Methods: Male patients after coronary interventions, bypass surgery, or acute coronary syndromes underwent exercise and resistance training. Before and after the program, pulsatile hemodynamics was measured. Exercise capacity was assessed with an incremental cycle ergometer protocol. A detailed two-dimensional and Doppler echocardiogram was obtained for systolic and diastolic left ventricular function., Results: A total of 27 men participated in the study. After the intervention (n = 24), carotid-femoral pulse wave velocity decreased significantly from 8.7 (standard deviation (SD): 1.7) to 7.9 (SD: 1.9) m/s (p = 0.019), and augmentation index normalized for a heart rate of 75/min decreased significantly from 20.4 (SD: 8.7) to 17.5 (SD: 8.1; p = 0.017)., Conclusion: The results suggest that a structured ambulatory rehabilitation program may improve pulsatile hemodynamics in coronary artery disease (CAD) patients.

Objectives: To translate, culturally adapt and psychometrically validate the Information Needs in Cardiac Rehabilitation (INCR) tool to Portuguese., Background: The identification of information needs is considered the first step to improve knowledge that ultimately could improve health outcomes., Methods: The Portuguese version generated was tested in 300 cardiac rehabilitation patients (CR) (34% women; mean age = 61.3 ± 2.1 years old). Test-retest reliability was assessed using intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and the criterion validity was assessed with regard to patients' education and duration in CR., Results: All 9 subscales were considered internally consistent (á > 0.7). Significant differences between mean total needs and educational level (p < 0.05) and duration in CR (p = 0.03) supported criterion validity. The overall mean (4.6 ± 0.4), as well as the means of the 9 subscales were high (emergency/safety was the greatest need)., Conclusion: The Portuguese INCR was demonstrated to have sufficient reliability, consistency and validity., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Patient education is an essential part of the treatment of coronary heart disease in cardiac rehabilitation. In Germany, no standardized and evaluated patient education programs for coronary heart disease have been available so far. In this article, we report the evaluation of a patient-oriented program. A multicenter quasi-experimental, sequential cohort design study of patients with coronary heart disease (n = 434) in inpatient cardiac rehabilitation was conducted. Intervention patients received the new patient-oriented program, control patients a traditional lecture-based program (usual care). Primary outcome illness knowledge and secondary behavioral and health outcomes were assessed at admission, discharge and 6- and 12-months follow-up. We found a significant, small between-group intervention effect in both patients' medical illness and treatment knowledge and behavior change knowledge at discharge (medical: η(2) = 0.013; behavior change: η(2) = 0.011) and after 12 months (medical: η(2) = 0.015). Furthermore, a significant, small effect was observed for physical activity after 12 months (η(2) = 0.011), but no effects on healthy diet and medication adherence emerged. Superiority of the patient-oriented educational program for patients with coronary heart disease was partially confirmed. The program produced improved illness knowledge and physical activity compared with usual care after 1 year.

The current study evaluates the levels of comparative optimism among patients with coronary heart disease (CHD) and examines its relationship to health outcomes 12 months later. 164 patients completed self-report questionnaires at the end of cardiac rehabilitation and the number of adverse clinical events in the following 12 months were recorded. Comparative optimism was assessed in relation to a typical other who has not had cardiac event, a typical other who has had the same cardiac event as the respondent, and a typical member of the cardiac rehabilitation class. Clinical-demographic details and distress were assessed. Participants were comparatively optimistic in all three ratings. Logistic regression (controlling for age, gender, co-morbidities, and distress) revealed that higher levels of adverse events were associated with older age, being male, and lower levels of overall comparative optimism. Comparative optimism was associated with decreased risk of adverse clinical events in the year following cardiac rehabilitation attendance.

Objective: To evaluate the safety and efficacy of exercise rehabilitation in coronary heart disease patients post reascularization procedure., Method: We searched the Cochrane Central Register of Controlled Trials (CCRCT), Pubmed, Wanfang, CNKI, CBM and VIP database for randomized controlled trials (RCTs) on exercise rehabilitation for patients with coronary artery disease post percutaneous coronary intervention revascularization or coronary artery bypass grafting. Quality assessment and data collection were conducted by two reviewers independently. The data were analyzed by Review Manager 5.0., Results: A total of 3 474 patients from 16 RCTs were included in this meta-analysis and patients were divided into exercise rehabilitation group (n = 1 425) and control group (n = 2 049). Meta-analysis results showed mortality rate was similar between the two groups (OR = 0.81, 95%CI 0.38-1.69, P > 0.05) and the incidence of major cardiovascular events rate (OR = 0.40, 95%CI 0.24-0.65, P < 0.01) and heart rate [mean difference (MD) = -2.82, 95%CI -4.72--0.92, P < 0.01] were significantly lower while LVEF (MD = 2.24, 95%CI 0.18-4.31, P < 0.05), the exercise metabolic equivalent (MD = 0.94, 95%CI 0.43-1.44, P < 0.01) , anaerobic threshold (MD = 1.83, 95%CI 0.67-3.00, P < 0.01) , and maximum oxygen consumption (MD = 3.22, 95%CI 2.42-4.03, P < 0.01) were significantly higher in exercise rehabilitation group than in control group., Conclusion: Exercise rehabilitation does not increase the risk of mortality in patients of coronary heart disease after revascularization and can effectively reduce major cardiovascular events.

