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In 2001-2002 the Italian Working Group on Cardiac Rehabilitation (CR) developed the ISYDE project, a survey on CR in Italy. In 2001, the CR units were 144 (57% in the North of the country), 58% in general hospitals, 23% in private hospitals, 8% in rehabilitative hospital, and only 2% in university clinics. Patients admitted to CR were 60,819 (vs 37.049 in 1996, +64%); 86% of CR units treated > 100 pts/year (vs 66% in 1996; +32%). Patients were admitted to CR units after cardiosurgery in 55% of cases, after myocardial infarction in 22%, and for chronic heart failure in 9.6%, without significant differences respect to 1996. A special survey investigated the work-up performed in patients with recent myocardial infarction. The admission ranges from 11th to 20th day, the mean duration of the CR programs ranges from 21 to 34 days. Most of italian CR units have a definite program for risk stratification and secondary prevention. In particular, the programs of exercise training, educational interventions concerning diet, lifestyle, and smoking cessation, and psychological intervention are well designed, developed, and evaluated before discharge in most cases. In conclusion, although in recent years the number of CR units are increasing, and the quality of care may be well-established by serial evaluations scheduled before discharge and during the long-term follow-up, a further development is mandatory to face the needs of cardiac patients in the post-acute and chronic phase of a cardiac disease.

Cardiac rehabilitation has gained widespread acceptance as an integral component in the management of patients with several forms of cardiac disease. Nevertheless, the benefits deriving from cardiac rehabilitation, and the most appropriate modalities of delivering this treatment, are still uncertain in patients older than 75 years who, beyond a high morbidity and mortality from ischemic heart disease, are characterized by frequent comorbidities, disability, psychological and emotional abnormalities, and cognitive impairment. All these conditions may concur to limit physical exercise capacity, are frequent causes of physical disability and deteriorated quality of life, and are a barrier to enrolling older patients into standardized rehabilitation programs. On the other hand, available evidence on cardiac rehabilitation in older patients derive from non homogeneous patient series, which are not fully representative of the average patient older than 75 years, whose peculiar clinical characteristics are largely different from those of subjects in 65-75 years age range. Therefore, the scientific community should design new strategies to promote recruitment of older individuals into cardiac rehabilitation programs. This can be attained by both spreading the results of beneficial effects of cardiac rehabilitation in advanced age and by precisely identifying the goals, as well as by defining assessment, rehabilitation and follow-up protocols targeting the peculiar characteristics of old and very old patients. This article offers a concise review of available evidence on cardiac rehabilitation in older patients, and a series of recommendations that may be useful in the clinical practice. In the first, introductory section, we describe the main components of comprehensive, cardiac rehabilitation programs of older patients (namely: physical exercise based on both endurance and muscle strength training; the role of multidisciplinary approach integrated into a secondary prevention strategy; interventions in the emotional and cognitive domain), as they result from an extensive analysis of the literature. On this regard, attention will be put to define the specific characteristics by which reported interventions may, or may not, have conformed to the many peculiarities of older individuals. In the further section, results of cardiac rehabilitation of older patients are described organizing them according to the different outcomes attained, with illustration of the effects on cardiocirculatory response to physical exercise, quality of life, body composition, lipid profile, arterial blood pressure control, myocardial ischemia, progression of cardiac failure, neuropsychological and cognitive profile, mortality and morbidity, and cost/benefit analysis. Also in this section, particular attention will be devoted to select and illustrate those results that are most valuable in the management and care of the oldest old. General principles that, based on available evidence, should guide the design of cardiac rehabilitation programs and the prescription of exercise to older cardiac patients, will be detailed next. In particular, we will underline the key role of a comprehensive, preliminary multidimensional and multidisciplinary assessment--whose basic components will also be given in detail-, and will describe the guidelines to design the rehabilitation program, the several methods of training to be used in the different phases of the rehabilitation program, and the most valuable and correct methods to assess both short- and long-term results. The general principles of specific rehabilitation protocols that can be used in older patients will be also described. In this context, we will detail the specific goals and instruments used in the preliminary assessment of cardiocirculatory response to physical exercise, as well as of nutritional habits and nutritional status, physical status and motion capacity, neuropsychological and cognitive profile, quality of life and possible functional limitations. In the last section, educational interventions, and physical endurance and muscle strength training programs, will be described. In this description, particular attention will be devoted to the concept of tailoring the rehabilitative program to the results of preliminary assessment. Indeed, the presence of comorbidity or of significant functional limitations should imply the design of alternative rehabilitation programs, which should be based on strongly individualized modalities as well as intensity and duration of physical exercise training. In summary, this article is intended to encourage and help the cardiological community to recruit even the oldest old into cardiac rehabilitation programs, through an adjustment and individualization process of the rehabilitative pathway that should be based on the enclosed recommendations and guidelines. This could reduce the otherwise high exclusion rate of older patients, who are frequently deprived of the potential benefits from cardiac rehabilitation consisting, at least, in improved functional capacity, neuropsychological and emotional profile, and quality of life.

