Abstracts of Plenary Sessions Cardiology 62: 69-81 (1977)
Session I 1
Introduction H. Denolin, Brussels, Belgium
In numerous countries, despite efforts of prevention, the number of ischemic cardiopathies is on the uprise. The level of other forms of cardiopathies, congenital or acquired, remains elevated in other regions. Also it is important to mobilize ef forts to reduce the clinical, physiological, psychological and social consequences of the disease. The totality of these measures, in effect, constitute rehabilitation. During the last few years, numerous modifications have been brought to con ventional treatment, especially in the area of ischemic disease. Much progress has been made in the areas of diagnosis and evaluation. The Council on Rehabilitation of the International Society of Cardiology, created in 1966, has certainly played an important role in this evolution. Also, it has appeared important to its members to focus on the existing situa tion and underline the multiple facets of rehabilitation: detection and evaluation of coronary heart disease; physical training, both early and late, with its clinical results and physiological bases; diagnosis and treatment of the psychological prob lems, including reinsertion into professional life with the problems of occupational medicine; and, finally, an important problem, secondary prevention. On a social level, the organization and results of this rehabilitation are still not devoid of prob lems, some of which remain controversial. The purpose of this conference is to focus on these diverse questions. It is well understood that problems of rehabilita tion in other clinical conditions than myocardial ischemia will be brought out, nota bly arterial hypertension and acquired valvulopathies, even though we are in pos session of fewer scientific facts in these areas. During the last few years, numerous practitioners and numerous centers throughout the world have developed, quite often, very precious experiences. One of the objectives of this congress is to invite them to share their observations and to discuss them. Also let us hope that we can, for the greatest benefit of our patients, develop the situation as it exists and eventually make useful recommendations for the application of these rehabilitative measures and direct the orientation of new research.
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Methodology and Interpretation of Exercise Tests Robert A. Bruce, Seattle, Wash., USA
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Clinical methods for exercise tests involve steps, stairs, bicycle ergometers, treadmills or reverse escalators for rhythmical leg exercise, or cranking devices for arm exercise. Numerous protocols have been devised, but more informative testing
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begins at a low work load, increases progressively and continuously as either step or ramp functions to individually determined symptom-limited end points of maximally tolerated effort within a few minutes. Standardized protocols are characterized by well-defined oxygen costs, acceptability by a broad spectrum of ambulatory per sons, short duration to avoid thermal stress, and demonstrated record of safety. The latter is assured by preliminary clinical and resting ECG examination to iden tify contraindications. It also requires professional monitoring of symptoms, signs, blood pressure and ECG - for changes in rhythm, rate, conduction and ventricular repolarization - during and shortly after such exertion, with predetermined criteria for interrupting effort, and facilities for emergency treatment for the very rare oc casions when either is necessary. Clinical interpretation of responses to exercise testing should provide quanti tative appraisal of an individual’s functional cardiovascular capacity in relation to average normal standards for sex, age and habitual physical activity. Percentage of average normal capacity may be derived by subtraction of functional aerobic im pairment from 100% when the Bruce treadmill protocol is used properly; this im pairment can be readily derived by nomogram from the duration of exercise. Total performance comparisons between individuals are better evaluated at similar relative aerobic requirements, i.e., the percentage relationship of the absolute value of oxygen uptake to the maximal oxygen uptake observed for each individual. In addition to type, severity and duration of symptoms, and any cardiovascular signs elicited by brief reexamination after exercise, several cardiac and circulatory mechanisms of functional impairment can be appraised from the observations at or just after maxi mal exercise evaluated in relation to normal standards. These include anginal chest pain or discomfort, arrhythmias, diastolic gallop(s), systolic murmur of papillary muscle dysfunction, or systolic click of mitral valve prolapse, restricted heart rate or chronotropic impairment, rate-dependent bundle branch block, ST depression of subendocardial ischemia, or ST elevation of transmural ischemia or dyskinesis, limit ed increase or a fall in systolic pressure and reduced product of systolic pressure and heart rate at maximal exertion of functional left ventricular impairment, and transient, postexertional T wave elevation of hyperkalemia. Overall performance is defined by a shortened duration of exertion and a reduced intensity of the work load or rate of oxygen uptake. Abnormal symptoms and cardiac performance also have prognostic value in relation to subsequent clinical manifestations of coronary heart disease in healthy men or in relation to subsequent risk of cardiac mortality, especially sudden car diac death, in ambulatory patients with clinically established coronary heart disease. With serial exercise testing, the functional changes in relation to natural history and to various types of treatment, including physical training for cardiac rehabili tation, may be quantified, and the relative contribution of cardiac and peripheral adaptations may be assessed. Necessary details and representative examples will be presented. Exercise Electrocardiography /. P. Broustet, Bordeaux, France Abstract not submitted Downloaded by: Lund University Libraries 130.235.66.10 - 1/1/2019 6:35:14 PM
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Computers in Exercise Electrocardiography M. L. Simoons, Rotterdam, The Netherlands
Symptom-limited exercise tests with stepwise work load increments on a bicy cle ergometer or on a treadmill are frequently used for screening of cardiac patients prior to participation in a rehabilitation program. These tests should be carried out under direct medical supervision. At the thorax center, a computer system is currently in use which performs the following functions: (1) automated regulation of the work load following a predetermined protocol; (2) analysis of the ST segment and its changes at l-min intervals during the test, and (3) generation of the full report of the test. A program for real time arrhythmia analysis is under development. Since the introduction of the computer system, the amount of time spent by the physician and the technician on each test has been considerably reduced. Quantitative analysis of the ST segment during exercise in male subjects with a normal ECG at rest provided a better prediction of the presence of coronary artery disease (sensitivity 88%, specificity 90%) than visual interpretation according to established criteria (sensitivity 50%, specificity 95%) both in a training group and in an independent test group. In patients after a myocardial infarction, the orientation of the ST changes appeared to be related to the location and to the extent of dyskinetic areas of the left ventricular wall. Anterior or lateral dyskinesis corresponds with anteriorly oriented ST shift during exercise, and inferior dyskinesis with inferiorly or posteriorly oriented ST shifts. The magnitude of the ST changes in these patients can be related to the heart rate changes during exercise and can thus be used as an estimation of the presence of myocardial ischemia during the test. With the computer system the exercise ECG can be analyzed in a quantitative manner at various intervals after the acute episode. This method is expected to aid the evaluation of the effect of rehabilitation in individual patients.