The underwater shower massage and electrical stimulation were applied to treat 120 patients presenting with coronary heart disease. The estimation of the effectiveness of this treatment with the use of functional diagnostic methods revealed its psychocorrective effect manifested in the form of reduced frequency and duration of painful and painless angina seizures, restricted sympathetic influences on the heart as well as normalized sympathovagal balance, lipid status, antioxidative system, central and peripheral hemodynamics, improved systolic and diastolic function of the myocardium, enhanced tolerability of mental, emotional, and physical workload. The study allowed the predictors of the effectiveness of therapeutic and health-promoting measures to be identified.

Cardiac rehabilitation (CR) is an essential element in the treatment of coronary artery disease. It can be conducted on an inpatient or ambulatory basis in cardiac rehabilitation units and includes complementary exercise training and a therapeutic patient education (TPE) program. Rehabilitation can reduce the occurrence of serious cardiac events and provide better control of cardiovascular risk factors. All epidemiological surveys show that this approach is beneficial: multidisciplinary care reduces mortality after myocardial infarction and improves cardiac patients' lifestyles. Rehabilitation centers are the only structures able to conduct 3- to 4-week program of cardiac training and TPE. Unfortunately, the number of patients who participate in such programs is still too low, and cardiac rehabilitation centers are underutilized (32 % in the French cohort of the EUROASPIRE III study and about 15 % of all coronary patients). This situation is regrettable, as all registers and epidemiological surveys have confirmed the capacity of CR to improve exercise tolerance, the ischemic threshold, and secondary prevention.

Purpose: Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment., Methods: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities., Results: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll., Conclusions: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.

Background: Coronary heart disease (CHD) is a major cause of morbidity and mortality, and cardiac rehabilitation (CR) is still not well developed in mainland China. The objective of this study is to investigate the barriers associated with those seeking cardiac rehabilitation (CR) and to explore appropriate secondary prevention modalities tailored to the needs of Chinese patients with coronary heart disease (CHD)., Methods: A consecutive series of eligible patients was recruited from the cardiac department of a teaching hospital in Nanjing, located in southeast China. Structured face-to-face interviews were conducted with 328 patients prior to hospital discharge. Patient preferences for seeking an outpatient CR program or an alternative outpatient self-choice, minimal-cost educational program were evaluated. Socio-demographic characteristics and clinical data were assessed. Additionally, patients were asked to provide the reasons affecting their choice., Results: Overall, only 14.3% patients preferred the standard CR program. Factors associated with non-participating were female gender (odds ratios [ORs], 6.05, 95% CI, 1.30-28.19), older age (ORs, 1.11, 95% CI, 1.04-1.19, per year), less education (ORs, 8.13, 95% CI, 2.83-23.38), low income (ORs, 3.26, 95% CI, 1.24-8.54), and having either basic medical care or a lack of health insurance (ORs, 10.01, 95% CI, 3.90-25.68). The most common reason for refusing to participate in CR was that patients could not afford it. Of the remaining patients, 65.8% patients chose self-choice educational programs, especially for female (ORs, 5.84, 95% CI, 2.67-12.79), older (ORs, 1.06, 95% CI, 1.02-1.11, per year), and low income (ORs, 2.14, 95% CI, 1.12-4.10) patients. The main reasons for their preferences were their desires for more information about disease and risk factors, the low cost, feasibility, and saving time., Conclusions: Multiple barriers, which may occur at the patient, health system, and societal levels, have prevented eligible patients from participating in CR programs. Self-choice educational programs, an alternative model incorporating more information, would strongly meet the needs of most patients. A feasible delivery format for secondary prevention should be provided for all CHD patients.

Background: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk., Objective: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking., Methods: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment., Results: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up., Conclusions: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Background: Depression and anxiety are common in cardiac patients, and psychological interventions may also be used as part of general cardiac rehabilitation programs., Purpose: This study aims to estimate effects of psychological interventions on mortality and psychological symptoms in this group, updating an existing Cochrane Review., Method: Systematic review and meta-regression analyses of randomized trials evaluating a psychological treatment delivered by trained staff to patients with a diagnosed cardiac disease, with a follow-up of at least 6 months, were used., Results: There was no strong evidence that psychological intervention reduced total deaths, risk of revascularization, or non-fatal infarction. Psychological intervention did result in small/moderate improvements in depression and anxiety, and there was a small effect for cardiac mortality., Conclusion: Psychological treatments appear effective in treating patients with psychological symptoms of coronary heart disease. Uncertainty remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Background: This study aimed to examine the mediating role of psychological distress in the relationship between the physical health component of health-related quality of life (HRQoL) of coronary heart disease patients and their socio-demographic and clinical characteristics., Methods: This was a cross-sectional study conducted from March 2009 to July 2010 with a total of 420 participants recruited from two hospital-based phase II cardiac rehabilitation centres. Participants' socio-demographic variables, self-reported medical history data, level of psychological distress, perceived social support, and HRQoL were collected by means of a structured questionnaire. Body weight and height, blood pressure and clinical data including fasting blood glucose, triglycerides, and low- and high-density lipoprotein cholesterol were also collected. Exploratory univariate analyses and multivariable regressions were conducted to identify socio-demographic and clinical determinants of the physical health component of HRQoL. Path analyses were then performed to examine the mediating role of psychological distress in the relationship between the physical health component of HRQoL and the determinants., Results: Path analysis revealed that age, sex, perceived social support, history of angina, and dyslipidaemia had both direct effect and indirect effect through psychological distress on the physical health component of HRQoL. Obesity and impaired left ventricular function only affected the physical health component of HRQoL directly, whereas household income only affected it indirectly, through psychological distress., Conclusion: Psychological distress mediates the effects of some socio-demographic and clinical variables of CHD patients on the physical health component of HRQoL. Our findings have important implications for rehabilitation care for people with CHD in order to enhance their HRQoL.

