Heart, Victor F. Froelicher, Jonathan Mayers, fifth edition

490 E X E R C I S E A N D T H E H E A R T TA B L E 1 4 – 1 1 . Trials of exercise training in humans with impaired left ventricular function—cont’d Randomized Number Mean Etiology Program Adaptions due to controlled studies subjects lvef(%) CAD-DCM duration training 8 wk Belardinelli et al (J 27 30 ↑ Peak VO2 2.8 mL/kg/min, Amer Coll Cardiol 52 wk ↑ peak work rate 21%, 1995;26:975–982) 3 mo ↓ HRrest, ↑ lactate 12 wk threshold 20%, Kavanagh et al (Heart 30 22 CAD-DCM ↑ skeletal muscle 1996;76:42–49) 23 CAD-DCM 36 mo mitochondria 21 CAD-DCM ↑ Peak VO2 2.6 mL/kg/min, Wilson et al 32 ↑ LVEF 5.8%, ↓ symptoms, 30 >6 mo post-MI ↓ HRrest (Circulation or CABG ↑ Peak VO2 1.2 mL/kg/min, 1996;94:1567–1572) 31 >2 yr post-MI ↑ exercise time 1.5 min 21 CAD-DCM Demopoulos et al 16 ↑ Peak VO2 3.5 mL/kg/min, ↑ leg blood flow, ↓ VE/VCO2, (J Am Coll Cardiol ↑ lactate threshold 1997;29:597–603) ↑ Work rate achieved, ↑ LVEF Single Limb Training Kellerman et al 11 (Cardiology 1990;77:130–138) Hertzeanu et al (Am J 11 60 mo ↓ NA, ↓ ventricular arrhythmias, 4 wk ↑ work rate achieved, ↑ QoL Cardiol 1993;71: ↑ Endothelial function 24–27) Horning et al 12 (Circulation 1996;93:210–214) Respiratory Muscle Training Mancini et al 14 22 CAD-DCM 3 mo ↑ Peak VO2 1.8 mL/kg/min, ↑ 6-min walk 320 ft, (Circulation ↓ Borg score 1995;91:320–329) ADP/ATP, adrenaline diphosphate/triphosphate; a-v, arteriovenous; CAD, coronary artery disease; DCM, dilated cardiomyopathy; HEART RATE, heart rate; [K+]a, arterial potassium concentration; LVEF, left ventricular ejection fraction (%); MI, myocardial infarction; mo, months; NA, nor- adrenaline; PCr, phosphocreatinine; QoL, quality of life; RR, relative risk; Symp, sympathetic activity; TRP, total peripheral resistance; Vagal, vagal activity; VO2, peak oxygen consumption (mL, min-1. kg-1); wk, weeks. extensive experience with training in CHF patients are clearly precursors to the development of heart now available in the literature has not been associ- failure and are important prognostic markers ated with increased morbidity or mortality. As after an infarction. mentioned earlier, two recent meta-analyses have demonstrated improved survival among heart fail- The concerns regarding the effects of training ure patients participating in exercise programs.51,52 on the hearts of patients with reduced ventricular Numerous studies have demonstrated improve- function after an infarction were reignited in 1988 ments in symptoms, and some of the studies have with the publication of a study from a Canadian documented improvements in quality of life.125,134,135 group. Judgutt et al136 studied 13 patients with anterior Q-wave MIs using echocardiography before EFFECTS OF TRAINING ON and after supervised low-level exercise training. POSTINFARCT REMODELING They found that patients with evidence of greater left ventricular asynergy (akinesis or dykinesis) at Myocardial remodeling is a term that has baseline had more detrimental ventricular shape been used to describe the adaptations of the heart distortion, with expansion and thinning of their left during the months following an MI. These adap- ventricle after exercise training. This was thought tations may include myocardial wall thinning, to be secondary to remodeling of an incompletely aneurysm formation, expansion of the infarct healed infarct zone. area, and ventricular dilatation. These responses The provocative observations of Judgutt et al136 were supported by several animal studies published in the early 1990s, some of which demonstrated

C H A P T E R 1 4 Cardiac Rehabilitation 491 severe global left ventricular dilation, left ventricu- heart failure does not cause further damage to the lar shape distortion, and scar thinning after periods left ventricle. of training.15,16,137 However, subsequent controlled trials among humans did not confirm these EXERCISE TRAINING IN POST- findings.125,127,129,132,138-140 Giannuzzi et al138 com- TRANSPLANT PATIENTS pleted a multicentric controlled trial of exercise training in Italy. After 1 year, patients in both the There are increasing numbers of patients who have trained and control groups whose ejection frac- undergone cardiac transplantation for end-stage tions were equal to or less than 40% demonstrated heart failure, and today more than three quarters some degree of additional global and regional dila- of these patients remain alive after 5 years.142 tion. Importantly, however, training had no effect The question has been raised as to whether these on this response, and there was no effect in either patients also can benefit from exercise training. group among patients with ejection fractions more Because the transplant patient’s heart is dener- than 40%. These investigators also completed a vated, some intriguing hemodynamic responses to larger randomized trial in patients with left ven- exercise are observed. The heart is not responsive tricular dysfunction after an MI.137 After 6 months, to the normal actions of the parasympathetic and patients in the control group demonstrated sympathetic systems. The absence of vagal tone increases in both end-systolic and end-diastolic vol- explains the high resting heart rate in these patients umes, and a worsening in both wall motion abnor- (100 to 110 beats per minute) and the relatively malities and regional dilation relative to patients slow adaptation of the heart to a given amount of in the exercise group. The latter study was the first submaximal work.143-145 This slows the delivery of to suggest that an exercise program may actually oxygen to the working tissue, contributing to an attenuate abnormal remodeling in patients with earlier-than-normal metabolic acidosis and hyper- reduced ventricular function. ventilation during exercise. Maximal heart rate is lower in transplant patients than in normal per- Data from Switzerland using MRI confirm that sons, which contributes to a reduction in cardiac exercise training in patients with reduced left output and exercise capacity. Only a few reports in ventricular function following an MI is effective the literature discuss the effects of training after in improving exercise capacity,124,127,132 and sup- cardiac transplantation. These results are encour- ports the recent Agency for Health Care Policy and aging, and suggest that post-transplant patients do Research recommendations141 that this modal- indeed respond favorably to training. These stud- ity is a useful adjunct to medical therapy in these ies have demonstrated increases in peak oxygen patients. Training did not cause further myocar- uptake, reductions in resting and submaximal heart dial damage (i.e., wall thinning, infarct expansion, rates, and improved ventilatory responses to changes in ejection fraction, or increase in ven- exercise.146,147 Whether the major physiologic tricular volume),124,132 nor were there any long- adaptation to training is improved cardiac function, term changes (1-year follow-up) in these measures changes in skeletal muscle metabolism, or simply assessed using MRI.127 The application of MRI to an improvement in strength remains to be deter- assess the remodeling process by this group repre- mined.146 Psychosocial studies of rehabilitation in sents a significant advance in precision over previ- transplant patients are lacking, as are the effects ous studies. of regular exercise on survival. Most recently, Giannuzzi et al129 randomized ELDERLY PATIENTS 90 patients with heart failure into a 6-month exer- cise program or a control group. Detailed echocar- The prevalence of coronary disease increases as diographic measures of left ventricular size and the population ages; roughly 25% of individuals function revealed that patients in the trained group equal to or older than 65 years of age have signifi- actually attenuated abnormal remodeling. Left ven- cant coronary disease. Older coronary patients are tricular volumes increased in the control group, at particularly high risk for disability. There has but trained subjects showed reductions in left ven- been an emphasis on research funding for pre- tricular volumes, and an improvement in ejection venting disability in the elderly, and along with fraction. In addition, trained subjects demonstrated this has come an interest in the effects of cardiac significant improvements in peak VO2, 6-minute walk performance, and quality of life, and fewer hospital admissions for heart failure. This trial pro- vided the most definitive evidence that training in