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Ventricular Function Delry, Brussels, Belgium Abstract not submitted
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Place of Coronaro- and Ventriculography in Cardiac Rehabilitation H. Roskamm, Bad Krozingen, FRG
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Coronary arteriography and left heart ventriculography should be performed in patients with coronary heart disease, when coronary bypass surgery or aneurys mectomy is being considered. The analysis of the correlation between the results of noninvasive diagnostic methods and the findings of coronary arteriography gives useful directives for the selection of patients to this obligatory diagnostic procedure prior to surgery. In patients with angina pectoris and having no previous transmural myo cardial infarction, the frequency of severe coronary artery disease - as left main
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coronary artery disease or three-vessel disease - significantly increases with the degree of ischemic ST-segmcnt depression and reduction of exercise tolerance. In patients with previous transmural infarction, the presence or absence of significant lesions in vessels, other than the one which belongs to the infarcted area, has importance regarding coronary bypass surgery. The involvement of additional vessels can be predicated on the basis of angina pectoris and/or ischemic ST-segment depression occurring during exercise. Severe narrowing (over 75%) of one or two additional vessels was found in 61.7% of patients with previous inferior myocardial infarction who developed angina pectoris and ischemic ST-segment depression dur ing exercise, whereas this finding was present only in 3.4% in patients who com pleted the exercise test without angina pectoris and ST-segment depression. Patients with noninvasive (ECG and X-ray) evidences of left ventricular aneurysma should be investigated by coronary arteriography and ventriculography prior to surgery if left heart failure, or ventricular arrhythmias cannot be controlled by drug therapy.
Session II 7
Physiology of Training in Normal and Coronary Patients Sanne, Göteborg, Sweden Abstract not submitted
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Methodology of Physical Training, Principles of Training and Exercise Prescription D. L. Dorossiev, Bankja, Bulgaria
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Based on sound experience with athletes and sedentary healthy individuals, repetitive dynamic exercising of large muscle groups (mainly of the legs) three or more times weekly, taxing over 75% of peak oxygen uptake for at least 30 min, has been shown to improve also in highly selected groups of IHD patients with near normal cardiac function (without or with previous MI) their physical perfor mance capacity including central circulatory and peripheral effects. Hence, the accepted aims of physical training in cardiac patients, although awaiting further precision, are set to (1) overcome deconditioning, improve physical fitness; (2) remove symptoms (angina pectoris) and psychological changes (anxiety, depression); (3) enhance cardiac function (reduce cardiac cost of external work); (4) produce favourable metabolic changes (muscle metabolic patterns, plasma lipids, fibrinolysis), and (5) obtain secondary preventive effects. Methods to provide the desired training
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results (level, frequency and duration of exercise) without major hazards are still empiric. Assessment of patients prior to training should define heart structure (preferably by non-invasive techniques), function, and overall fitness based on cardiovascular and other work parameters. A heterogeneous group of patients with different aims of training will require different approach, although common principles can already be formulated: intensity of training is more critical than duration, should be derived from preliminary tests and quantified in terms of meta bolic cost and cardiac demand (as percent of oxygen uptake, METS, percent of real maximal heart rate, relation to ‘limiting exercise loading’, etc.). Intensity of training should push the heart to maximal stroke volume and exceed 60% of actual aerobic capacity. Work both with legs and arms should be included, avoiding iso metric exercises and Valsalva manoeuvres. Practical considerations will dominate the design of exercise programmes using methods of equivalence of activities. Response to exercise prescription should be known (a treadmill or bicycle ergometer may be included in circuit routine of 4-8 different exercises). Target levels for exercise prescription should not be restricted to heart rate (HR) since abnormal elevation of arterial blood pressure (BP) may impose extreme loads upon the heart. Pressure rate products (PRP = HR x BP) can be used as a more universal indicator. Tables of PRP values related to oxygen uptake and external work for normotensive and hypertensive males (without or with previous MI) are presented. The patient’s motivation as a factor for the success of training is stressed (need of health educa tion, information on progress in his performance).
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Methodology of Physical Training, Practical Implementation by the Physiotherapist Hoylaerts, Brussels, Belgium Abstract not submitted
Secondary Prevention and Associated Drug Therapy K. Donat, Hamburg, FRG
The Hamburg Model is a form of rehabilitation for patients with myocardial infarction. The organization of these comprehensive coronary infarction rehabilita tion program, that stretches from the cardiac care unit to a normal active life, will be presented. In its last phase, this organization relies on the coronary infarction groups within neighborhood sports clubs. Meaningful transfer to rehabilitation clinics and advancement of social insurance-supported medical treatment as well as neighborhood care programs are planned economically by central coordination. Two groups of patients recovering from myocardial infarction have been observed during 1-2 years. One group performed the physical program in their home town whereas the other was rather inactive. Physical performance capacity was much improved in the active group and some risk factors for myocardial infarction (smoking, elevated serum lipids) decreased. Of great importance was the improve ment of the psychological situation of patients in the active group, resulting in their
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earlier return to work. The rate of cardiac complications with exercise is minimal if participants are properly selected. Complications are less in the active group, a longer survival, however, has not yet been demonstrated. The results of the Ham burg Model are representative for other forms of comprehensive coronary infarc tion rehabilitation and secondary prevention.
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General Aspects Secondary Prevention after Myocardial Infarction Dag Elmfeldt, Lars Wilhehnsen, Anders Vedin, Claes Wilhelmsson, A ke Hjahnarson, Robert Bergstrand and Harald Sanne, Göteborg, Sweden
The natural history of myocardial infarction (MI) as well as secondary preven tive measures after a MI were studied in a representative series of patients who had been discharged alive from hospital. The risk of death during a follow-up period of 2 years was mainly associated with variables related to the extension of the myo cardial damage. Mortality could be well predicted by means of a multiple logistic regression function, but non-fatal reinfarction was related to other factors. The mortality and the non-fatal reinfarction rate during the 2-year follow-up were lower in a series of 231 males who stopped smoking after their first MI when compared to 174 patients who continued to smoke. The 5-year mortality also dif fered significantly between those who stopped smoking and continuing smokers. In spite of treatment of high blood pressure there was a higher incidence of non-fatal reinfarction among 184 hypertensive men compared to 320 normotensive men having survived a first MI. The mortality did not differ between the groups during the 2-year follow-up. The level of serum cholesterol was not related to the prognosis after the infarct in a series of 996 men with a first MI. The possible secondary preventive effect of supervised physical training was analysed in a randomized study. There were no differences in mortality or nonfatal reinfarction rate between the 158 trainees when compared to the 157 controls during the 4-year follow-up, but the physical performance improved. 96 male patients who were followed at a special post-myocardial infarction clinic for 2 years had a lower non-fatal reinfarction rate than 85 controls, but no difference in mortality was found. The rate of sudden death was reduced in a group of 114 patients given continuous ^-receptor blockade during the 2-year follow-up when compared to 116 controls.