Objective: To investigate the long-term effects of motivational interviewing on clinical outcomes, psychological outcomes, health-related quality of life among cardiac rehabilitation patients with poor motivation., Design: A randomized controlled trial with blind data collectors., Setting: Cardiac rehabilitation centre., Subjects: A total of 146 cardiac rehabilitation patients with poor motivation., Intervention: All participants received usual care, including exercise and education, while those in the experimental group also received 10 sessions of motivational interviewing, each lasting 30-45 minutes., Main Measures: Clinical and psychological outcomes and health-related quality of life were assessed at baseline and at six, nine and 12 months for both groups., Result: There was no significant difference between the two groups at baseline on demographic and clinical outcomes except for monthly family income (p = 0.034). Patients in the experimental group had higher increases in health-related quality of life (SF-36) scores in bodily pain (88.7 SD 16.7 vs. 87.6 SD 18.7 at month 12, p = 0.044) and role limitation owing to emotional problems (86.9 SD 19.2 vs. 78.6 SD 21.8 at month 9, p = 0.019; 85.8 SD 18.9 vs. 76.9 SD 23.9 at month 12, p = 0.022). No statistically significant group difference was found among other outcomes., Conclusion: The long-term effect of motivational interviewing on clinical and psychological outcomes and health-related quality of life in studied patients is limited.

The results of the study on the influence of carbon dioxide baths differing in the total mineralization levels on the clinical course of hypertensive disease associated with coronary heart disease and on various functional systems of the body. The data obtained provide an insight into the role of salt concentrations (10 and 20 g/l) in carbon dioxide bath water (1.2 g/l) applied for the traditional treatment of the patients with hypertensive disease associated with concomitant coronary heart disease and musculoskeletal pathology. Highly mineralized bath water has a greater influence on the functional state of the cardiovascular system by causing a more pronounced decrease in peripheral vascular resistance and hypotensive effect. Baths with a salt concentration of 20 g/l markedly reduced pain and had anti-inflammatory effect in the patients with pathology of support and locomotor organs.

Background: Despite documented benefits of cardiac rehabilitation, adherence to programs is suboptimal with an average dropout rate of between 24% and 50%. The goal of this study was to identify organizational and patient factors associated with cardiac rehabilitation adherence., Methods and Results: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry Project (N = 38) were surveyed and records of 4412 enrolled patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. The results show that organizational factors associated with significantly increased adherence were relaxation training and diet classes (group and individual formats) and group-based psychological counseling, medication counseling, and lifestyle modification, the medical director's presence in the cardiac rehabilitation activity area for ≥ 15 min/week, assessment of patient satisfaction, adequate space, and adequate equipment. Patient factors associated with significantly increased adherence were aged ≥ 65 years, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) high-risk category, having received coronary artery bypass grafting, and diabetes disease. Non-white race was negatively associated with adherence. There was no significant gender difference in adherence. None of the baseline patient clinical profiles were associated with adherence including body mass index, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and blood pressure., Conclusions: Factors associated with adherence to cardiac rehabilitation included both organizational and patient factors. Modifiable organizational factors may help directors of cardiac rehabilitation programs improve patient adherence to this beneficial program.

Aim: To describe lifestyle and risk-factor management in patients attending cardiac rehabilitation programmes (CRPs) compared to those who do not., Design: A cross-sectional survey., Methods: The EUROASPIRE III survey was conducted in 76 centres in 22 European countries. Consecutive patients having had a coronary event or revascularization before the age of 80 were identified and interviewed at least 6 months after hospital admission., Results: 13,935 medical records were reviewed and 8845 patients interviewed (participation rate 73%); 44.8% of patients reported being advised to attend a CRP and of these 81.4% did so (36.5% of all patients). There were wide variations between countries and diagnostic categories, ranging from 15.9% in the Ischaemia group to 68.1% in the CABG group. Characteristics associated with participation in a CRP included younger age, male sex, higher educational level and CABG as a recruiting index event, while smokers were less likely to attend a CRP. Patients who attended a CRP had a significantly lower prevalence of smoking, better control of total and LDL-cholesterol and higher use of beta-blockers, ACE inhibitors/ARBs and lipid-lowering drugs., Conclusions: CRPs in Europe are underused, with poor referral and low participation rate and wide variations between countries. Despite this heterogeneity, the control of smoking and cholesterol and the use of cardioprotective medication is better in those who attend a CPR. There is an urgent need for comprehensive, multidisciplinary rehabilitation programmes to integrate professional lifestyle interventions with effective risk-factor management, appropriately adapted to the medical, cultural and economic settings of a country.