492 E X E R C I S E A N D T H E H E A R T rehabilitation on physical functioning in elderly effects of exercise rehabilitation on exercise capac- patients. Williams et al148 studied 361 patients ity, return to work, or quality of life in patients grouped according to age with 76 patients who who have undergone bypass surgery is now were 65 years of age or older, all of whom were post- considerable.152-171 acute MI or post-CABG and enrolled in a 12-week exercise program. They found that the improve- These studies differ considerably in terms ment in physical capacity by the elderly group was of design (many were retrospective), study entry the same as for the younger groups, and that ben- (some used preoperative exercise tolerance as the efits from cardiac rehabilitation were unrelated to baseline, others used postoperative exercise capac- age. Ades et al149 performed a comprehensive eval- ity as the baseline), and duration of follow-up. uation of exercise training in elderly (mean, 69 ± Most previous studies only considered patients with 6 years) coronary patients. Forty-five patients successful surgery that alleviated angina, whereas who had sustained a recent cardiac event (MI or our study group included approximately one third CABS) participated in a 12-week, 3 hours per week, with signs or symptoms of ischemia. outpatient program. Exercise time to exhaustion on a submaximal endurance treadmill protocol A summary of studies evaluating the effects of was increased more than 40%, with associated cardiac rehabilitation after bypass surgery is pre- decreases in serum lactate, perceived exertion, res- sented in Table 14-12. The evidence would suggest piratory exchange ratio, minute ventilation, heart that patients who have recently undergone bypass rate, and SBP. The 40% increase in submaximal surgery respond to exercise training much the exercise capacity was contrasted by a far more mod- same was as patients with history of MI (mean est 16% increase in peak VO2. In a comprehensive increase in exercise tolerance 30%, with a range study by Lavie and Milani,150 a formal cardiac reha- of 7% to 73%). Several observations among these bilitation program in 268 consecutive patients studies are noteworthy. Fletcher et al157 reported older than 65 years was reported. In addition to that patients who participated in a rehabilitation a marked increase in exercise capacity (34%), program had greater exercise capacity, smoked improvements were observed in BMI, lipids, and less, were less often rehospitalized, and were more quality of life scores. Demonstrable improvements often fully employed compared to patients who were also reported in anxiety, depression, hostility dropped out of their program. Similarly, Perk scores, and somatization. Similar observations et al159 demonstrated less medication use and fewer were made by this group of investigators among hospitalizations in patients with history of CABG very elderly (≥75 years) patients.151 The findings who participated in an exercise program. Nakai from these studies are very important because, as et al158 reported an improved graft patency rate at was mentioned earlier, the majority of MIs occur 7 weeks post-CABG among patients who exercised in this age group, and this will increasingly be the (98% patency in the exercise group versus 80% case as the population ages. patency in the control group), as documented by coronary angiography. In two randomized studies, EXERCISE PROGRAMS FOR Dubach et al164,165 observed that among patients PATIENTS POST-BYPASS SURGERY who were randomized 1 month after surgery, con- trol patients improved their exercise capacity to a Coronary artery bypass surgery has been shown similar extent as patients who participated in the to prolong life and relieve angina in selected 1-month concentrated residential programs typi- groups of patients with CAD. Advances in opera- cal of central Europe. This finding may reflect tive techniques, including cardioplegia, the use something unique about the spontaneous time of the internal mammary artery, and more com- course of healing after bypass surgery, or that plete revascularization have improved operative 1 month does not provide an adequate training results. Postoperative exercise programs are one stimulus, or both. means of optimizing the surgical result and helping those with inadequate revascularization. Because In the PERFEXT study,171 CABG patients rep- of the large number of patients undergoing coro- resented a third of the total study group. Among nary artery bypass and their potential for rehabil- 53 CABG patients who were randomized, 28 were itation, some of these patients have been included in the exercise-intervention group and 25 in the in exercise rehabilitation programs. The number control group. This was a unique opportunity of studies that have been reported assessing the to evaluate the effects of CABG in rehabilitation because the numbers were fairly high, radionuclide changes were assessed, and, unlike many studies, it was a controlled trial. The mean time from sur- gery until entry into the study was 2 years, with a

C H A P T E R 1 4 Cardiac Rehabilitation 493 TA B L E 1 4 – 1 2 . Summary of studies evaluating the effects of cardiac rehabilitation after bypass surgery Investigator Study design No. of Duration % Change in subjects Study entry Oldridge 1978 Prospective 32 mo exercise capacity 21 1 week postsurgery Gohlke 1982 Retrospective 5 yr Exercise: 28% Waites 1983 Retrospective 467 postsurgery 6 mo Control: 3% Kappagoda 1983 Randomized, 22 9 mo postsurgery 9 mo Exercise: 37% 30 1–2 days postsurgery Exercise: 25% Stevens 1984 prospective 4 mo Exercise: 73% Retrospective 204 44 days postsurgery Control: 29.6% Froelicher 1985 1 year Supervised: 19% Randomized, 53 Mean 2 yr postsurgery Unsupervised: 18% Maresh 1985 prospective 12 wk Exercise: 7.1% Ben-Ari 1986 54 30 days postsurgery 1 year Control: 2.9% Retrospective 96 10–14 days postsurgery Exercise: 56% Hedback 1990 Prospective 1 year Exercise: 81 watts 147 6 wk postsurgery Control: 61 watts Dubach 1993 Randomized, 3 mo Exercise: 32% retrospective 28 1 mo postsurgery Control: 23% Dubach 1995 4 wk Exercise: 16% Randomized, 42 25 days postsurgery Control: 19% Goodman 1999 crossover 12 wk Exercise: 11% Adachi 2001 31 8–10 wk postsurgery 2 wk Control: 14% Randomized, 57 2 wk postsurgery Exercise:13% Kodis 2001 prospective 6 mo Exercise: 42% 1042 6–8 wk postsurgery Control: 4% Prospective Exercise: 21% Prospective Retrospective standard deviation of 2 years and a range of has been dramatic. Today, more than one million 6 months to 9 years. This time period was rather coronary angioplasty and stent implantation pro- long and exercise training likely has a greater cedures are performed annually. Despite improve- effect if applied sooner. Favorable training effects ments in equipment and techniques, late vessel were observed, however, which were similar to restenosis occurs frequently within 3 to 6 months the larger group, but radionuclide changes were of the procedure. Depending on the types of not found to be significant. patients studied and the definition of restenosis, it occurs in 12% to 48% of patients.172 Because an The effects of revascularization vary, but many average of 30% of patients will experience resteno- patients are presently 10 to 20 years or more post- sis, this constitutes a significant number of patients CABG; there is a recurrence rate of angina of 5% or who are destined to have recurrence of symptoms less 1 year postsurgery. Randomized trials of aspirin associated with ischemia. Currently, the annual and statins have demonstrated improved graft risk of a major cardiac event following PCI is patency, and so efficacy could be improved even 5% to 7%. Cardiac rehabilitation can assist these further. The available studies, although limited by patients symptomatically as well as physically and methodology, patient numbers, and highly variable mentally in coping with their coronary disease. details of the rehabilitation programs employed, Fitzgerald et al173 have shown that despite the demonstrate that exercise programs improve minimal invasiveness of PTCA and lack of any phys- exercise capacity and the ability to return to work ical contraindications, some patients have found it in patients who have undergone CABG. difficult to return to work because of low self-con- fidence; only 81% of PTCA patients actually return REHABILITATION AFTER to work.174 It would therefore seem practical to PERCUTANEOUS CORONARY offer cardiac rehabilitation to these patients so INTERVENTION that they, too, can benefit from an improvement in exercise capacity. The exponential growth in percutaneous translu- minal coronary angioplasty (PTCA) since its first Ben-Ari et al175 studied the effects of cardiac clinical application in 1977 by Andreas Gruentzig rehabilitation in patients with history of PTCA and compared them to a group of matched patients

494 E X E R C I S E A N D T H E H E A R T who received usual care post-PTCA without reha- fashion, and suggests that, at least in some patients bilitation. They found a higher physical work with stable CAD, lifestyle intervention can be an capacity and ejection fraction in the rehabilitation alternative approach to an interventional strategy. group compared to controls, and lower total cho- As a minimum, PCI should be combined with lesterol, lower LDL, and higher HDL as well. There aggressive lifestyle intervention, including exercise. was no difference in the rate of restenosis at 5.5 months of follow-up. Further work by this group RETURN TO WORK documented a higher return to work after their program.176 In Japan, Kubo et al177 recently evalu- The presumed inability to resume gainful employ- ated the effects of exercise training on the develop- ment can contribute greatly to a patient’s loss of ment of restenosis after PTCA. Single photon self-esteem and perceived economic impotence. A emission computed tomography (SPECT) imag- concerted effort by the medical/rehabilitation team ing was performed 1 and 13 weeks after PTCA in must be directed to allay these concerns.179 A symp- 18 patients who underwent exercise training and tom-limited exercise test, if normal, can do much to 20 controls. After the study period, the restenosis encourage and reinstill confidence in patients to rate was 17% in the exercise group versus 40% resume their job-related activities. Conversely, an among controls. Patients in the exercise group exercise test showing a lower exercise capacity can demonstrated improvements in exercise capacity be used to guide a patient’s level of activity at work. and significantly improved SPECT redistribution images, whereas these variables remained Occupational evaluation and counseling unchanged among controls. was shown to be of benefit by Dennis et al,180 who decreased the time interval between infarction The results of the PCI versus Exercise Training and return to work by an average of 32% by coun- (PET) study were recently published.178 This was a seling low-risk patients. Cost-benefit analysis of unique trial performed in Germany which will these same patients revealed that total medical likely have an important impact for some time. costs per patient during the 6 months post-MI were The PET study was a randomized trial designed lower by $502, and their occupational income gen- to compare the effects of exercise training versus erated during this same time period was $2102 standard PCI with stenting on clinical symptoms, greater.181 The fact that people are working longer angina-free exercise capacity, myocardial perfusion, into their later years, and 80% of patients younger cost-effectiveness, and frequency of a combined than 65 years of age eventually return to work after clinical endpoint (cardiovascular death, stroke, their MIs underscores the fact that many patients bypass surgery, angioplasty, acute MI, and wors- with history of MI can benefit from this type of ening angina with objective evidence resulting counseling. Engblom et al182 assessed the effects in hospitalization). A total of 101 male patients of a rehabilitation program 5 years after CABS in younger than or equal to 70 years of age were Finland. The patients who were randomized to an recruited after routine coronary angiography and exercise program after their surgery demonstrated randomized to 12 months of exercise training better physical function scores (Nottingham (20 minutes of bicycle ergometry per day) or to Health Profile), better perception of health, and PCI. Cost-efficiency was calculated as the average better perception of quality of life compared to expense (in U.S. dollars) needed to improve the controls. However, a greater proportion of these Canadian Cardiovascular Society class by 1 class. patients were working only at the 3-year evalua- The results demonstrated that exercise training tion (not at 4 or 5 years). The Agency for Health was associated with a higher event-free survival Care Policy and Research Guidelines on Cardiac (88% versus 70% in the PCI group) and increased Rehabilitation141 summarized the results of 28 maximal oxygen uptake (+16%). To gain 1 Canadian studies, and the results of the effects of rehabilita- Cardiovascular Society class, $6956 was spent in tion on return to work were mixed. Return to work the PCI group versus $3429 in the training group. is a complex issue that is influenced by social and Compared with PCI, the 12-month program of political factors, economic incentives or disincen- regular physical exercise resulted in superior event- tives to resume working, employer attitudes, and free survival and exercise capacity at lower costs, preillness employment status of the patient.141 Few notably owing to reduced rehospitalizations and of these factors have been considered in studies on fewer repeat revascularizations. This landmark trial the effects of rehabilitation on return to work, and was the first to directly compare cardiac rehabilita- this remains an area in need of further study. tion with an invasive intervention in a randomized