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Rehabilitation versus Surgery M. M. Gertler, New York, N.Y., USA Abstract not submitted
Prescription of Vocational and Leisure Activities: Practical Aspects H. Hellerstein, Cleveland, Ohio, USA Abstract not submitted
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Session III
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Assessment and Approach to the Patient J. E. Acker, Knoxville, Tenn., USA Abstract not submitted
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Psychological Approach E. Cay, Edinburgh, England Abstract not submitted
Group Therapy in Cardiac Rehabilitation Thomas P. Hackett, Harvard, Mass., USA
A review of literature, pertaining to the use of groups in MI convalescence, will be presented. A brief discussion will be given of the types of cardiac groups currently in use: exercise, activity, education, relaxation, autohypnosis, etc. The organization of groups will be discussed. Should the group be continuous and ongo ing with new members added as the old drop out? Most agree that membership should not exceed 12. Ought the group consist of those with uncomplicated Mis or a mixture of patients with different prognoses? Should it start in the hospital with the leader meeting the individual while he is still convalescing or after discharge? Should the group contain spouses, or should these be treated in another group? What is the most effective periodicity: weekly? biweekly? monthly? Should the groups have a fixed duration of 3 months? 6 months? 1 year? What financial ar rangements can be made for remuneration. What are the most effective ways for running the groups? It is the consensus that the leader should be an informed, empathetic individual with considerable medical authority such as a nurse-clinician or a doctor. The co-leader, if one is used, should be a lay person who has been specially educated in heart disease and group dynamics. It is the consensus that the primary goal of therapy should not be insight. Psychodynamic group therapy techniques arc not popular with MI patients. Rather, the group should be primarily educative in nature, with a large component of experience sharing. The group leaders must, however, know group dynamics to handle group process, particularly in response to the death of a member through MI. Goals of the group are (1) to alter faulty habits (smoking, sedentary living, diet); (2) to learn the facts of the illness and to correct misconceptions; (3) to reduce loneliness and alienation through con tact with others sharing the same problem; (4) to facilitate return to work and nor mal socializing; (5) to identify special problems (e.g. unwarranted invalidism) for referral; (6) to reduce overall stress through information, group support and thera peutic leadership, and (7) to promote research which will determine the therapeutic usefulness of the group through controlled study.
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Organization of Services K. König, Waldkirch, FRG
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As far as the organizing of institutions which deal with cardiological rehabili tation is concerned, there are no ideal solutions which are valid in general. The various possibilities depend on certain socioeconomic factors and regional traditions. With special regard to the three-phase concept of the WHO, a systematization of the present usual forms of cardial rehabilitation after heart infarct yields the follow ing picture: After the end of phase I (hospitalization), the rehabilitation is continued in phase II (convalescence phase) in the form of (1) stationary ‘comprehensive care’ in a specialized rehabilitation center for 4-6 weeks (Anschlussheilbehandlung); (2) ambulatory care in a special rehabilitation department connected with a university medical center or a large hospital; (3) ambulatory care in so-called coronary clubs which have only loose, if any at all, connection with clinical institutions, and (4) unorganized ambulatory care of a house doctor. For the conditions 1-4, respectively, there are the following possibilities for the continuation of the practically lifelong rehabilitation in phase III (postconvales cence or maintenance phase): Condition 1: (a) Follow-up at the same rehabilitation center in regular shorter intervals (ambulatory, about biannual) or in longer intervals (stationary, about bien nial); (b) continuation of the rehabilitation in coronary clubs; a combination of a and b is also possible. Condition 2: (a) Follow-up in regular intervals in the same department depend ing on local capacity; (b) continuation of the rehabilitation in coronary clubs or a combination of a and b. Condition 3: Continued care in coronary clubs. Condition 4: Continued care of a house doctor. There are contradicting opinions, above all concerning phase II, with regard to the efficiency as well as the cost-benefit relation. The advantages and disadvan tages of the various systems are being discussed; the decisive argument for the stationary rehabilitation in a rehabilitation center (condition 1) is the optimal appli cation of comprehensive care with its various diagnostic-therapeutic, psychosocial and educational aspects. The patient in a group is more easily motivated to change harmful living habits. The principle of comprehensive care is likewise feasible for the conditions of ambulatory rehabilitation in a special department (condition 2), however, the inten sity and, therefore, the efficiency would have to be less; exact results of this method are indeed lacking. The rehabilitation in coronary clubs (condition 3) will be able to realize mainly the psychosocial, but also the educational care only fragmentarily; it also entails the danger in phase II that overburdening of the patients will not be recognized, or recognized too late, because of seldom or insufficient control tests. The domain of the coronary clubs is the lifelong care in phase III. The unorganized care of a house doctor exclusively can hardly be considered a form of rehabilitation to be recommended; in view of certain socioeconomic con ditions, this form of rehabilitation will have to be accepted in certain regions for
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some time to come; it demands a great deal of personal dedication on the part of the house doctor.
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Health Education M. J. Halhuher, Bernried, FRG Abstract not submitted
Session IV 19
Results in Rehabilitation of Coronary Patients Veikko Kallio, Turku, Finland
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Studies of the effects of cardiac rehabilitation can be divided into several categories depending on the aims of the rehabilitation programme and methods used. Physical training programmes, aimed at increasing the physical capacity of patients after acute myocardial infarction (AMI), have been evaluated by several investigators. Short-term progressive exercise training courses have been found to be feasible resulting in haemodynamic changes and improvement of exercise tolerance comparable with those seen in healthy people. However, in a few controlled studies on patients after AMI, no significant differences in ergometric performance between the physical training and control groups were found. This is partly due to the high drop-out rate from the regular training programme, too low intensity of training as well as activation of the control group. The effect of a physical training programme on return to work is favourable, according to some studies, while in a few recent controlled studies no significant effect in this respect could be shown. A comprehensive rehabilitation programme including secondary preventive measures has been used in two ongoing Finnish studies (Turku and Helsinki) co ordinated by WHO. They aim at evaluating its effects on return back to work, quality of life in general and, finally, as an important aim of the WHO-coordinated multicentre study, on mortality and morbidity. The two controlled studies include together 73 women and 301 men with AMI under the age of 65. Evaluation methods have been carefully standardized between the centres, while the intervention pro grammes differ from each other. Return to work was similar in the intervention and control group in Turku while a difference in favour of the intervention group was seen in Helsinki. Rehabilitation seemed to have a positive effect on quality of life. The cumulative mortality after a follow-up period of about 3 years is 12.8% in the intervention group and 19.9% in the controls. Sudden deaths in the control group are twice as common as in the intervention group.