Background: Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients' decisions to participate., Methods: To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms., Results: Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients' participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women's experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation., Conclusions: Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a 'consumer behaviour' and interventions should mobilize family support, promote 'patient friendly' scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Background: High-intensity interval exercise (HIIE) is gaining in popularity in fitness centres, even among coronary heart disease (CHD) patients. However, whether HIIE can have deleterious acute effects on the vasculature in CHD has not been studied. We hypothesized that when compared with moderate-intensity continuous exercise (MICE), a single bout of HIIE could lead to vascular damage and increasing numbers of circulating endothelial and platelet microparticles (EMPs, PMPs) in stable, physically fit CHD patients., Methods: Nineteen male CHD patients (aged 62 ± 11 years) underwent, in random order, a single session of HIIE corresponding to 15-second intervals at 100% of peak power output and 15-second passive recovery intervals, and an isocaloric MICE session. EMPs (CD31+ and/or CD62E+ and CD42b-); PMPs (CD42b+); nitrates and nitrites; prostacycline; and troponin T, cardiac form (cTnT), were measured 10 minutes before exercise and 20 minutes, 24 hours, and 72 hours after both exercise sessions., Results: EMPs, PMPs, nitrates and nitrites, prostacycline, and cTnT remained unchanged after both HIIE and MICE exercise sessions. Initial EMP concentration correlated inversely with EMP concentration 20 minutes post exercise, irrespective of exercise modality (r = 0.78, P < 0.0001)., Conclusions: A single HIIE session with very short exercise and passive recovery periods appears safe and does not induce changes to markers of endothelial function. Future studies are required to determine the safety of a long-term HIIE training program., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Methods of measuring return to work (RTW) following temporary disability are diverse. The purpose of this study was to compare different measures of RTW within a 12-month period using a well-defined population of patients treated with Percutaneous Coronary Intervention (PCI) and weekly administrative data on transfer payments., Methods: Different RTW measures were defined based on weekly data from 12 months follow-up after PCI and agreement between definitions was expressed as Cohen's kappa. Prognostic factors for RTW were compared using logistic regression., Results: Among those working before the PCI, 70 % were back to work at 6 months after the PCI and 76 % 1 year after when using cross-sectional measures and excluding those who left the workforce permanently during follow up. When using a time to event measure, 77 % experienced RTW during follow up, while only 60 % experienced RTW without recurrent sick-leave events during the following year. We found moderate to near perfect agreement when comparing the measures, with lowest agreement between the time-to-event measure without relapses compared to the other measures. When comparing prognostic factors for the different RTW outcomes, we found most associations similar in size, except from the clinical measure left ventricular ejection fraction, possibly related to recurrent sick leave., Conclusions: Different measures revealed some differences in proportions of RTW. However, high agreement between RTW-definitions was found. Choice of RTW-definitions should depend on study purpose; simple cross-sectional methods are sufficient in prediction of RTW and analysis of risk factors, while methods capturing relapses are recommended when sustainability, prognosis and vulnerability are in focus.

Objective: To examine published literature investigating the relationship between illness perceptions, mood and quality of life (QoL) in coronary heart disease (CHD) populations., Methods: Key databases were systematically searched (CINAHL, Medline, PsycINFO, Scopus and Web of Science) for studies matching the inclusion criteria between November 2011 and February 2012. References of included studies were examined and key authors contacted. Studies were subject to a quality control check., Results: 21 studies met the inclusion criteria. A synthesis of the results found that illness perceptions were correlated to and predicted QoL and mood across CHD diagnoses. Specific illness perceptions (control, coherence and timeline) were found to be important for patients that had experienced an unexpected medical event, such as myocardial infarction., Conclusion: The results of this study provide support that illness perceptions are related to outcomes across CHD populations and disease progression, however the results do not selectively support one particular model. Recommendations are consistent with cardiac rehabilitation guidelines. Further research should focus on the systemic impact of illness perceptions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Available guidelines and treatment standards are not sufficiently detailed to give practical guidance for psychological interventions in the rehabilitation of patients with coronary heart disease. We therefore aimed at developing evidence- and consensus-based practice guidelines for psychological interventions in the rehabilitation of individual patients with coronary heart disease. The following steps were taken: (1) A systematic search for guidelines and reviews, and a survey of rehabilitation centres concerning present structures and the practice of psychological services, (2) development of a first draft of the practice guidelines in an expert workshop, (3) a survey of all senior psychologists and chief physicians of the rehab centres for their approval, as well as focus groups with rehab patients, and (4) revision of the recommendations and final consensus development in an expert workshop. Significant aspects of the guidelines that go beyond present practice are routine screening for psychological comorbidity, neuropsychological screening for cognitive dysfunction in particular patients, and employment of defined psychologically grounded interventions by the entire rehab team. So far, the practice guidelines have been widely accepted by professionals in the field of rehabilitation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Few studies have analyzed the relationship between job satisfaction and return to work (RTW) in cardiac patients. The aim of this paper was to investigate whether job satisfaction predicted early RTW in patients sick listed after cardiac invasive procedures., Methods: A 6-month prospective study was carried out in a sample of 83 patients in working age who had recently been treated with angioplasty or cardiac surgery. Job satisfaction was measured using the scale from the Occupational Stress Indicator during cardiac rehabilitation. Time to RTW was assessed at the 6-month occupational physician examination. Logistic regression analyses were used to study the association between job satisfaction at baseline and early RTW at follow-up, adjusted for socio-demographic, medical (type of cardiac intervention, ejection fraction) and psychological (depression, locus of control, illness perception) factors., Results: Participants with high job satisfaction were more likely to return early to work, with an odds ratio (OR) of 5.92 (95 % CI, 1.69-20.73) in the most-adjusted model, compared to participants with low job satisfaction. Satisfaction with organizational processes was the job satisfaction component most strongly associated with early RTW (OR, 4.30; 95 % CI, 1.21-15.03)., Conclusions: To the best of our knowledge, this is the first prospective study that investigated whether job satisfaction predicts time to RTW after cardiac interventions. The results suggested that when patients are satisfied with their job and positively perceived their work environment, they will be more likely to early RTW, independently of socio-demographic, medical and psychological factors.