C H A P T E R 1 4 Cardiac Rehabilitation 495 RISK-FACTOR MODIFICATION beginning 2 weeks after their event. They found a decrease in blood pressure, lower body weight, and Given the recurrence rate of reinfarction and improved serum cholesterol and triglycerides in overall cardiovascular mortality in survivors the treated group; however, smoking decreased by of MI, theoretical benefits of risk factor modifica- 50% in both the treated and control groups. The tion in this high-risk population could be very National Exercise and Heart Disease Project184 significant.183 There have been numerous efforts showed a reduction in LDL fractions. An analysis to assess the effects of controlled, multifactorial of 10-year mortality from cardiovascular disease risk-factor reduction programs on cardiovascular in relation to cholesterol level by Pekkanen et al185 risk. Exercise training programs alone have incon- demonstrated the importance of serum cholesterol sistent effects on smoking cessation, lipids, and in men with pre-existing cardiovascular disease. body weight.141 However, multifactorial programs Hamalainen et al186 noted a reduction in sudden including exercise, lipid-lowering therapy, dietary deaths by almost 50% in patients enrolled in an education and counseling, and other interventions aggressive, multifactorial intervention program have been demonstrated to be effective (Fig. 14-2). for 10 years post-MI. Their interventions included As part of a WHO study, Kallio et al33 performed a control of smoking, hypertension, and lipids, and multifactorial intervention combined with car- the use of antiarrhythmic agents in addition to diac rehabilitation in patients with history of MI beta-blockers. 25 22 Exercise only Multifactorial 20 Number of lipid outcomes 15 13 10 7 54 0 No difference Significant benefit ■ FIGURE 14–2 Note: Effects of types of cardiac rehabilitation interventions on lipid levels in randomized controlled trials (significant reductions in total cholesterol, LDL Changes in lipid levels in 18 random- cholesterol, and triglyceride levels, and significant increases in HDL cholesterol ized controlled trials of cardiac reha- levels). Multifactorial rehabilitation interventions appear more likely to effect a bilitation by intervention beneficial change in lipid levels than does exercise training alone. All trials strategy-exercise only versus multi- compared rehabilitation versus control patients. Some studies reported more factorial intervention. (From Agency than one lipid result. for Health Care Policy and Research, Guidelines for Cardiac Rehabilitation, 1995).

496 E X E R C I S E A N D T H E H E A R T Previously, it was argued that when atheromas the basis of initial data, much time and money are well established and cause symptoms, alter- could be saved and rehabilitation services could ations in serum cholesterol would have little effect. be directed to patients who would benefit the In recent years, it has been demonstrated repeat- most. Several groups have made efforts to address edly that this is not the case. Evidence that the this, and most have been rather disappointing. progression of coronary atherosclerosis may be Pierson et al190 recently studied 60 patients who arrested and actually reversed with aggressive participated in an outpatient rehabilitation pro- dietary and medical therapy is accumulating.187,188 gram for 5 to 9 months. The best predictor of a Meta-analysis of lipid-lowering trials using digital training response was low baseline fitness level; coronary angiography now consistently confirm there was no association between the increase in that this is the case. The recent multidisciplinary exercise tolerance during rehabilitation and age, risk reduction trials that have included exercise revascularization status, or markers of ischemia. training as a component and their effect on the ath- erosclerotic process are summarized in Table 14-13. In the PERFEXT study, peak VO2 and other The data presented in Table 14-13 are noteworthy markers of a training effect were considered and in several respects. Atherosclerotic regression, the following questions were addressed191: (1) Can when it occurs, is demonstrated much more often clinical features prior to training predict whether in patients who receive lipid-lowering agents, or not beneficial changes occur with training?, (2) dietary, or other interventions compared with con- do initial treadmill or radionuclide measurements trols. It also should be noted that the percentage contribute information to improve this predic- reductions in coronary arterial lumen diameter tion?, and (3) does the intensity of training over are small, and they do not occur in all patients in the year predict beneficial changes? Our major the treatment groups. Lastly, although exercise finding was that a patient’s success or failure in training has been included as a component of improving aerobic capacity following a 1-year aer- multifactorial intervention, it is difficult at present obic exercise program was poorly predicted on the to determine the effects of diet, drugs, exercise, or basis of initial clinical, treadmill, or radionuclide other interventions independently. data. Correlations between initial parameters and outcome were poor. Training intensity had little Nevertheless, the recent observation that the to do with outcome. Those with ischemic markers atherosclerotic process can be reversed has had (exercise test-induced angina, ST depression, or a major effect on clinical practice. Current recom- dropping ejection fraction) did not have a differ- mendations suggest that all individuals with ent response to training than patients without existing heart disease should have aggressive man- ischemia; neither did those with markers of agement to lower their LDL cholesterol to below myocardial damage. History of CABS or MI had no 100.189 The interaction of triglycerides with gene bearing on whether a patient’s work capacity site activity, typing of apo-B, ultracentrifugation would improve following the training period. of LDL, and other new findings are leading to an Multivariate analyses did not greatly improve the exciting new hope that atherosclerosis can be ability to predict outcome. Previous studies have treated more effectively. These studies are prom- found that those with the lowest initial measured ising and emphasize the medical rehabilitation oxygen uptake often have the largest improve- team’s responsibility to encourage patients to alter ment with an exercise program, but this was not lifestyles that could be deleterious to their health the case in PERFEXT. and institute medical therapy as necessary to con- trol cardiac risk factors. Thus, a very detailed initial evaluation did not allow accurate prediction of who would benefit PREDICTING OUTCOME IN from training and who would not. Even those CARDIAC REHABILITATION patients whose characteristics suggested they had PATIENTS the most ischemia or largest scar showed as much improvement from training as patients without Cardiac rehabilitation programs can be expensive such characteristics. Therefore, it would appear and may be difficult to provide to some patients that using angina, a low resting ejection fraction, due to financial reasons, lack of insurance, distance ST-segment depression, or a dropping ejection to the hospital or rehabilitation facility, comor- fraction with exercise as contraindications to an bidities, or other reasons. If a patient’s likelihood exercise program is unjustified. Because many of of improving work capacity could be predicted on the benefits obtained from an exercise program are intangible, it seems inappropriate to eliminate any patient from an exercise program on the basis