A sedentary lifestyle has definitively demonstrated to be one of the major risk factors for cardiovascular events as outlined by the American Heart Association. There is mounting evidence in the scientific literature that physical activity and physical fitness have a powerful influence on preventing coronary heart disease. Moreover, protective effects of physical activity have been demonstrated for non-insulin-dependent diabetes, hypertension, obesity. A continued, moderate exercise improves muscular function and strength, the body's ability to take and use oxygen (maximal oxygen consumption or aerobic capacity) and improves the capacity of blood vessel to dilate in response to exercise or hormones. Also muscular strength and flexibility improve after exercise program as well as the ability to perform daily activities, preventing disability particularly in aged people. Cardiac Rehabilitation programs including formal exercise improve quality of life reducing stress and anxiety after an acute coronary event and reduce long-term mortality by 20-25%. Recently published recommendation of Expert panels defined exercise as a key component to health promotion and disease prevention and delineated the intensity of exercise desired.

Objectives: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age-related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI., Design, Setting, and Participants: Data is from baseline assessment of 265 post-MI patients (age range 45-85 years) enrolled in the Cardiac Rehabilitation in Advanced Age randomized, controlled trial. Patients with major comorbidities or severe MI complications were excluded from the trial. Exercise tolerance was determined from symptom-limited exercise testing and expressed as total work capacity (TWC, kg.m) or peak oxygen consumption (VO2peak, mL/kg/min). The associations between both TWC and VO2peak and baseline demographic, social, clinical, and neuropsychological variables and an index of health-related quality of life were determined with univariate and multivariate analysis., Results: With univariate analysis, TWC decreased by 1285 kg.m per decade of increasing age between 45 and 85 years of age. With multivariate analysis, TWC decreased by 922 kg.m per decade. Increasing age (P < .001), female gender (P < .001), a small body surface area (P < .001), a low level of usual physical exercise before MI (P < .002), and the presence of post-MI depressive symptoms (P < .024) were independently associated with a lower TWC. The same factors, in addition to a small arm muscle area (P < .002), were also independently associated with a lower VO2peak., Conclusions: Age per se accounts for approximately 70% of the age-related decay in TWC or VO2peak. However, the inclusion of modifiable factors such as physical exercise and depression in the prediction model reinforces the importance of a multidimensional approach to the evaluation and treatment of older patients with a recent MI.

A program of physical conditioning for the rehabilitation of the patients affected by myocardial infarction is founded on a preliminary ergometric evaluation and on following examinations of the effects of the prescribed treatment. Submaximal ergometric stress tests utilizing non invasive methods which contain sufficient information about the cardiocirculatory response to the physical effort are required. Sixteen patients underwent hemodynamic evaluation, during ergometric stress test, two months after myocardial infarction. A statistical analysis of the results shows a significant correlation between stroke volume and oxygen pulse. The oxygen pulse, under an increasing effort, describes a curve; the end of its ascending limb may be regarded as the point of the maximal stroke volume. The workload where the curve of oxygen pulse changes the slope can be used as the caloric expense which should be safely attained during the physical conditioning.