The aim of the review was to assess the effect of patient education in ischaemic heart disease. Thirteen randomised controlled trials of moderate to good quality including 68,556 patients were selected. The effect on mortality, cardiac morbidity, hospitalisation and health-related quality of life was assessed and only non-significant tendencies of effect were found. The authors of the review nevertheless conclude that the review supports current rehabilitation programmes that include patient education. Further research in patient education, especially concerning the most effective methods of education delivery, is needed.

Objective: To quantify the efficacy of mental health (antidepressants & psychotherapies) and cardiac rehabilitation treatments for improving secondary event risk and depression among patients with coronary heart disease (CHD)., Methods: Using meta-analytic methods, we evaluated mental health and cardiac rehabilitation therapies for a) reducing secondary events and 2) improving depression severity in patients with CHD. Key word searches of PubMed and Psychlit databases and previous reviews identified relevant trials., Results: Eighteen mental health trials evaluated secondary events and 22 trials evaluated depression reduction. Cardiac rehabilitation trials for the same categories numbered 17 and 13, respectively. Mental health treatments did not reduce total mortality (absolute risk reduction [ARR] = -0.001, confidence interval [95% CI] = -0.016 to 0.015; number needed to treat [NNT] = ∞), showed moderate efficacy for reducing CHD events (ARR = 0.029, 95% CI = 0.007 to 0.051; NNT = 34), and a medium effect size for improving depression (Cohen d = 0.297). Cardiac rehabilitation showed similar efficacy for treating depression (d = 0.23) and reducing CHD events (ARR = 0.017, 95% CI = 0.007 to 0.026; NNT = 59) and reduced total mortality (ARR = 0.016, 95% CI = 0.005 to 0.027; NNT = 63)., Conclusions: Among patients with CHD, mental health treatments and cardiac rehabilitation may each reduce depression and CHD events, whereas cardiac rehabilitation is superior for reducing total mortality risk. The results support a continued role for mental health treatments and a larger role for mental health professionals in cardiac rehabilitation.

Background: For exercise prescription, rating of perceived exertion is the subjective tool most frequently used in addition to methods based on percentage of peak exercise variables. The aim of this study was the validation of a subjective method widely called the Talk Test (TT) for optimization of training intensity in patients with recent myocardial revascularization., Design and Methods: Fifty patients with recent myocardial revascularization (17 by coronary artery bypass grafting and 33 by percutaneous coronary intervention) were enrolled in a cardiac rehabilitation programme. Each patient underwent three repetitions of the TT during three different exercise sessions to evaluate the within-patient and between-operators reliability in assessing the workload (WL) at TT thresholds. These parameters were then compared with the data of a final cardiopulmonary exercise testing, and the WL range between the individual aerobic threshold (AeT) and anaerobic threshold (AnT) was considered as the optimal training zone., Results: The within-patient and between-operators reliability in assessing TT thresholds were satisfactory. No significant differences were found between patients' and physiotherapists' evaluations of WL at different TT thresholds. WL at Last TT+ was between AeT and AnT in 88% of patients and slightly

Health-related quality of life (QoL) is an important and widely used outcome measure in cardiac populations. We examined the relationship between positive affect and health-related quality of life, controlling for traditional cardiovascular risk factors, clinical variables and negative affect. We further investigated the role of gender in this relationship given the well-known gender differences in cardiovascular health. We enrolled 746 patients with coronary heart disease (CHD) before they entered outpatient cardiac rehabilitation. All patients completed the Global Mood Scale and the SF-36 Health Survey. Positive affect was independently associated with mental (p < .001) and physical QoL (p < .001) after controlling for control variables. Gender moderated the relationship between positive affect and physical QoL (p = .009) but not mental QoL (p = .60). Positive affect was positively associated with physical QoL in men (p < .001) but not in women (p = .44). The health-related QoL of patients with CHD is associated with a person's level of positive affect.