TA B L E 1 4 – 1 3 . Human coronary regression studies using exercise as an intervention Study Study population Length Intervention Result (% of sample) 1 yr Exercise Therapy 62 (No LM CAD, no Low-fat diet, exercise Progression- Heidelberg bypass, no intervention (10%) Hambrecht 1993 hypercholesterolemia) Low-fat diet, intensive Control (45%) exercise >3 hours/wk No change-intervention (62%) Heidelberg 36 (CAD, stable 1 yr Control (49%) Schuler 1992 symptoms) Diet (low-fat, Regression-intervention (28%) vegetarian) smoking Control (6%) Lifestyle Heart 41 (35–75, no lipid- 1 yr cessation, stress Progression-intervention (28%) Trial lowering drugs, no CAD, management training, Ornish et al 1990 no recent MI, 5 females) exercise Control (33%) Diet (low-fat, No change-intervention (33%) Lifestyle Heart 35 (moderate to severe 1 yr and vegetarian) smoking Control (61%) Trial cessation, stress Regression-intervention (39%) Ornish et al 1998 CHD, 20 intervention and 5 yr management training Control (6%) exercise Progression-intervention (18%) 20 control) Control (53%) Low-fat and No change-intervention (0%) Schuler et al 1992 36 (stable angina pectoris, 1 yr cholesterol exercise Control (5.3%) 18 intervention, 18 >3 hr/week Regression-intervention (82%) control) Control (42.7%) Low-fat diet, exercise 1 yr (relative change) Schuler et al 1992 113 (stable angina 1 yr Progression-intervention (5.4%) pectoris) Low-fat and Control (0%) cholesterol diet, Regression-intervention (0%) SCRIP 300 (angiographically 4 yr exercise, weight loss, Control (4.5%) Haskell 1994 detectable smoking 5 yr (relative change) atherosclerosis, less/cessation, niacin, Progression-intervention (27.7%) 41 females) lovastatin, Control (0%) gemfibrozil, probucol Regression-intervention (0%) Bellardinelli 2001 118 randomized to 6 mo Control (7.9%) exercise or control Exercise training Regression-intervention (38.9%) Control (5.6%) Hambrecht 2004 101 randomized to PCI or 1 year Exercise training No change-intervention (33%) intervention Control (61%) Progression-intervention (27.8%) Control (33%) Progression-intervention (23%) Control (43%) Regression-intervention (32%) Control (17%) No change-intervention (45%) Control (35%) New lesions-intervention (15%) Control (14%) New occlusions- intervention (10%) Control (14%) Progression-intervention (50.4%) Control (49.6%) Regression-intervention (21%) Control (10%) Restenosis rate 29% exercise, 33% control; Residual diameter stenosis 30% lower in exercise group Exercise 32% progression; PCI 45% progression; Better event-free survival in exercise group

498 E X E R C I S E A N D T H E H E A R T of clinical, treadmill, or radionuclide data. Van This model provides an integrated system that Dixhoorn et al192 added psychosocial variables and includes appropriate triage, education, coun- were better able to predict “failure” to improve seling on lifestyle interventions, and long-term than success. Data from the major exercise trials follow-up. in chronic heart failure were recently combined, and there were no variables at baseline that were Several studies have demonstrated the efficacy found to be significant predictors of success.193 of comprehensive risk factor management using a Mixed results have been observed by other investi- case management approach. In each of these stud- gators on this issue,194 and more studies are needed ies, a nurse or exercise physiologist, as case man- that include hemodynamic, exercise, clinical, and ager, functions as the coordinator and the point of psychosocial variables. contact who identifies, triages, provides surveil- lance on safety and efficacy, performs follow-up, and NEW MODELS OF CARDIAC in many instances, quantifies patient outcomes. Case REHABILITATION management has been the cornerstone of recent multidisciplinary efforts to reduce cardiovascular Changes in reimbursement patterns over the last risk. In addition, it has provided a framework for 15 years, along with the demonstration that clinical comprehensive management of existing disease, outcomes can be improved by multidisciplinary risk particularly for patients with heart failure.62,207-210 factor intervention,195,196 have led to the develop- This approach involves the coordination of risk ment of new models of cardiac rehabilitation. The reduction strategies for targeted groups of patients need for new approaches has also been fueled by by a single individual, most commonly a nurse or the recent observation that a wider spectrum of exercise physiologist, with appropriate medical patients can benefit from cardiac rehabilitation supervision. The case management concept is based (e.g., valvular surgery, heart failure, transplanta- on the idea that risk factors are strongly inter- tion, peripheral vascular disease, and the elderly). related, and an individualized, integrated approach Moreover, innovative strategies have been propo- to management will optimize care such that clin- sed in order to increase the proportion of eligible ical outcomes will be improved and costs will be patients who receive cardiac rehabilitation services saved. The case management approach has been despite reductions in reimbursement. In addition, applied in various settings over the last decade and physicians have not been particularly effective in has been successful in reducing risk markers for assisting patients in achieving defined risk factor CAD and improving outcomes in patients with goals,197-202 and strategies have been suggested to existing disease. Some of the more prominent stud- facilitate a greater proportion of patients meeting ies performed during the 1990s using case man- evidence-based treatment guidelines. agement approaches are described in the following. Models that have been developed to meet these The Butterworth Heath System in Michigan needs include the transformation of rehabilitation reorganized their cardiac rehabilitation program centers into “secondary prevention centers”,196 the to focus on improvement in long-term outcomes “inclusive chronic disease model”,203 the implemen- using a case-management model.208 The model tation of affordable, evidence-based, comprehensive included the use of referral pathways, education risk reduction in primary and secondary preven- sessions, and intervention by social workers as nec- tion settings,195,204 home exercise programs,205,206 essary. In addition, they added regular phone call and case-management systems.207–210 The concept follow-up to assess the effectiveness of the risk- that cardiac rehabilitation should be the primary reduction interventions. One year after initiating medium to implement comprehensive cardiovas- the program, 77% of patients were on appropriate cular risk reduction has been embraced by the lipid-lowering therapy, 78% reported exercising American Heart Association (AHA),196 the Agency at least 3 days a week, and 66% of prior smokers for Health Care Policy and Research Clinical reported smoking cessation. Practice Guidelines,141 and the AACVPR.29 The recent AHA consensus statement on “Core The MULTIFIT program of DeBusk et al207 Components of Rehabilitation/Secondary Preven- has been a model for other case management pro- tion Programs”193 defines specific evidence-based grams, and its success led to it being adopted by risk factor goals for management of lipids, blood the Kaiser Permanente Health Care System. pressure, weight, smoking cessation, diabetes man- MULTIFIT is a case-managed program for patients agement, and physical activity (Table 14-14). hospitalized with acute MI in Northern California. Patients were randomized to either special risk reduction intervention by a nurse case manager or to usual care. The intervention patients received

C H A P T E R 1 4 Cardiac Rehabilitation 499 TA B L E 1 4 – 1 4 . Core components for cardiac rehabilitation/secondary prevention programs From the AHA and AACVPR: Scientific Statement on Core Components of Cardiac Rehabilitation/Secondary Prevention Programs. Circulation 2000;102:1069–1073. education and counseling regarding smoking discharged from UCLA Medical Center with a cessation, regular physical activity, and nutrition. diagnosis of CAD or other vascular disease. The Medical management, such as lipid-lowering ther- case managed approach emphasized close adher- apy, was instituted as indicated for risk factors not ence to appropriate use of aspirin, beta-blockers, controlled by lifestyle change. Much of the inter- ACE inhibitors, and lipid-lowering agents, com- vention was mediated by phone and mail contact. bined with outpatient exercise, nutrition, and The intervention group showed greater improve- smoking cessation counseling. After the study ment at 6 months and 1 year in functional capacity, period, there was greater use of appropriate med- rate of smoking cessation, and changes in LDL-C ications, an increase in the percentage of patients compared with the usual care group, and subse- achieving an LDL-C level less than 100 mg/dl, a quent analyses have shown MULTIFIT to be cost- reduction in recurrent MI, and a lower 1-year effective.210 mortality. The recently completed Cardiac Hospital At Stanford, a randomized, controlled trial Atherosclerosis Management Program (CHAMP)209 funded by the NIH was performed to evaluate compared outcomes among 302 patients enrolled the efficacy of case-managed, physician-directed in a case-managed risk reduction intervention and multirisk factor intervention (the SCRIP Study).62 compared them with 256 control patients. All were Case managers coordinated care along with a team