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Rehabilitation in Arterial Hypertension Rune Sannerstedt, Göteborg, Sweden
In comparison with coronary heart disease, experience of physical conditioning in patients with arterial hypertension is very limited. The studies reported have used a wide variety of training programmes of varying length making a comparison of the results obtained difficult. However, an analysis of available data from the literature and our own experimental results so far indicate that physical condition ing in patients with early, latent arterial hypertension of the hyperkinetic type yields a lower blood pressure level both at rest and during physical exercise. On the other hand, convincing evidence that such procedures lower the blood pressure in patients with established, normokinetic arterial hypertension is lacking. Nevertheless, these patients should be encouraged to maintain a good level of physical fitness as part of a programme of general measures also including correction of over-weight, limitation of salt intake and abstention from smoking. The possibility that physical training in individuals with early, latent arterial hypertension results in haemo dynamic changes of sufficient magnitude to keep the blood pressure permanently at a lower level, thereby postponing the start of drug treatment, making previous drug treatment superfluous, or at least the lessening of the amounts of antihypertensive drugs needed, is worth testing further. Our present experimental programme for evaluation of this question, including both dynamic and isometric training, is out lined.
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Rehabilitation in Acquired Valvular Diseases - Survey Vincenzo Rulli, Rome, Italy
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In the last years, the rehabilitation of cardiac patients has achieved very im portant progress both on the ground of the scientific knowledge and on the practical and organizational ground. The physiological and clinical bases of rehabilitation have been quite clearly established; the related psychological and social problems have been thoroughly analyzed; the most suitable techniques, devised to reach, as far as possible, the earlier and most successful requalification, particularly in the patients suffering from ischemic cardiac disease, are well known. Referring to the foregoing disease, we are today quite sure about the actual advantages related to rehabilitative treat ment, at least as to the improvement of the functional capacity. Available data about the rehabilitation of patients with acquired valvular dis eases are quite less numerous and not examined thoroughly at all. Some very in teresting attempts about this subject have been made in the last years but, later, they have not been followed by numerous practical applications and not prolonged enough to allow substantial and general formulation of these ideas. In fact, the rehabilitative experiences in this field are rather lacking and the characterizing physiopathologic bases of valvular diseases appear discouraging. But, first of all, it is necessary to consider two different aspects related to the rehabilitation of this type of patients: rehabilitation of the patients who did not undergo surgery and rehabilitation of patients who did. In the first event, when the
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patients are not operated, the concept of rehabilitation must be relied upon the maintenance of a good physical condition and the prevention of every deterioration. This goal can be achieved especially by appropriate drug therapy and style of life. However, it seems quite obvious that the patients with valvular diseases belonging to the first class of NYHA may undergo also a physical training with the aim of keeping a good functional capacity. The patients belonging to the second and third classes will find, on the contrary, a definite indication for surgery, well bearing in mind, however, that patients of the second class, for whom surgery had been post poned for some reason, may, within limits, show improvement from physical activ ity, able to keep and maintain good functional conditions, at least till the surgery may be effected. For patients belonging to the third class and waiting for surgery, the rehabilita tion may consist in improving the respiratory parameters, cardiac function by drug therapy and psychological conditions. The treatment will be useful in obtaining a reduction of the post-surgery sequelae and will shorten immediately the post-surgery period; after that, the rehabilitation will be started again. In patients who underwent surgery, and without complications, physical recon ditioning may increase the rapidity of progress to good physical and mental condi tions and to the work resumption. It must be stressed that the psychological recon ditioning is always important in the rehabilitation of patients wih valvular diseases as well as in familial, social and juridicial attitudes, also if diversified in various systems of health organization.
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WHO Collaborative Study on Rehabilitation and Comprehensive Secondary Prevention of Patients after Acute Myocardial Infarction G. Lamm and D. L. Dorossiev, Copenhagen, Denmark
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Rehabilitation should be considered as an integral part of comprehensive care for cardiac patients since evidence shows that it contributes to early somatic and psychical recovery, especially in patients with acute myocardial infarction (AMI). Data from the WHO project on AMI registers have, however, shown that during the 2nd and 3rd months after the attack only 19% of the patients followed a rehabili tation programme in Europe. Under WHO coordination, a prospective controlled study was started in June 1973 to assess how far intensive rehabilitation and com prehensive secondary prevention after AMI can prevent reinfarction, prolong life and enhance its quality. Until October 1975, 2,770 male patients with confirmed AMI aged up to 65 years were accepted in the study from 24 centres (23 in Europe and 1 in Israel). They were randomized into an intervention group (n = 1,500) receiving comprehensive rehabilitation and secondary prevention (graded physical activity, intervention on risk factors, appropriate medical treatment, psycho-social and voca tional evaluation and intervention) and a control group (n= 1,270) which was left to the existing routine medical care. Both groups were reviewed at 12-month inter vals according to a common protocol. Extensive efforts were devoted to standardi zation of methods and measurements (exercise testing, coding of ECGs, X-ray, serum lipids, glucose tolerance test, measurement of heart volume), whereas the evaluation and quantification of psycho-social factors proved extremely difficult
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and biased. Interim evaluation of the progress of the study has already demon strated considerable difficulties and sources of potential errors in the randomiza tion procedures, the comparability of groups with respect to risk factor levels and actual comprehensiveness of intervention, alongside with rates of drop-in and drop out patients in the two groups. These findings point to the extreme complexity and difficulty in the collection, pooling and handling of data in cooperative controlled studies in cardiac rehabilitation. Multiple logistic approaches in analysis may be needed to make the best possible use of data collected. The follow-up will be com pleted by the end of 1978 when the target minimum of 6,900 patient-years of obser vation may be reached. The final evaluation will be carried out in 1979. The study is supposed to provide then information on the long-term effects of comprehensive secondary prevention.
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Activities of Rehabilitation International H. Renker, Halle, FRG Abstract not submitted
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National Exercise and Heart Disease Programs Naughton, Buffalo, N.Y., USA Abstract not submitted
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World Rehabilitation Fund M. M. Gertler, New York, N.Y., USA Abstract not submitted
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Future of Rehabilitation - Components of Routine Cardiac Care N. K. Wenger, Atlanta, Ga., USA
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Rehabilitative efforts for the patient after myocardial infarction and for the patient after aortocoronary bypass surgery must be integrated into a comprehensive program of acute and ambulatory cardiac care. They should involve the patient’s primary physician; should involve the patient’s family and social environment as a support system; and should have as a component the training of young cardiologists in rehabilitation concepts and methodology. Important questions yet to be answered include (1) the mechanism(s) of im provement of physical work capacity and cardiocirculatory performance with physical training; (2) the effect of exercise on the natural history of coronary atherosclerotic heart disease and the atherosclerotic process; (3) the effect of exer cise training on coronary collateral flow and myocardial perfusion; (4) the hemo dynamic effects and the effect on myocardial contractility of early mobilization
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after myocardial infarction; (5) the criteria for identifying subgroups of myocardial infarction and postsurgery patients most likely to require and/or benefit from rehabilitative services; (6) the long-term economic implications of cardiac rehabili tative services, and (7) the identification of the most efficient, safest, and most effective manner of implementing programs for cardiac rehabilitation.