Background: Sexual dysfunction is a problem for some patients with cardiovascular disease. This study was the final phase of the Cardiac Health and Assessment of Relationship Management and Sexuality (CHARMS) study of sexual function, assessment, and counseling for people with coronary heart disease in Ireland., Objectives: The aim of this study was to explore the perspectives of patients, cardiac rehabilitation staff, and general practitioners on the provision of sexual assessment and counseling within Irish health services and how it can be optimized., Methods: Group interviews with cardiac rehabilitation staff (n = 14) and patients (n = 13) and telephone interviews with general practitioners (n = 9) were conducted. The interviews were semistructured, digitally recorded, transcribed verbatim, and analyzed using qualitative, descriptive analysis., Results: All 3 stakeholder groups reported that the problem of sexual dysfunction among cardiac patients was an important issue that was underaddressed in practice. Patients want the issue to be addressed in an explicit way throughout and after the rehabilitation process by confident and knowledgeable professionals. Cardiac rehabilitators widely acknowledged the role that they could play in the provision of sexual assessment and counseling, but many were constrained by a perceived lack of knowledge and confidence. Most cardiac rehabilitation staff would welcome relevant guidelines and training. General practitioners were unlikely to initiate a discussion about sexual dysfunction; however, most were confident that patients would be comfortable in raising it. General practitioners would welcome more awareness raising but did not identify a need for specific training or resources., Conclusions: Perspectives differed both across and within stakeholder groups about current services and the development of future services. A disconnect exists between the service that the professionals perceive they give and that experienced by patients. Sexual assessment and counseling should be addressed more explicitly, and patients should be empowered to seek individual assessment and counseling at a time that is appropriate for them.

Introduction: Cardiac rehabilitation programs are designed to improve patients' functional capacity, as well as to educate them and to monitor their cardiovascular risk factors., Aim: The study aims to evaluate the effects of cardiac rehabilitation programs in patients with coronary disease over a 12-month follow-up period with regard to control of cardiovascular risk factors., Methods: This was a prospective study of patients diagnosed with coronary disease who completed an exercise-based cardiac rehabilitation program between January 2008 and December 2009 and who were not lost to follow-up. Patients were evaluated at an early stage (first medical consultation in phase II of the program) and 3, 6 and 12 months later, the following parameters being assessed: weight and body mass index, waist circumference, lipid profile, HbA1c in diabetic patients, blood pressure, smoking status and physical activity (using the International Physical Activity Questionnaire)., Results: In the sample of 256 patients (76.2% male, mean age 67 years), dyslipidemia proved to be the most prevalent risk factor (74.2%), followed by overweight (71.5%). There was a statistically significant improvement (p<0,05) in all risk factors studied at the end of phase II of the program, which was maintained at 6 and 12 months of follow-up, with the exception of body mass index (loss of statistical significance at 6-month assessment, p=0,92)., Conclusion: This study highlights the need for cardiac rehabilitation programs in the context of secondary prevention of cardiovascular disease and the importance of implementing strategies that promote long-term maintenance of their benefits., (Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Purpose: Maintenance of exercise after completing phase II cardiac rehabilitation (CR) is challenging for many patients. We offered a telephone-based maintenance intervention and found improvement in exercise participation in the intervention group at 12 months post-CR discharge. We examined the effects of the intervention on psychosocial outcomes., Methods: The effects of a home-based exercise maintenance intervention on psychosocial outcomes among patients who had completed phase II CR versus contact control were evaluated in a randomized controlled trial. Data were collected in 2005 to 2010 and analyzed in 2011. One hundred thirty patients (mean age = 63.6 [SD = 9.7] years, 20.8% female) were randomized to exercise counseling (Maintenance Counseling group, n = 64) or contact control (Contact Control group, n = 66). Maintenance Counseling group participants received exercise counseling (based on the transtheoretical model and social-cognitive theory) delivered via telephone for 6 months, as well as print materials and feedback reports. Assessments of depression, quality of life, and mental health were conducted at baseline, 6 months, and 12 months., Results: The Maintenance Counseling group reported statistically significant higher quality of life than the Contact Control group at 6 months (b = 0.29, SE = 0.08, P < .001) and 12 months (b = 0.27, SE = 0.09, P = .002). Intervention effects on depressive symptoms were significant at 12 months (b = -6.42, SE = 2.43, P = .009). Effects on overall mental health were nonsignificant at both followups. No significant moderators of treatment effects were found., Conclusion: A telephone-based intervention that helped maintain exercise showed statistically significant improvements in quality of life and reduced depressive symptoms in this patient population.