500 E X E R C I S E A N D T H E H E A R T of nutritionists, psychologists, and physicians to sections describe suggestions for the survival of provide clinical and lifestyle interventions, attempt- cardiac rehabilitation. ing to achieve nationally recognized goals for risk factor reduction. Three hundred subjects were ran- As suggested by Ribisl et al,203,211 a new era domized to intervention or usual care groups. After requires a new model. The old model of a standard, the 4-year study period, the intervention group fixed 36-session program in which every patient demonstrated an increase in exercise participation; receives the same intervention, regardless of spe- reductions in dietary fat and cholesterol intake; cific needs or characteristics, is outmoded and a reductions in SBP, body mass index and blood disservice to patients. Part of the reason for adher- lipids; an improvement in glucose tolerance; and a ing to the old model was failure to interact with 27% reduction in Framingham Risk Score. These third-party payers in the design of appropriate changes were associated with reductions in hos- programs that met patient needs. The security of pitalizations and coronary events. Angiographic a safe and reliable means of obtaining reimburse- results included both a decreased progression of ment was the driving force behind this approach— CAD and greater stabilization of plaque in the and programs have been reluctant to make any intervention group. change because of fear that revenues would be lost. Some observations or suggestions follow in The home-based model of rehabilitation, vali- subsequent sections, as well as recommendations dated at Stanford University in the 1980s,205 has of several models for consideration that are based been used in many centers over the last 15 years. on impressions of current trends and opportunities This approach uses home exercise that is either that exist today. unmonitored or monitored via telephone or com- puter. Some programs feature regular feedback via Initiate Patient Contact Early telephone or home visits, and recent approaches have used exercise monitoring devices such as Too many patients are leaving the in-patient set- pedometers, accelerometers, and heart rate record- ting without being contacted by the cardiac reha- ing devices to encourage and document compli- bilitation specialists. Efforts must be intensified ance with prescribed exercise. Safety and efficacy of to ensure an early contact during the in-patient these home programs have been shown to be simi- setting. The cardiac rehabilitation team must be lar to those of more conventional programs.205,206 integrated into the clinical pathway to work with these patients at this ideal time. Waiting until well FUTURE DIRECTIONS FOR after discharge has proven to be ineffective. The CARDIAC REHABILITATION current trend is to reduce the length of both the hospital stay and the follow-up period as a method Cardiac rehabilitation professionals must continue of cost saving. Thus, it becomes even more impor- to develop innovative means to deliver their ser- tant that these patients be provided with an oppor- vices and to document what they are doing by using tunity to interact with rehabilitation specialists outcome assessment and cost control. They must who can assist them in their recovery. Practitioners gather evidence on consequences of care—not must be more active in educating primary care just at completion of formal treatment, but much physicians, managed care administrators, and con- later—and with assessment tools that are sensi- sumers about the value of rehabilitation. Under a tive to lifestyle factors associated with disease risk capitated system, they must be convinced that low- and progression, as well as quality of life. Their ser- technology alternatives are in place to minimize vices must have a focus that is population-based, costs. They also must be able to readily access ser- with a primary responsibility to manage capitated vices so admissions occur at acceptable rates when enrollees. Rather than respond to hospital direc- appropriate cases arise. With cardiac rehabilita- tors, they must relate to executives responsible for tion care serving approximately 15% to 20% of managing primary care. Re-engineering is critical. eligible patients today, utilization is low. Cardiac rehabilitation professionals must start ask- ing, “Do we really need this particular aspect of Reach a More Diverse Pool of rehabilitation?,” “Is there a better and cheaper way Patients to deliver this service?,” and “Which patients really need and benefit from a particular component?” The treatment plan for patients with cardiovascu- No longer can each hospital or clinic have a pro- lar disease is really limited to a single diagnosis. It gram simply to be competitive. One or two centers is unusual to find an older patient who is free of will be sufficient for each community. The following

C H A P T E R 1 4 Cardiac Rehabilitation 501 other diagnoses of chronic disease. It is likely that has never been an integral part of medical educa- many patients with cardiac disease have one or tion, efforts must be made to convince current more additional diseases such as obesity, diabetes, practitioners and medical students about the ben- chronic obstructive pulmonary disease,212 arthritis, efits to patients. or other complications that must be taken into account in the intervention plan. Yet few programs Include Underserved Populations market their services to patients with these other diagnoses and thereby lose a key opportunity to The misconception that cardiovascular disease serve the widest client base with a common set of predominantly afflicts men is a major deterrent interventional strategies applicable to the treat- to referrals of women to rehabilitative programs. ment of multiple disease. For instance, weight con- Cardiovascular disease is still the major cause of trol is an important intervention in the treatment death in women and mortality rates are compara- of those chronic diseases that are aggravated by ble between the sexes. Other groups, who are obesity. Dietary modification, including a reduction underserved, due to reasons of economics as well as of fat and cholesterol intake, and an increase in misconception, are the elderly, the poor or unedu- complex carbohydrates in the form of whole grains, cated, and minorities. The population being served fresh fruits, and vegetables, is not only essential in most programs across the nation remains rela- in clinical efforts to slow the progress of atheroscle- tively young, white, professional, and male. rotic lesions, but also helps the diabetic, arthritic, and the obese. The benefits of exercise to each of Expand Utilization these chronic disease groups are well docu- mented, as are the use of relaxation and cognitive Although less than 20% of all eligible cardiac strategies in behavior change. Cardiac rehabilita- patients are referred to cardiac rehabilitation pro- tion needs to consider a new and broader identity grams, 100% of all eligible patients could benefit and expand its scope of practice to include all from some form of cardiac rehabilitation. One rea- chronic disease—especially as the aged segment of son for this discrepancy may be a physician belief our patient population continues to grow, requiring system that fails to incorporate secondary preven- the most costly services available in the healthcare tion (e.g., cardiac rehabilitation) into the patient’s system. treatment plan. Physicians should become more familiar with alternatives to their current practice Increase Physician Awareness and utilize other healthcare professionals to effi- ciently and economically extend their capacity to There is a clear lack of awareness among those in treat their patients. Ideally, specialists who would the medical profession who are responsible for determine their needs and individualize a pro- making decisions regarding the treatment options gram would see every patient at a rehabilitation available to their patients in the community. It is center. All of the modalities of rehabilitation would a well-recognized fact that physicians infrequently be considered (home-based to monitored groups) counsel their patients regarding healthy habits, without outside pressures to enter patients into even though most authorities would agree to the expensive approaches. In addition, eligibility should benefits. Whether it is a lack of awareness of the be expanded to the elderly, patients with CHF, and availability of these services or whether it is simply those patients in need of post-surgical interven- negligence, ignorance, or skepticism—the fact tion. In some circumstances, all the rehabilitation remains that few patients are being referred to needed or available might be counseling by a pri- rehabilitative programs. The critical step in any mary care physician. Patients who are more suc- effort to change this pattern rests with the primary cessful in changing their lifestyle behaviors report care physician, who now serves as a “gatekeeper” to that the physician’s recommendation had a strong these potential services. Primary care physicians influence on their willingness to change. Physicians must become an integral part of the treatment plan who are confident and have good counseling skills for their patients who are most likely to benefit are often effective in changing the behavior of from cardiac rehabilitation. They must become their patients. Physicians with good personal educated about the short- and long-term benefits; health habits and positive health beliefs are also otherwise, without this collaborative treatment more likely to have a positive influence on their planning and consequent increase in clientele, it patients’ lifestyles. It has even been suggested that is unlikely that these programs can survive in the the traditional physical examination in apparently future. Because training in preventive strategies

502 E X E R C I S E A N D T H E H E A R T healthy persons is a waste of physician and patient hospitalization charges for rehabilitation partici- time—time that could better be spent on counsel- pants were $739 lower than for nonparticipants. ing to encourage better lifestyle habits. Bondestam et al216 described the effects of early rehabilitation that relied totally upon the primary Highlight Potential Reduction healthcare system on consumption of medical care in Mortality resources during the first year after acute MI in patients 65 years of age or older. Patients from Cardiac rehabilitation is successful, as dem- one primary healthcare district were assigned to a onstrated by several independent meta-analyses rehabilitation program, whereas patients from a described earlier in this chapter; these rigorous neighboring district constituted a control group. analyses have demonstrated 25% reductions in The rehabilitation measures were initiated very cardiovascular mortality. This mortality benefit was early after the infarction with individual counseling recently extended to patients with heart failure51,52 in the home of the patient and later in the local In fact, these latter analyses demonstrated that health center, where 21% of the patients also joined the mortality benefit may even be slightly greater a low-intensity exercise group. During the first in patients with heart failure. Numerous studies 3 months there was a significantly lower incidence have documented the benefits of lowering serum of rehospitalization in the intervention group, cholesterol using drugs. Angiographic studies have expressed both in terms of percentage of patients consistently shown regression or slowing of pro- and days of rehospitalization. Visits to the emer- gression, whereas one recent follow-up study found gency department without rehospitalization also a 25% and 42% reduction in mortality and CABS, were significantly lower in the intervention group. respectively. Because recent studies indicating After 12 months the differences still remained, with regression of coronary disease and decrease in the exception of no intergroup difference in follow- events with cholesterol-lowering statins under- up relative to days of rehospitalization. In the score the benefits of rehabilitation, the control of matched groups the same result was seen. Although lipid abnormalities must be a key part of any reha- readmissions and emergency department visits bilitation program. generally were well justified in the intervention group, vague symptoms dominated among the con- Document Cost-Efficacy trols. Levin et al217 presented the results of an eco- nomic evaluation of patients followed-up for 5 years Like all clinical interventions today, cardiac reha- after rehabilitation intervention or usual care that bilitation programs must demonstrate to hospi- demonstrated that mean patient costs were $8800 tal administrators that they are cost effective. lower in the rehabilitation group. These cost-savings Although such documentation is likely to exist for associated with rehabilitation compare favorably to many, if not most, programs, few have made the the cost-effectiveness of other preventive measures, effort to publish such data. There has been a prolif- with the exception of smoking cessation.218 eration of research methodologies in recent years that consider alternative ways of conducting eco- SUMMARY nomic evaluation of healthcare.213 Although this has added some uncertainty of approach, standard- Cardiac rehabilitation has been going through the ization is coming and decision makers are begin- same dramatic changes as the entire healthcare ning to consider these findings as they reformulate system. However, its principles have become part the scope of their health insurance coverage. of good medical practice. The outcome for nearly all Importantly, recent studies clearly demonstrate clinical interventions carried out for cardiovascular that cardiac rehabilitation is cost-effective. disease can be improved by lifestyle intervention, Oldridge et al214 performed an economic evalua- and cardiac rehabilitation has been an impor- tion of patients 1 year after randomization to tant medium for these lifestyle changes. A major either an 8-week rehabilitation intervention or challenge that remains is providing rehabilita- usual care and revealed that cardiac rehabilitation tion services to a greater proportion of eligible is an efficient use of healthcare resources. Ades et patients. The emphasis on the health benefits of al215 presented the results of a 3-year economic physical activity, rather than physical fitness and evaluation of patients undergoing 12 weeks of the reduction of iatrogenic deconditioning, have rehabilitation, which revealed that per capita decreased the emphasis on exercise prescription and the phased approach. Cardiac rehabilitation is