Session I 1
Introduction H. Denolin, Brussels, Belgium
In numerous countries, despite efforts of prevention, the number of ischemic cardiopathies is on the uprise. The level of other forms of cardiopathies, congenital or acquired, remains elevated in other regions. Also it is important to mobilize ef forts to reduce the clinical, physiological, psychological and social consequences of the disease. The totality of these measures, in effect, constitute rehabilitation. During the last few years, numerous modifications have been brought to con ventional treatment, especially in the area of ischemic disease. Much progress has been made in the areas of diagnosis and evaluation. The Council on Rehabilitation of the International Society of Cardiology, created in 1966, has certainly played an important role in this evolution. Also, it has appeared important to its members to focus on the existing situa tion and underline the multiple facets of rehabilitation: detection and evaluation of coronary heart disease; physical training, both early and late, with its clinical results and physiological bases; diagnosis and treatment of the psychological prob lems, including reinsertion into professional life with the problems of occupational medicine; and, finally, an important problem, secondary prevention. On a social level, the organization and results of this rehabilitation are still not devoid of prob lems, some of which remain controversial. The purpose of this conference is to focus on these diverse questions. It is well understood that problems of rehabilita tion in other clinical conditions than myocardial ischemia will be brought out, nota bly arterial hypertension and acquired valvulopathies, even though we are in pos session of fewer scientific facts in these areas. During the last few years, numerous practitioners and numerous centers throughout the world have developed, quite often, very precious experiences. One of the objectives of this congress is to invite them to share their observations and to discuss them. Also let us hope that we can, for the greatest benefit of our patients, develop the situation as it exists and eventually make useful recommendations for the application of these rehabilitative measures and direct the orientation of new research.
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Methodology and Interpretation of Exercise Tests Robert A. Bruce, Seattle, Wash., USA
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Clinical methods for exercise tests involve steps, stairs, bicycle ergometers, treadmills or reverse escalators for rhythmical leg exercise, or cranking devices for arm exercise. Numerous protocols have been devised, but more informative testing
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begins at a low work load, increases progressively and continuously as either step or ramp functions to individually determined symptom-limited end points of maximally tolerated effort within a few minutes. Standardized protocols are characterized by well-defined oxygen costs, acceptability by a broad spectrum of ambulatory per sons, short duration to avoid thermal stress, and demonstrated record of safety. The latter is assured by preliminary clinical and resting ECG examination to iden tify contraindications. It also requires professional monitoring of symptoms, signs, blood pressure and ECG - for changes in rhythm, rate, conduction and ventricular repolarization - during and shortly after such exertion, with predetermined criteria for interrupting effort, and facilities for emergency treatment for the very rare oc casions when either is necessary. Clinical interpretation of responses to exercise testing should provide quanti tative appraisal of an individual’s functional cardiovascular capacity in relation to average normal standards for sex, age and habitual physical activity. Percentage of average normal capacity may be derived by subtraction of functional aerobic im pairment from 100% when the Bruce treadmill protocol is used properly; this im pairment can be readily derived by nomogram from the duration of exercise. Total performance comparisons between individuals are better evaluated at similar relative aerobic requirements, i.e., the percentage relationship of the absolute value of oxygen uptake to the maximal oxygen uptake observed for each individual. In addition to type, severity and duration of symptoms, and any cardiovascular signs elicited by brief reexamination after exercise, several cardiac and circulatory mechanisms of functional impairment can be appraised from the observations at or just after maxi mal exercise evaluated in relation to normal standards. These include anginal chest pain or discomfort, arrhythmias, diastolic gallop(s), systolic murmur of papillary muscle dysfunction, or systolic click of mitral valve prolapse, restricted heart rate or chronotropic impairment, rate-dependent bundle branch block, ST depression of subendocardial ischemia, or ST elevation of transmural ischemia or dyskinesis, limit ed increase or a fall in systolic pressure and reduced product of systolic pressure and heart rate at maximal exertion of functional left ventricular impairment, and transient, postexertional T wave elevation of hyperkalemia. Overall performance is defined by a shortened duration of exertion and a reduced intensity of the work load or rate of oxygen uptake. Abnormal symptoms and cardiac performance also have prognostic value in relation to subsequent clinical manifestations of coronary heart disease in healthy men or in relation to subsequent risk of cardiac mortality, especially sudden car diac death, in ambulatory patients with clinically established coronary heart disease. With serial exercise testing, the functional changes in relation to natural history and to various types of treatment, including physical training for cardiac rehabili tation, may be quantified, and the relative contribution of cardiac and peripheral adaptations may be assessed. Necessary details and representative examples will be presented. Exercise Electrocardiography /. P. Broustet, Bordeaux, France Abstract not submitted Downloaded by: Lund University Libraries 130.235.66.10 - 1/1/2019 6:35:14 PM
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Computers in Exercise Electrocardiography M. L. Simoons, Rotterdam, The Netherlands
Symptom-limited exercise tests with stepwise work load increments on a bicy cle ergometer or on a treadmill are frequently used for screening of cardiac patients prior to participation in a rehabilitation program. These tests should be carried out under direct medical supervision. At the thorax center, a computer system is currently in use which performs the following functions: (1) automated regulation of the work load following a predetermined protocol; (2) analysis of the ST segment and its changes at l-min intervals during the test, and (3) generation of the full report of the test. A program for real time arrhythmia analysis is under development. Since the introduction of the computer system, the amount of time spent by the physician and the technician on each test has been considerably reduced. Quantitative analysis of the ST segment during exercise in male subjects with a normal ECG at rest provided a better prediction of the presence of coronary artery disease (sensitivity 88%, specificity 90%) than visual interpretation according to established criteria (sensitivity 50%, specificity 95%) both in a training group and in an independent test group. In patients after a myocardial infarction, the orientation of the ST changes appeared to be related to the location and to the extent of dyskinetic areas of the left ventricular wall. Anterior or lateral dyskinesis corresponds with anteriorly oriented ST shift during exercise, and inferior dyskinesis with inferiorly or posteriorly oriented ST shifts. The magnitude of the ST changes in these patients can be related to the heart rate changes during exercise and can thus be used as an estimation of the presence of myocardial ischemia during the test. With the computer system the exercise ECG can be analyzed in a quantitative manner at various intervals after the acute episode. This method is expected to aid the evaluation of the effect of rehabilitation in individual patients.