In order to determinate the incidence, predictivity and prognosis of ventricular fibrillation in the early phase of acute myocardial infarction a series of 301 patients with acute myocardial infarction consecutively assisted by the Mobile Coronary Care Unit of Florence was analyzed. 151 patients (50.2%) received intensive care within 2 hours from the onset of the symptoms, 75 patients (24.9%) received intensive care between the second and sixth hour. 38 patients (12.6%) had at least one episode of ventricular fibrillation. 30% of the episodes of ventricular fibrillation happened within 1 hours from the onset of the symptoms, 47.4% within 2 hours, 74% within 6 hours. Serious arrhythmias complicated the early phase of acute myocardial infarction, but only sinus bradycardia seems to have a significant predicativity of ventricular fibrillation (P less than 0.05). We found that hospital survival resuscitated patients is strictly related to the time between early symptoms and the episode of ventricular fibrillation: 91% of the patients with ventricular fibrillation within 1 hour were discharged alive from hospital, 71% of those with ventricular fibrillation within 6 hours, 20% of those with ventricular fibrillation beyond 6 hours (P less than 0.01). The high rate and the favourable prognosis of ventricular fibrillation in the early phase of acute myocardial infarction must lead to a widespread implementation of rapid response emergency care systems away from hospital.

The aim of Mobile Coronary Care Units (M.C.C.U.) is to reduce the delay in delivering intensive care to patients with a heart attack. In the city of Florence a M.C.C.U. has been available since November 1979. During the first year the staff of the M.C.C.U. has treated 158 cases of serious cardiac arrhythmias which occurred among 486 interventions. In 94 patients cardiac arrhythmias followed an acute coronary attack. In 64 patients coronary heart disease could not be demonstrated. This study concerns the latter group of patients. The mean age was 65.2 years and 39 patients (61%) were women. The mean time from the onset of the symptoms to the arrival of the M.C.C.U. team was 3h and 2 min, whereas the mean time from the call to the arrival was 14 min. Sixty patients had atrial arrhythmias (29 atrial fibrillation, 2 atrial flutter, 22 atrial tachycardia, 7 premature atrial contractions) and 4 patients had ventricular arrhythmias (1 ventricular tachycardia, 1 ventricular flutter, 2 premature ventricular contractions). In thirty-nine patients (61%) the cardiac arrhythmia was abolished by the staff of the M.C.C.U.. Of the remaining 28 patients, 10 were brought to the hospital and 18 were left at home. None of these needed later admission to the hospital. So the treatment at home of cardiac arrhythmias has been successful in the majority of patients. Bunaftine was the antiarrhythmic drug more frequently used (23 cases, 34%) with a high percentage of success (87%). In planning medical emergency services to the community, one can envisage the use of the M.C.C.U. facilities to treat at home those arrhythmias that are not associated with an acute coronary attack.

The effect of IV fructose-1,6-diphosphate (FDP) on transient, reproducible myocardial ischemia was evaluated in ten patients, aged 50 to 66 years, with chronic, stable exertional angina. FDP or placebo (glucose) were administered between basal and posttreatment ergometric stress testing; an identical procedure was repeated in each patient with the second treatment on the following day according to a single-blind, cross-over design. FDP improved exercise tolerance and total work capacity, significantly delaying the onset of ST-segment depression and angina. Nevertheless, the critical level of the rate x pressure (R X P) product, causing appearance of myocardial ischemia, was not remarkably changed. However, the R X P product at same workload was significantly lower after FDP. These results suggest that improved exercise tolerance might have resulted from peripheral (increased oxygen delivery to skeletal muscle) rather than from central (cardiac) effects of FDP.