C H A P T E R 1 4 Cardiac Rehabilitation 503 appropriately evolving from simple exercise 21. Cain HD, Frasher WG, Stivelman R: Graded activity program for programs toward comprehensive secondary pre- safe return to self-care after myocardial infarction. JAMA vention. As studies continue to demonstrate 1961;177:111–120. physiologic benefits, improved mortality, and cost efficacy, rehabilitation and secondary prevention 22. Torkelson LO: Rehabilitation of the patient with acute myocardial will become a standard of care for patients with infarction. J Chronic Dis 1964;17:685–704. cardiovascular disease. 23. Sivarajan ES, Snydsman A, Smith B, et al: Low-level treadmill testing REFERENCES of 41 patients with acute myocardial infarction prior to discharge from the hospital. Heart Lung 1977;6:975–980. 1. Braunwald E, Antman EM, Beasley JW, et al: ACC/AHA 2002 guide- line update for the management of patients with unstable angina 24. Hayes MJ, Morris GK, Hampton JR: Comparison of mobilization and non-ST segment elevation myocardial infarction—summary after two and nine days in uncomplicated myocardial infarction. article: A report of the American College of Cardiology/American BMJ 1974;3:10–13. Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll 25. Bloch A, Maeder J, Haissly J, et al: Early mobilization after myocardial Cardiol 2002;40:1366–1374. infarction: A controlled study. Am J Cardiol 1974;34:152–157. 2. Arciero TJ, Jacobsen SJ, Reeder GS, et al: Temporal trends in the 26. Sivarajan E, Bruce RA, Almes MJ, et al: A randomized study of cardiac incidence of coronary disease. Am J Med 2004;117:228–233. rehabilitation. N Engl J Med 1981;305:357–362. 3. Dargie H: Myocardial infarction: Redefined or reinvented? Heart 27. World Health Organization (WHO) Report of Expert Committee: 2002;88:1–3. Rehabilitation of patients with cardiovascular diseases. Technical report no. 270. Geneva, WHO, 1964. 4. Dalby M, Bouzamondo A, Lechat P, Montalescot G: Transfer for pri- mary angioplasty versus immediate thrombolysis in acute myocar- 28. American College of Sports Medicine: Guidelines for Exercise dial infarction: A meta-analysis. Circulation 2003;108:1809–1814. Testing and Prescription, 6th ed. Baltimore, Lippincott Williams & Wilkins, 2000. 5. Goldman L, Phillips KA, Coxson P, et al: The effect of risk factor reductions between 1981 and 1990 on coronary heart disease inci- 29. American Association of Cardiovascular and Pulmonary dence, prevalence, mortality and cost. J Am Coll Cardiol 2001;38: Rehabilitation: Guidelines for Cardiac Rehabilitation Programs, 1012–1017. 4th ed. Champaign, Ill, Human Kinetics, 2003. 6. Maisel AS, Ahnve S, Gilpin E, et al: Prognosis after extension of 30. Kelemen MH, Stewart KJ, Gillilan RE, et al: Circuit weight training myocardial infarct: The role of Q-wave or non-Q-wave infarction. in cardiac patients. J Am Coll Cardiol 1986;7:38–42. Circulation 1985;71:211–217. 31. Sparling PB, Cantwell JD, Dolan CM, Niederman RK: Strength 7. Maisel AS, Gilpin E, Hoit B, et al: Survival after hospital discharge training in a cardiac rehabilitation program: A six-month follow- in matched populations with inferior or anterior myocardial infarc- up. Arch Phys Med Rehabil 1990;71:148. tion. J Am Coll Cardiol 1985;6:731–736. 32. Sanchez OA, Leon A: Resistance exercise for patients with diabetes 8. Moon JC, De Arenaza DP, Elkington AG, et al: The pathologic basis mellitus. In Graves JE, Franklin BA (eds): Resistance Training for of Q-wave and non-Q-wave myocardial infarction: A cardiovascular Health and Rehabilitation. Champaign Ill, Human Kinetics, 2001, magnetic resonance study. J Am Coll Cardio. 2004;44:554–560. pp 295–318. 9. Guidelines for Risk Stratification after Myocardial Infarction. 33. Kallio V, Hamalainen H, Hakkila J, Luurila OJ: Reduction in sud- American College of Physicians. Ann Intern Med 1997;126: den deaths by a multifactorial intervention programme after acute 556–560. myocardial infarction. Lancet 1979;2:1091–1094. 10. Eagle KA, Lim MJ, Dabbous OH, et al: A validated prediction model 34. Kentala E: Physical fitness and feasibility of physical rehabilitation for all forms of acute coronary syndrome: Estimating the risk of after myocardial infarction in men of working age. Ann Clin Res 6-month postdischarge death in an international registry. JAMA 1972;4:1–25. 2004;291:2727–2733. 35. Palatsi I: Feasibility of physical training after myocardial infarction 11. Plebani M, Zaninotto M: Cardiac markers: Present and future. Int J and its effect on return to work, morbidity, and mortality. Acta Med Clin Lab Res 1999;29:56–63. Scand Suppl 1976;599:1–100. 12. Cucherat M, Bonnefoy E, Tremeau G: Primary angioplasty versus 36. Wilhelmsen L, Sanne H, Elmfeldt D, et al: A controlled trial of intravenous thrombolysis for acute myocardial infarction. physical training after myocardial infarction. Prev Med Cochrane Database Syst Rev 2003;3:CD001560. 1975;4:491–508. 13. Hammerman H, Schoen FJ, Kloner RA: Short-term exercise has a 37. Shaw LW: Effects of a prescribed supervised exercise program on prolonged effect on scar formation after experimental acute mortality and cardiovascular mortality in patients after a myocar- myocardial infarction. J Am Coll Cardiol 1983;2:979–982. dial infarction. Am J Cardiol 1981;48:39–46. 14. Kloner RA, Kloner JA: The effect of early exercise on myocardial 38. Shepard RJ: Exercise regimens after myocardial infarction: infarct scar formation. Am Heart J 1983;106:1009–1014. Rationale and results. Cardiovasc Clin 1985;14:145–157. 15. Gaudron P, Hu K, Schamberger R, et al: Effect of endurance training 39. Bengtsson K: Rehabilitation after myocardial infarction. Scand J early or late after coronary artery occulusion on left ventricular Rehabil Med 1983;15:1–9. remodeling, hemodynamics, and survival in rats with chronic transmural myocardial infarction. Circulation 1994;89:402–412. 40. Carson P, Phillips R, Lloyd M, et al: Exercise after myocardial infarction: A controlled trial. J R Coll Physicians Lond 1982;16: 16. Oh BH, Ono S, Rockman HA, Ross J: Myocardial hypertrophy in the 147–151. ischemic zone induced by exercise in rats after coronary reperfu- sion. Circulation 1993;87:598–607. 41. Vermeulen A, Liew KI, Durrer D: Effects of cardiac rehabilitation after myocardial infarction: Changes in coronary risk factors and 17. Hochman JS, Healy B: Effect of exercise on acute myocardial long-term prognosis. Am Heart J 1983;105:798–801. infarction in rats. J Am Coll Cardiol 1986;7:126–132. 42. Roman O: Do randomized trials support the use of cardiac rehabil- 18. Levine SA, Lown B: The “chair” treatment of acute coronary itation? J Cardiopulm Rehabil 1985;5:93–96. thrombosis. Trans Assoc Am Physicians 1951;64:316–319. 43. Mayou RA: A controlled trial of early rehabilitation after myocardial 19. Saltin B, Blomquist G, Mitchell JH, et al: Response to exercise after infarction. J Cardiopulm Rehabil 1983;3:397–402. bed rest and after training. Circulation 1968;1(suppl VII):37–38. 44. Hedback B, Perk J, Perski A: Effect of a post-myocardial infarction 20. Convertino VA: Effect of orthostatic stress on exercise performance rehabilitation program on mortality, morbidity, and risk factors. after bed rest: Relation to in-hospital rehabilitation. J Cardiopulm J Cardiopulm Rehabil 1985;5:576–583. Rehabil 1983;3:660–663. 45. Agency for Health Care Policy and Research. Guidelines for Cardiac Rehabilitation, 1995. 46. Ades PA: Cardiac rehabilitation and secondary prevention of coro- nary heart disease. N Engl J Med 2001;345:892–902. 47. May GS, Eberlein KA, Furberg CD, et al: Secondary prevention after myocardial infarction: A review of long-term trials. Prog Cardiovasc Dis 1982;24:331–352. 48. O’Connor GT, Buring JE, Yusuf S, et al: An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234–244.