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Ventricular Function Delry, Brussels, Belgium Abstract not submitted
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Place of Coronaro- and Ventriculography in Cardiac Rehabilitation H. Roskamm, Bad Krozingen, FRG
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Coronary arteriography and left heart ventriculography should be performed in patients with coronary heart disease, when coronary bypass surgery or aneurys mectomy is being considered. The analysis of the correlation between the results of noninvasive diagnostic methods and the findings of coronary arteriography gives useful directives for the selection of patients to this obligatory diagnostic procedure prior to surgery. In patients with angina pectoris and having no previous transmural myo cardial infarction, the frequency of severe coronary artery disease - as left main
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coronary artery disease or three-vessel disease - significantly increases with the degree of ischemic ST-segmcnt depression and reduction of exercise tolerance. In patients with previous transmural infarction, the presence or absence of significant lesions in vessels, other than the one which belongs to the infarcted area, has importance regarding coronary bypass surgery. The involvement of additional vessels can be predicated on the basis of angina pectoris and/or ischemic ST-segment depression occurring during exercise. Severe narrowing (over 75%) of one or two additional vessels was found in 61.7% of patients with previous inferior myocardial infarction who developed angina pectoris and ischemic ST-segment depression dur ing exercise, whereas this finding was present only in 3.4% in patients who com pleted the exercise test without angina pectoris and ST-segment depression. Patients with noninvasive (ECG and X-ray) evidences of left ventricular aneurysma should be investigated by coronary arteriography and ventriculography prior to surgery if left heart failure, or ventricular arrhythmias cannot be controlled by drug therapy.
Session II 7
Physiology of Training in Normal and Coronary Patients Sanne, Göteborg, Sweden Abstract not submitted
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Methodology of Physical Training, Principles of Training and Exercise Prescription D. L. Dorossiev, Bankja, Bulgaria
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Based on sound experience with athletes and sedentary healthy individuals, repetitive dynamic exercising of large muscle groups (mainly of the legs) three or more times weekly, taxing over 75% of peak oxygen uptake for at least 30 min, has been shown to improve also in highly selected groups of IHD patients with near normal cardiac function (without or with previous MI) their physical perfor mance capacity including central circulatory and peripheral effects. Hence, the accepted aims of physical training in cardiac patients, although awaiting further precision, are set to (1) overcome deconditioning, improve physical fitness; (2) remove symptoms (angina pectoris) and psychological changes (anxiety, depression); (3) enhance cardiac function (reduce cardiac cost of external work); (4) produce favourable metabolic changes (muscle metabolic patterns, plasma lipids, fibrinolysis), and (5) obtain secondary preventive effects. Methods to provide the desired training
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results (level, frequency and duration of exercise) without major hazards are still empiric. Assessment of patients prior to training should define heart structure (preferably by non-invasive techniques), function, and overall fitness based on cardiovascular and other work parameters. A heterogeneous group of patients with different aims of training will require different approach, although common principles can already be formulated: intensity of training is more critical than duration, should be derived from preliminary tests and quantified in terms of meta bolic cost and cardiac demand (as percent of oxygen uptake, METS, percent of real maximal heart rate, relation to ‘limiting exercise loading’, etc.). Intensity of training should push the heart to maximal stroke volume and exceed 60% of actual aerobic capacity. Work both with legs and arms should be included, avoiding iso metric exercises and Valsalva manoeuvres. Practical considerations will dominate the design of exercise programmes using methods of equivalence of activities. Response to exercise prescription should be known (a treadmill or bicycle ergometer may be included in circuit routine of 4-8 different exercises). Target levels for exercise prescription should not be restricted to heart rate (HR) since abnormal elevation of arterial blood pressure (BP) may impose extreme loads upon the heart. Pressure rate products (PRP = HR x BP) can be used as a more universal indicator. Tables of PRP values related to oxygen uptake and external work for normotensive and hypertensive males (without or with previous MI) are presented. The patient’s motivation as a factor for the success of training is stressed (need of health educa tion, information on progress in his performance).
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Methodology of Physical Training, Practical Implementation by the Physiotherapist Hoylaerts, Brussels, Belgium Abstract not submitted
Secondary Prevention and Associated Drug Therapy K. Donat, Hamburg, FRG
The Hamburg Model is a form of rehabilitation for patients with myocardial infarction. The organization of these comprehensive coronary infarction rehabilita tion program, that stretches from the cardiac care unit to a normal active life, will be presented. In its last phase, this organization relies on the coronary infarction groups within neighborhood sports clubs. Meaningful transfer to rehabilitation clinics and advancement of social insurance-supported medical treatment as well as neighborhood care programs are planned economically by central coordination. Two groups of patients recovering from myocardial infarction have been observed during 1-2 years. One group performed the physical program in their home town whereas the other was rather inactive. Physical performance capacity was much improved in the active group and some risk factors for myocardial infarction (smoking, elevated serum lipids) decreased. Of great importance was the improve ment of the psychological situation of patients in the active group, resulting in their
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earlier return to work. The rate of cardiac complications with exercise is minimal if participants are properly selected. Complications are less in the active group, a longer survival, however, has not yet been demonstrated. The results of the Ham burg Model are representative for other forms of comprehensive coronary infarc tion rehabilitation and secondary prevention.
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General Aspects Secondary Prevention after Myocardial Infarction Dag Elmfeldt, Lars Wilhehnsen, Anders Vedin, Claes Wilhelmsson, A ke Hjahnarson, Robert Bergstrand and Harald Sanne, Göteborg, Sweden
The natural history of myocardial infarction (MI) as well as secondary preven tive measures after a MI were studied in a representative series of patients who had been discharged alive from hospital. The risk of death during a follow-up period of 2 years was mainly associated with variables related to the extension of the myo cardial damage. Mortality could be well predicted by means of a multiple logistic regression function, but non-fatal reinfarction was related to other factors. The mortality and the non-fatal reinfarction rate during the 2-year follow-up were lower in a series of 231 males who stopped smoking after their first MI when compared to 174 patients who continued to smoke. The 5-year mortality also dif fered significantly between those who stopped smoking and continuing smokers. In spite of treatment of high blood pressure there was a higher incidence of non-fatal reinfarction among 184 hypertensive men compared to 320 normotensive men having survived a first MI. The mortality did not differ between the groups during the 2-year follow-up. The level of serum cholesterol was not related to the prognosis after the infarct in a series of 996 men with a first MI. The possible secondary preventive effect of supervised physical training was analysed in a randomized study. There were no differences in mortality or nonfatal reinfarction rate between the 158 trainees when compared to the 157 controls during the 4-year follow-up, but the physical performance improved. 96 male patients who were followed at a special post-myocardial infarction clinic for 2 years had a lower non-fatal reinfarction rate than 85 controls, but no difference in mortality was found. The rate of sudden death was reduced in a group of 114 patients given continuous ^-receptor blockade during the 2-year follow-up when compared to 116 controls.