Although obesity is a coronary heart disease risk factor, in cohorts of patients with coronary heart disease, an "obesity paradox" exists whereby patients with obesity have a better prognosis than do leaner patients. Obesity is generally defined by body mass index, with relatively little described regarding body fat (BF). In this study, 581 consecutive patients with coronary heart disease divided into the Gallagher BF categories of underweight (n = 12), normal (n = 189), overweight (n = 214), and obese (n = 166) were evaluated, and 3-year mortality was assessed using the National Death Index. Mortality was U shaped, being highest in the underweight group (25%, p <0.0001 vs all groups) and lowest in the overweight group (2.3%), with intermediate mortality in the normal-BF (6.4%, p = 0.02 vs overweight) and obese (3.6%) groups. In multiple regression analysis, high BF (odds ratio 0.89, 95% confidence interval 0.82 to 0.95) and higher Gallagher class (odds ratio 0.46, 95% confidence interval 0.25 to 0.84) were independent predictors of lower mortality. In conclusion, on the basis of Gallagher BF, an obesity paradox exists, with the highest mortality in the underweight and normal-BF groups and the lowest mortality in the overweight group. Lower BF as a continuous variable and by Gallagher classification as a categorical value were independent predictors of higher mortality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The 6-minute walk test (6 MWT) is widely used to assess exercise tolerance in cardiac rehabilitation (CR). However, previous research shows it to be insufficiently responsive, especially for patients with a relatively high maximal exercise tolerance at baseline. We therefore designed a 6-minute walk/run test (6 MWRT), which has the same duration as the 6 MWT but allows running. The objective of this study was to determine the test-retest reproducibility and responsiveness of this 6 MWRT., Design: Responsiveness was investigated in a prospective cohort study among a group of patients entering CR at Maastricht University Medical Center, with a cross-sectional part to assess the test-retest reproducibility., Methods: Test-retest reproducibility (reliability and agreement) was investigated using the intraclass correlation (ICC) and a Bland-Altman plot of two measurements implemented in the first week of rehabilitation. Responsiveness of the 6 MWT and the 6 MWRT was calculated using the standard response mean (SRM) over a 6-week period., Results: The first reproducibility analysis included 34 patients, the second 22 patients. The ICCs were 0.935 and 0.906, respectively, with limits of agreement of ± 79 and ± 61 m. The responsiveness analysis included 27 patients. The SRM values were 0.83 for the 6 MWT and 0.71 for the 6 MWRT., Conclusions: Although the 6 MWRT is a reproducible test in CR, its responsiveness is not superior to that of the 6 MWT. We therefore prefer the conventional 6 MWT as an evaluative measurement in CR and advise against using the 6 MWRT as (evaluative) measurement in CR for this purpose.

Substantial data have established that higher levels of physical activity (PA), participating in exercise training (ET), and higher overall cardiorespiratory fitness (CRF) provide considerable protection in the primary and secondary prevention of coronary heart disease (CHD). This review surveys data from epidemiological and prospective ET studies supporting the favorable impact of PA, ET, and CRF in primary CHD prevention. Clearly, cardiac rehabilitation and ET (CRET) programs have been underutilized for patients with CHD, particularly considering the effect of CRET on CHD risk factors, including CRF, obesity indices, fat distribution, plasma lipids, inflammation, and psychological distress, as well as overall morbidity and mortality. These data strongly support the routine referral of patients with CHD to CRET programs and that patients should be vigorously encouraged to attend CRET following major CHD events.

Vital exhaustion is an acknowledged psychosocial risk factor of incident coronary heart disease (CHD) and recurrent CHD events. Little is known about trajectories in vital exhaustion in patients with CHD and the factors predicting this change. We hypothesized that vital exhaustion would decrease during outpatient cardiac rehabilitation and that an increase in positive affect over time would be associated with decreased vital exhaustion at discharge from cardiac rehabilitation. We also explored the role of the patient's sex in this context. Vital exhaustion was reduced during outpatient cardiac rehabilitation, especially in patients who experienced an increase in positive affect over time (p < .001). This relationship was significant in men (p < .001) but not in women (p = .11).

Aim: this paper reports the results of a nursing-administered theory-based intervention, the "Moving Heart Program", based on the implementation intention theory and pointed at improving physical activity adherence among coronary heart disease outpatients in Brazil., Methods: this experimental study applied assessments at baseline, 1 and 2 months after baseline. The Consolidated Standards of Reporting Trials statement was followed. Participants were randomly assigned to intervention, comprising action and coping plans on how to deal with anticipated barriers (n=69), or a standard-care control group (n=67)., Results: participants submitted to the intervention showed significant higher levels of physical activity 2 months after baseline and were significantly more active than the control group., Conclusions: the results indicate that the intervention is feasible for patients with coronary heart disease and can be a useful tool to facilitate intended lifestyle changes. This study brings relevant contributions to the Nursing field and other health-related areas, once the intervention presents low cost to health services and can be applied in cardiac rehabilitation programs, showing significant benefits to participants.

The Comprehensive Lifestyle Intervention, which integrates psychological and educational intervention, is a program to improve self-efficacy, self-regulation, self-care, body mass index and quality of life of the patients with coronary heart disease during early stages following hospitalization. The purpose of this study was to investigate the effects of the Comprehensive Cardiac Rehabilitation Program affecting psychological factors including self-efficacy, self-regulation, self-care, quality of life (QoL), and body mass index (BMI). This study was a quasi-experimental research with a repeated one group design. Eighty patients with coronary artery disease were recruited from either the Medicine or Surgical Ward at the Phramongkutklao Hospital where the patients joined the Comprehensive Cardiac Rehabilitation Program, which included attending exercising practice and receiving face-to-face counseling while being admitted to the hospital. Telephone counseling was thereafter performed one week after being discharged from the hospital, followed by undergoing individual or group counseling at the Cardiac Rehabilitation Clinic the following week. The follow-up period was performed within six weeks after hospitalization. Data was collected on two occasions before discharging from the hospital (pretest) and six weeks after (post-test) by using the self-efficacy, self-regulation, and self-care questionnaires, as well as the Short Form(SF) -36 (Thai version). The results indicated that by six weeks, 50%, 58.80%, 46.20%, and 72.50% of patients, respectively, had experienced increases with self-efficacy, self-regulation, self-care, and quality of life scores, while 12.50% of patients had decreased their body mass index in comparison with the pretest score. From the paired t-test, the self-efficacy, self-regulation and quality of life scores were statistically significant, having increased to the p<0.01 level; self-care was statistically significant, having increased to the p<0.05 level along with body mass index, which was statistically significant having experienced a decrease to the p<0.01 level.