504 E X E R C I S E A N D T H E H E A R T 49. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA: Cardiac rehabili- 73. Myers J, Voodi L, Umann T, Froelicher VF: A survey of exercise test- tation after myocardial infarction. Combined experience of ran- ing: Methods, utilization, interpretation, and safety in the VAHCS. domized clinical trials. JAMA 1988;260:945–950. J Cariopulm Rehabil 2000;20:251–258. 50. Taylor RS, Brown A, Ebrahim S, et al: Exercise-based rehabilitation 74. Haskell WL: Cardiovascular complications during exercise training for patients with coronary heart disease: Systematic review and of cardiac patients. Circulation 1978;57:920–924. meta-analysis of randomized controlled trails. Am J Med 2004;16: 682–692. 75. Hossack KF, Hartwig R: Cardiac arrest associated with supervised cardiac rehabilitation. J Cardiac Rehab 1982;2:402–408. 51. Piepoli MF, Davos C, Francis DP, Coats AJ: Exercise training meta- analysis of trials in patients with chronic heart failure. BMJ 76. Fletcher G, Cantwell JD, Murray PM, Thomas RJ: Exercise and the 2004;328:189. heart: Current management of service exercise-related cardiac events. Chest 1988;93:1264–1269. 52. Smart N, Marwick TH: Exercise training for heart failure patients: A systemic review of factors that improve patient mortality and 77. Van Camp SP, Peterson RA: Cardiovascular complications of outpa- morbidity. Am J Med 2004;116:693–706. tient cardiac rehabilitation programs. JAMA 1986;256:1160–1163. 53. Kent KM, Smith ER, Redwood DR, et al: Electrical stability of 78. Thompson PD, Funk EJ, Carleton RA, Sturner WQ: Incidence of acutely ischemic myocardium. Circulation 1973;47:291–298. death during jogging in Rhode Island from 1975 through 1980. JAMA 1982;247:2535–2538. 54. Billman GE, Schwartz PJ, Stone HL: The effects of daily exercise on susceptibility to sudden cardiac death. Circulation 1984;69: 79. Thompson PD: The benefits and risks of exercise training in 1182–1189. patients with chronic coronary artery disease. JAMA 1988;259: 1537–1540. 55. Hull SS, Vanoli E, Adamson PB, et al: Exercise training confers anticipatory protection from sudden death during acute myocar- 80. Leon AS, Franklin BA, Costa F et al: Cardiac rehabilitation and sec- dial ischemia. Circulation 1994;89:548–552. ondary prevention of coronary heart disease. An American Heart Association Scientific Statement from the Council on Clinical 56. Kloner RA, Bolli R, Marban E, et al: Participants, medical and cellular Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, implications of stunning, hibernation, and preconditioning: An and Prevention (and the Council on Nutrition, Physical Activity, NHLBI workshop. Circulation 1998;97:1847–1867. and Metabolism (subcommittee on Physical Activity), in collabora- tion with the American Association of Cardiovascular and 57. Abete P, Ferrara N. Cacciatore F, et al: Angina-induced protection Pulmonary Rehabilitation. Circulation 2005;111:369–376. against myocardial infarction in adult and elderly patients: A loss of preconditioning mechanism in the aging heart? J Am Coll 81. Giri S, Thompson PD, Kiernan FJ, et al: Clinical and angiographic Cardiol 1997;30:947–954. characteristics of exertion-related acute myocardial infarction. JAMA 1999;282:1731–1736. 58. Maybaum S, Ilan M, Mogilevsky J, et al: Improvement in ischemic parameters during repeated exercise testing: A possible model for 82. Miller NH, Haskell WL, Berra K, DeBusk RF: Home versus group myocardial preconditioning. Am J Cardiol 1996;78:1087–1091. exercise training for increasing functional capacity after myocar- dial infarction. Circulation 1984;70:645–649. 59. Kloner RA: Preinfarct angina and exercise: Yet another reason to stay physically active. J Am Coll Cardiol 2001;38:1366–1368. 83. Kelbaek H, Eskildsen P, Hansen PF, Godtfredsen J: Spontaneous and/or training-induced hemodynamic changes after myocardial 60. Schuler G, Hambrecht R, Schlierf G, et al: Myocardial perfusion infarction. Int J Cardiol 1981;1:205–213. and regression of coronary artery disease in patients on a regimen of intensive physical exercise and low fat diet. J Am Coll Cardiol 84. Greenland P, Chu JS: Efficacy of cardiac rehabilitation services. 1992;19:34–42. With emphasis on patients after myocardial infarction. Ann Intern Med 1988;109:650–666. 61. Hambrecht R, Niebauer J, Marburger C, et al: Various intensities of leisure time physical activity in patients with coronary artery disease: 85. Goebbels U, Myers J, Dziekan G, et al: A randomized comparison of Effects on cardiorespiratory fitness and progression of coronary exercise training in patients with normal vs. reduced ventricular atherosclerotic lesions. J Am Coll Cardiol 1993;22:468–477. function. Chest 1998;113:1387–1393. 62. Haskell WL, Alderman EL, Fair JM, et al: Effects of intensive mul- 86. Scheuer J: Effects of physical training on myocardial vascularity tiple risk factor reduction on coronary atherosclerosis and clinical and perfusion. Circulation 1982;66:491–495. cardiac events in men and women with coronary artery disease: The Stanford Coronary Risk Intervention project (SCRIP). Circulation 87. Bloor CM, White F, Sanders T: Effects of exercise on collateral 1994;89:975–990. development in myocardial ischemia in pigs. J Appl Physiol 1984;56:656–665. 63. Hambrecht R, Wolf A, Gielen S, et al: Effect of exercise on coronary endothelial function in patients with coronary artery disease. 88. Ferguson RJ, Petitclerc R, Choquette G, et al: Effect of physical N Engl J Med 2000;342:454–460. training on treadmill exercise capacity, collateral circulation and progression of coronary disease. Am J Cardiol 1974;34:764–772. 64. Hambrecht R, Fiehen E, Weigl C, et al: Regular physical exercise corrects endothelial dysfunction and improves exercise capacity 89. Nolewajka AJ, Kostuk WJ, Rechnitzer PA, et al: Exercise and human in patients with chronic heart failure. Circulation 1998;98: collateralization: An angiographic and scintigraphic assessment. 2709–2715. Circulation 1979;60:114–122. 65. Edwards DG, Schofield RS, Lennon SL, et al: Effect of exercise 90. Sim DN, Neill WA: Investigation of the physiological basis for training on endothelial function in men with coronary artery dis- increased exercise threshold for angina pectoris after physical con- ease. Am J Cardiol 2004;93:617–620. ditioning. J Clin Invest 1974;54:763–770. 66. Gokce N, Vita JA, Bader DS, et al: Effect of exercise on upper and 91. Verani MS, Hartung GH, Harris-Hoepfel J, et al: Effects of exercise lower extremity endothelial function in patients with coronary training on left ventricular performance and myocardial perfusion artery disease. Am J Cardiol 2002;90:124–127. in patients with coronary artery disease. Am J Cardiol 1981;47: 797–803. 67. Moyna NM, Thompson PD: The effect of physical activity on endothelial function in man. Acta Physiol Scand 2004;180: 92. Cobb FR, Williams RS, McEwan P, et al: Effects of exercise training 113–123. on ventricular function in patients with recent myocardial infarc- tion. Circulation 1982;66:100–108. 68. Rochmis P, Blackburn H: Exercise tests: A survey of procedures, safety and litigation experience in approximately 170,000 tests. 93. DeBusk RF, Hung J: Exercise conditioning soon after myocardial JAMA 1971;217:1061–1066. infarction: Effects on myocardial perfusion and ventricular func- tion. Ann NY Acad Sci 1982;382:343–351. 69. Irving JB, Bruce RA: Exertional hypotension and postexertional ventricular fibrillation in stress testing. Am J Cardiol 1977;39: 94. Todd IC, Bradnam MS, Cooke MBD, Ballantyne D: Effects of daily 849–851. high-intensity exercise on myocardial perfusion in angina pectoris. Am J Cardiol 1991;68:1593–1600. 70. Gibbons L, Blair SN, Kohl HW, Cooper K: The safety of maximal exercise testing. Circulation 1980;80:846–852. 95. Schuler G, Schlierf G, Wirth A, et al: Low-fat diet and regular, supervised physical exercise in patients with symptomatic coronary 71. Yang JC, Wesley RC Jr, Froelicher VF: Ventricular tachycardia dur- artery disease: Reduction of stress-induced myocardial ischemia. ing routine treadmill testing. Arch Intern Med 1991;151:349–353. Circulation 1988;77:172–181. 72. Franklin BA, Gordon S, Timmis GC, O’Neill WW: Is direct physician 96. Schuler G, Hambrecht R, Schlierf G, et al: Regular physical exer- supervision of exercise stress testing routinely necessary? Chest cise and low-fat diet: Effects on progression of coronary artery dis- 1997;111:262–264. ease. Circulation 1992;86:1–11.