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Rehabilitation versus Surgery M. M. Gertler, New York, N.Y., USA Abstract not submitted
Prescription of Vocational and Leisure Activities: Practical Aspects H. Hellerstein, Cleveland, Ohio, USA Abstract not submitted
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Session III
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Assessment and Approach to the Patient J. E. Acker, Knoxville, Tenn., USA Abstract not submitted
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Psychological Approach E. Cay, Edinburgh, England Abstract not submitted
Group Therapy in Cardiac Rehabilitation Thomas P. Hackett, Harvard, Mass., USA
A review of literature, pertaining to the use of groups in MI convalescence, will be presented. A brief discussion will be given of the types of cardiac groups currently in use: exercise, activity, education, relaxation, autohypnosis, etc. The organization of groups will be discussed. Should the group be continuous and ongo ing with new members added as the old drop out? Most agree that membership should not exceed 12. Ought the group consist of those with uncomplicated Mis or a mixture of patients with different prognoses? Should it start in the hospital with the leader meeting the individual while he is still convalescing or after discharge? Should the group contain spouses, or should these be treated in another group? What is the most effective periodicity: weekly? biweekly? monthly? Should the groups have a fixed duration of 3 months? 6 months? 1 year? What financial ar rangements can be made for remuneration. What are the most effective ways for running the groups? It is the consensus that the leader should be an informed, empathetic individual with considerable medical authority such as a nurse-clinician or a doctor. The co-leader, if one is used, should be a lay person who has been specially educated in heart disease and group dynamics. It is the consensus that the primary goal of therapy should not be insight. Psychodynamic group therapy techniques arc not popular with MI patients. Rather, the group should be primarily educative in nature, with a large component of experience sharing. The group leaders must, however, know group dynamics to handle group process, particularly in response to the death of a member through MI. Goals of the group are (1) to alter faulty habits (smoking, sedentary living, diet); (2) to learn the facts of the illness and to correct misconceptions; (3) to reduce loneliness and alienation through con tact with others sharing the same problem; (4) to facilitate return to work and nor mal socializing; (5) to identify special problems (e.g. unwarranted invalidism) for referral; (6) to reduce overall stress through information, group support and thera peutic leadership, and (7) to promote research which will determine the therapeutic usefulness of the group through controlled study.
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Organization of Services K. König, Waldkirch, FRG
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As far as the organizing of institutions which deal with cardiological rehabili tation is concerned, there are no ideal solutions which are valid in general. The various possibilities depend on certain socioeconomic factors and regional traditions. With special regard to the three-phase concept of the WHO, a systematization of the present usual forms of cardial rehabilitation after heart infarct yields the follow ing picture: After the end of phase I (hospitalization), the rehabilitation is continued in phase II (convalescence phase) in the form of (1) stationary ‘comprehensive care’ in a specialized rehabilitation center for 4-6 weeks (Anschlussheilbehandlung); (2) ambulatory care in a special rehabilitation department connected with a university medical center or a large hospital; (3) ambulatory care in so-called coronary clubs which have only loose, if any at all, connection with clinical institutions, and (4) unorganized ambulatory care of a house doctor. For the conditions 1-4, respectively, there are the following possibilities for the continuation of the practically lifelong rehabilitation in phase III (postconvales cence or maintenance phase): Condition 1: (a) Follow-up at the same rehabilitation center in regular shorter intervals (ambulatory, about biannual) or in longer intervals (stationary, about bien nial); (b) continuation of the rehabilitation in coronary clubs; a combination of a and b is also possible. Condition 2: (a) Follow-up in regular intervals in the same department depend ing on local capacity; (b) continuation of the rehabilitation in coronary clubs or a combination of a and b. Condition 3: Continued care in coronary clubs. Condition 4: Continued care of a house doctor. There are contradicting opinions, above all concerning phase II, with regard to the efficiency as well as the cost-benefit relation. The advantages and disadvan tages of the various systems are being discussed; the decisive argument for the stationary rehabilitation in a rehabilitation center (condition 1) is the optimal appli cation of comprehensive care with its various diagnostic-therapeutic, psychosocial and educational aspects. The patient in a group is more easily motivated to change harmful living habits. The principle of comprehensive care is likewise feasible for the conditions of ambulatory rehabilitation in a special department (condition 2), however, the inten sity and, therefore, the efficiency would have to be less; exact results of this method are indeed lacking. The rehabilitation in coronary clubs (condition 3) will be able to realize mainly the psychosocial, but also the educational care only fragmentarily; it also entails the danger in phase II that overburdening of the patients will not be recognized, or recognized too late, because of seldom or insufficient control tests. The domain of the coronary clubs is the lifelong care in phase III. The unorganized care of a house doctor exclusively can hardly be considered a form of rehabilitation to be recommended; in view of certain socioeconomic con ditions, this form of rehabilitation will have to be accepted in certain regions for
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some time to come; it demands a great deal of personal dedication on the part of the house doctor.
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Health Education M. J. Halhuher, Bernried, FRG Abstract not submitted
Session IV 19
Results in Rehabilitation of Coronary Patients Veikko Kallio, Turku, Finland
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Studies of the effects of cardiac rehabilitation can be divided into several categories depending on the aims of the rehabilitation programme and methods used. Physical training programmes, aimed at increasing the physical capacity of patients after acute myocardial infarction (AMI), have been evaluated by several investigators. Short-term progressive exercise training courses have been found to be feasible resulting in haemodynamic changes and improvement of exercise tolerance comparable with those seen in healthy people. However, in a few controlled studies on patients after AMI, no significant differences in ergometric performance between the physical training and control groups were found. This is partly due to the high drop-out rate from the regular training programme, too low intensity of training as well as activation of the control group. The effect of a physical training programme on return to work is favourable, according to some studies, while in a few recent controlled studies no significant effect in this respect could be shown. A comprehensive rehabilitation programme including secondary preventive measures has been used in two ongoing Finnish studies (Turku and Helsinki) co ordinated by WHO. They aim at evaluating its effects on return back to work, quality of life in general and, finally, as an important aim of the WHO-coordinated multicentre study, on mortality and morbidity. The two controlled studies include together 73 women and 301 men with AMI under the age of 65. Evaluation methods have been carefully standardized between the centres, while the intervention pro grammes differ from each other. Return to work was similar in the intervention and control group in Turku while a difference in favour of the intervention group was seen in Helsinki. Rehabilitation seemed to have a positive effect on quality of life. The cumulative mortality after a follow-up period of about 3 years is 12.8% in the intervention group and 19.9% in the controls. Sudden deaths in the control group are twice as common as in the intervention group.