Background: Effective goal setting is a vital component of cardiac rehabilitation (CR) programs., Objective: The objectives of this study were to investigate the types of goals set by patients attending a CR program in a tertiary teaching hospital and the compatibility of the goals set with the patient's risk factor profile., Methods: A descriptive, cross sectional, retrospective audit of the medical records of patients who attended the CR program in a tertiary teaching hospital in Sydney NSW between January 2007 and December 2009 was undertaken. The medical records of 355 patients who attended CR within the stipulated time frame were audited., Results: Short and long term goals were set by 104 and 50 patients, respectively. Four themes identified in the analysis of the goal data were reducing behavioural risk factors for further cardiovascular events, improvements in physical symptoms, enhancing mental well being and return to normal life. The majority of the goals related to physical activity (82%)., Conclusion: Collaborative goal setting and the need to establish goals that are attainable and correspond with the patient's health behaviours and clinical measures that require modification is vital.

Aim: The study purpose was to examine how and under what circumstances immigrants combine diabetes self-care with cardiac rehabilitation recommendations., Background: Cardiac rehabilitation can improve and lengthen life in people with coronary heart disease as it promotes healthy physical and psychosocial behaviours and outcomes. This study is the first to examine the convergence of two common issues on participation: (1) the problems posed when cardiac rehabilitation patients must also contend with type II diabetes and (2) the experiences of immigrants in cardiac rehabilitation., Design: A critical ethnographic approach was employed., Methods: Two in depth interviews were conducted with 18 immigrants (eight men, ten women) enrolled in cardiac rehabilitation. Data were collected from 2008-2010., Findings: Threaded throughout immigrant participants' descriptions were biographical accounts of crossing geographical borders, establishing a sense of belonging in their adopted country and trying to feel 'at home' in cardiac rehabilitation. Participants described creative hybridization of transnationally informed knowledges and particularized practices to manage diabetes self-care and to reduce cardiac risk. Participants judiciously considered, assessed and blended knowledges from cardiac rehabilitation, experience with their own bodies and general 'wisdoms' passed on within their own and other immigrant communities., Conclusion: These findings suggest that migration constitutes an important social positioning that contextualizes individual efforts to activate diabetes self-care and cardiac rehabilitation. Support to immigrants may improve when nurses recognize the significance of such experiences. Efforts are needed in practice and research to recognize and explore immigrants' creative efforts to engage in cardiac rehabilitation., (© 2012 Blackwell Publishing Ltd.)

Coronary atherosclerosis is a complex entity with behavioral, genetic and environmental antecedents. Most risk factors for coronary heart disease have a behavioral component. These include tobacco use, hyperlipidemia, hypertension, obesity, insulin resistance, diabetes and physical inactivity. The role of monetary incentives to encourage healthful behaviors related to the prevention and treatment of coronary heart disease has received little attention. In this review, the potential role of monetary incentives to prevent or treat coronary heart disease is discussed. In particular, the potential role of providing incentives for patients to participate in cardiac rehabilitation (CR), a multi-risk intervention, is highlighted., (Copyright © 2011. Published by Elsevier Inc.)

Aims: In a recent genome-wide study, cytosine bases in the F2RL3 gene, which codes for a protein relevant for cardiovascular physiology, were discovered to be hypomethylated in smokers. We aimed to determine the clinical importance of methylation at the F2RL3 locus., Methods and Results: In the KAROLA prospective cohort study, 1206 participants of inpatient cardiovascular rehabilitation programmes after experiencing an acute coronary syndrome, myocardial infarction, or coronary intervention were recruited in two clinics in Germany. Active follow-up was conducted over 8 years. Methylation at loci in F2RL3 was characterized by Sequenom matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Associations of methylation and smoking with secondary cardiovascular events, and cause-specific and all-cause mortality were examined by multiple Cox's regression estimating confounder-controlled hazard ratios. A total of 49 non-fatal myocardial infarctions, 41 non-fatal strokes, 64 cardiovascular deaths, and 50 deaths due to other causes were observed. In Cox's models controlling for established prognostic factors, F2RL3 methylation was strongly associated with mortality. Adjusted hazard ratios (95% confidence intervals) for death from cardiovascular, non-cardiovascular, or any cause were 2.32 (0.97-5.58), 5.16 (1.81-14.7), and 3.19 (1.64-6.21) in subjects in the lowest quartile of methylation in comparison to the highest quartile. In contrast, no association was seen with the combined secondary event outcome. The strong association of smoking with all outcomes was markedly attenuated when F2RL3 was included in the regression models., Conclusion: The results seem to indicate methylation in F2RL3 to be a potential mediator of the detrimental impact of smoking and to be strongly related to mortality among patients with stable coronary heart disease. Multidisciplinary research efforts are needed to unravel prognostic, preventive, and therapeutic potentials of these pronounced associations.