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Rehabilitation in Arterial Hypertension Rune Sannerstedt, Göteborg, Sweden
In comparison with coronary heart disease, experience of physical conditioning in patients with arterial hypertension is very limited. The studies reported have used a wide variety of training programmes of varying length making a comparison of the results obtained difficult. However, an analysis of available data from the literature and our own experimental results so far indicate that physical condition ing in patients with early, latent arterial hypertension of the hyperkinetic type yields a lower blood pressure level both at rest and during physical exercise. On the other hand, convincing evidence that such procedures lower the blood pressure in patients with established, normokinetic arterial hypertension is lacking. Nevertheless, these patients should be encouraged to maintain a good level of physical fitness as part of a programme of general measures also including correction of over-weight, limitation of salt intake and abstention from smoking. The possibility that physical training in individuals with early, latent arterial hypertension results in haemo dynamic changes of sufficient magnitude to keep the blood pressure permanently at a lower level, thereby postponing the start of drug treatment, making previous drug treatment superfluous, or at least the lessening of the amounts of antihypertensive drugs needed, is worth testing further. Our present experimental programme for evaluation of this question, including both dynamic and isometric training, is out lined.
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Rehabilitation in Acquired Valvular Diseases - Survey Vincenzo Rulli, Rome, Italy
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In the last years, the rehabilitation of cardiac patients has achieved very im portant progress both on the ground of the scientific knowledge and on the practical and organizational ground. The physiological and clinical bases of rehabilitation have been quite clearly established; the related psychological and social problems have been thoroughly analyzed; the most suitable techniques, devised to reach, as far as possible, the earlier and most successful requalification, particularly in the patients suffering from ischemic cardiac disease, are well known. Referring to the foregoing disease, we are today quite sure about the actual advantages related to rehabilitative treat ment, at least as to the improvement of the functional capacity. Available data about the rehabilitation of patients with acquired valvular dis eases are quite less numerous and not examined thoroughly at all. Some very in teresting attempts about this subject have been made in the last years but, later, they have not been followed by numerous practical applications and not prolonged enough to allow substantial and general formulation of these ideas. In fact, the rehabilitative experiences in this field are rather lacking and the characterizing physiopathologic bases of valvular diseases appear discouraging. But, first of all, it is necessary to consider two different aspects related to the rehabilitation of this type of patients: rehabilitation of the patients who did not undergo surgery and rehabilitation of patients who did. In the first event, when the
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patients are not operated, the concept of rehabilitation must be relied upon the maintenance of a good physical condition and the prevention of every deterioration. This goal can be achieved especially by appropriate drug therapy and style of life. However, it seems quite obvious that the patients with valvular diseases belonging to the first class of NYHA may undergo also a physical training with the aim of keeping a good functional capacity. The patients belonging to the second and third classes will find, on the contrary, a definite indication for surgery, well bearing in mind, however, that patients of the second class, for whom surgery had been post poned for some reason, may, within limits, show improvement from physical activ ity, able to keep and maintain good functional conditions, at least till the surgery may be effected. For patients belonging to the third class and waiting for surgery, the rehabilita tion may consist in improving the respiratory parameters, cardiac function by drug therapy and psychological conditions. The treatment will be useful in obtaining a reduction of the post-surgery sequelae and will shorten immediately the post-surgery period; after that, the rehabilitation will be started again. In patients who underwent surgery, and without complications, physical recon ditioning may increase the rapidity of progress to good physical and mental condi tions and to the work resumption. It must be stressed that the psychological recon ditioning is always important in the rehabilitation of patients wih valvular diseases as well as in familial, social and juridicial attitudes, also if diversified in various systems of health organization.
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WHO Collaborative Study on Rehabilitation and Comprehensive Secondary Prevention of Patients after Acute Myocardial Infarction G. Lamm and D. L. Dorossiev, Copenhagen, Denmark
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Rehabilitation should be considered as an integral part of comprehensive care for cardiac patients since evidence shows that it contributes to early somatic and psychical recovery, especially in patients with acute myocardial infarction (AMI). Data from the WHO project on AMI registers have, however, shown that during the 2nd and 3rd months after the attack only 19% of the patients followed a rehabili tation programme in Europe. Under WHO coordination, a prospective controlled study was started in June 1973 to assess how far intensive rehabilitation and com prehensive secondary prevention after AMI can prevent reinfarction, prolong life and enhance its quality. Until October 1975, 2,770 male patients with confirmed AMI aged up to 65 years were accepted in the study from 24 centres (23 in Europe and 1 in Israel). They were randomized into an intervention group (n = 1,500) receiving comprehensive rehabilitation and secondary prevention (graded physical activity, intervention on risk factors, appropriate medical treatment, psycho-social and voca tional evaluation and intervention) and a control group (n= 1,270) which was left to the existing routine medical care. Both groups were reviewed at 12-month inter vals according to a common protocol. Extensive efforts were devoted to standardi zation of methods and measurements (exercise testing, coding of ECGs, X-ray, serum lipids, glucose tolerance test, measurement of heart volume), whereas the evaluation and quantification of psycho-social factors proved extremely difficult
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and biased. Interim evaluation of the progress of the study has already demon strated considerable difficulties and sources of potential errors in the randomiza tion procedures, the comparability of groups with respect to risk factor levels and actual comprehensiveness of intervention, alongside with rates of drop-in and drop out patients in the two groups. These findings point to the extreme complexity and difficulty in the collection, pooling and handling of data in cooperative controlled studies in cardiac rehabilitation. Multiple logistic approaches in analysis may be needed to make the best possible use of data collected. The follow-up will be com pleted by the end of 1978 when the target minimum of 6,900 patient-years of obser vation may be reached. The final evaluation will be carried out in 1979. The study is supposed to provide then information on the long-term effects of comprehensive secondary prevention.
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Activities of Rehabilitation International H. Renker, Halle, FRG Abstract not submitted
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National Exercise and Heart Disease Programs Naughton, Buffalo, N.Y., USA Abstract not submitted
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World Rehabilitation Fund M. M. Gertler, New York, N.Y., USA Abstract not submitted
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Future of Rehabilitation - Components of Routine Cardiac Care N. K. Wenger, Atlanta, Ga., USA
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Rehabilitative efforts for the patient after myocardial infarction and for the patient after aortocoronary bypass surgery must be integrated into a comprehensive program of acute and ambulatory cardiac care. They should involve the patient’s primary physician; should involve the patient’s family and social environment as a support system; and should have as a component the training of young cardiologists in rehabilitation concepts and methodology. Important questions yet to be answered include (1) the mechanism(s) of im provement of physical work capacity and cardiocirculatory performance with physical training; (2) the effect of exercise on the natural history of coronary atherosclerotic heart disease and the atherosclerotic process; (3) the effect of exer cise training on coronary collateral flow and myocardial perfusion; (4) the hemo dynamic effects and the effect on myocardial contractility of early mobilization
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after myocardial infarction; (5) the criteria for identifying subgroups of myocardial infarction and postsurgery patients most likely to require and/or benefit from rehabilitative services; (6) the long-term economic implications of cardiac rehabili tative services, and (7) the identification of the most efficient, safest, and most effective manner of implementing programs for cardiac rehabilitation.