C H A P T E R 1 4 Cardiac Rehabilitation 505 97. Schuler G, Hambrecht R, Schlierf G, et al: Myocardial perfusion 122. Piepoli MF, Flather M, Coats AJ: Overview of studies of exercise and regression of coronary artery disease in patients on a regimen training in chronic heart failure: The need for a prospective ran- of intensive physical exercise and low fat diet. J Am Coll Cardiol domized multicenter European trial. Eur Heart J 1998;19: 1992;19:34–42. 830–841. 98. Froelicher VF, Jensen D, Genter F, et al: A randomized trial of 123. Hambrecht R, Niebauer J, Fiehn E, et al: Physical training in exercise training in patients with coronary heart disease. JAMA patients with stable chronic heart failure: Effects on cardiorespi- 1984;252:1291–1297. ratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol 1995;25:1239–1249. 99. Atwood JE, Jensen D, Froelicher VF, et al: Agreement in human interpretation of analog thallium myocardial perfusion images. 124. Dubach P, Myers J, Dziekan G, et al: Effect of high intensity exercise Circulation 1981;64:601–609. training on central hemodynamic responses to exercise in men with reduced left ventricular function. J Am Coll Cardiol 1997; 100. Sebrechts CP, Klein JL, Ahnve S, et al: Myocardial perfusion changes 29:1591–1598. following 1 year of exercise training assessed by thallium-201 cir- cumferential count profiles. Am Heart J 1986;112:1217–1226. 125. Pina IL, Apstein CS, Balady GJ, et al: Exercise and heart failure: A statement from the American Heart Association Committee on 101. Myers J, Ahnve S, Froelicher V, et al: A randomized trial of the exercise, rehabiliation, and prevention. Circulation 2003;107: effects of 1 year of exercise training on computer-measured ST 1210–1225. segment displacement in patients with coronary artery disease. J Am Coll Cardiol 1984;4:1094–1102. 126. Stratton J, Dunn J, Adamopoulos S, et al: Training partially reverses skeletal muscle metabolic abnormalities during exercise 102. Ehsani AA, Martin WH, Heath GW, Coyle EF: Cardiac effects of in heart failure. J Appl Physiol 1994;76:1575–1582. prolonged and intense exercise training in patients with coronary artery disease. Am J Cardiol 1982;50:246–254. 127. Myers J, Goebbels U, Dzeikan G, et al: Exercise training and myocardial remodeling in patients with reduced ventricular func- 103. Hossack KF, Hartwick R: Cardiac arrest associated with supervised tion: One-year follow-up with magnetic resonance imaging. Am cardiac rehabilitation. J Cardiac Rehabil 1982;2:402–408. Heart J 2000;139:252–261. 104. Donovan CM, Brooks GA: Endurance training affects lactate clear- 128. Hambrecht R, Gielen S, Linke, et al: Effects of exercise training on ance, not lactate production. Am J Physiol 1983;244:E83–E92. left ventricular function and peripheral resistance on patients with chronic heart failure. JAMA 2000;283:3095–3101. 105. Myers J, Ashley E: Dangerous curves—A perspective on exercise, lactate and the anaerobic threshold. Chest 1997;111:787–795. 129. Giannuzzi P, Temporelli PL, Corra U, Tavazzi L: Antiremodeling effect of long-term exercise training in patients with stable 106. Hossack KF, Bruce RA, Kusumi F: Altered exercise ventilatory chronic heart failure: Results of the Exercise in Left Ventricular responses by apparent propranolol-diminished glucose metabolism: Dysfunction and Chronic Heart Failure (ELVD-CHF) Trial. Implications concerning impaired physical training benefit in Circulation 2003;108:554–559. coronary patients. Am Heart J 1981;102:378–382. 130. Sullivan MJ, Higginbotham MB, Cobb FR: Exercise training in 107. Malmborg R, Isaccson S, Kallivroussis G: The effect of beta-blockade patients with severe left ventricular dysfunction: Hemodynamic and/or physical training in patients with angina pectoris. Curr and metabolic effects. Circulation 1988;78:506–515. Ther Res Clin Exp 1974;16:171–183. 131. Coats A, Adamopoulos S, Radaelli A, et al: Controlled trial of 108. Obma RT, Wilson PK, Goebel ME, Campbell DE: Effect of a condi- physical training in chronic heart failure. Circulation 1992; tioning program in patients taking propranolol for angina pectoris. 85:2119–2131. Cardiology 1979;64:365–371. 132. Dubach P, Myers J, Dzieken G, et al: Effect of exercise training on 109. Pratt CM, Welton DE, Squired WG, et al: Demonstration of training myocardial remodeling in patients with reduced left ventricular effect during chronic beta-adrenergic blockade in patients with function after myocardial infarction: Application of magnetic res- coronary artery disease. Circulation 1981;64:1125–1129. onance imaging. Circulation 1997;95:2060–2067. 110. Vanhees L, Fagard R, Amery A: Influence of beta-adrenergic block- 133. Hambrecht R, Fiehn E, Weigl C, et al: Regular physical exercise ade on the hemodynamic effects of physical training in patients corrects endothelial dysfunction and improves exercise capacity with ischemic heart disease. Am Heart J 1984;108:270–275. in patients with chronic heart failure. Circulation 1998;98: 2709–2715. 111. Pavia L, Orlando G, Myers J, et al: The effect of beta-blockade ther- apy on the response to exercise training in postmyocardial infarc- 134. Coats AJS, Adamopoulos S, Meyer TE, et al: Effects of physical tion patients. Clin Cardiol 1995;18:716–720. training in chronic heart failure. Lancet 1990;335:63–66. 112. Forissier JF, Vernochet P, Bertrand P, Charbonnier B, et al: Influence 135. Tyni-Lenne R, Gordon A, Sylven C: Improved quality of life in of carvedilol on the benefits of physical training in patients with chronic heart failure patients following local endurance training moderate chronic heart failure. Eur J Heart Fail 2001;3:335–342. with leg muscle. J Cardiac Failure 1996;2:111–117. 113. Curnier D, Galinier M, Pathak A, et al: Rehabilitation of patients 136. Judgutt BI, Michorowski BL, Kappagoda CT: Exercise training with congestive heart failure with or without beta-blockade ther- after anterior Q-wave myocardial infarction: Importance of regional apy. J Card Fail 2001;7:241–248. left ventricular function and topography. J Am Coll Cardiol 1988; 12:363–372. 114. Ewy GA, Wilmore JH, Morton AR, et al: The effect of beta-adrenergic blockade on obtaining a trained exercise state. J Cardiac Rehabil 137. Oh BH, Ono S, Gilpin E, Ross J: Altered left ventricular remodel- 1983;3:25–29. ing with beta-adrenergic blockade and exercise after coronary reperfusion in rats. Circulation 1993;87:608–616. 115. Tesch PA, Kaiser P: Effects of beta-adrenergic blockade on 02 uptake during submaximal and maximal exercise. J Appl Physiol 138. Giannuzzi P, Tavazzi L, Temporelli PL, et al: Long-term physical 1983;54:901–905. training and left ventricular remodeling after anterior myocardial infarction. Results of exercise in anterior myocardial infarction 116. Sable DL, Brammell HL, Shehan MV, et al: Attenuation of exercise (EAMI) trial. J Am Coll Cardiol 1993;22:1821–1829. conditioning by beta-adrenergic blockade. Circulation 1982;65: 679–684. 139. Giannuzzi P, Corra U, Gattone M, et al: Attenuation of unfavorable remodeling by exercise training in postinfarction patients with 117. Marsh RC, Hiatt WR, Brammel HL, Horowitz L: Attenuation of left ventricular dysfunction: Results of exercise in left ventricular exercise conditioning by low dose beta-adrenergic receptor block- dysfunction (ELVD) trial. Circulation 1997;96:1790–1797. ade. J Am Coll Cardiol 1983;2:551–556. 140. Cannistra LB, Davidoff R, Picard MH, Balady GJ: Effect of exercise 118. Gordon EP, Savin WM, Bristow MR, Haskell WL: Cathecholamines training after myocardial infarction on left ventricular remodel- and cardiac hypertrophy in exercise training. Circulation ling relative to infarct size. J Cardiopulm Rehabil 1999; 1983;68:III–376. 19:373–380. 119. Froelicher VF, Sullivan M, Myers J, Jensen D: Can patients with 141. Agency for Health Care Policy and Research Clinical Practice coronary artery disease receiving beta blockers obtain a training Guidelines: Cardiac Rehabilitation. Washington, D.C., U.S. effect? Am J Cardiol 1985;55:155D–161D. Department of Health and Human Services, 1995. 120. Kentala E: Physical fitness and feasibility of physical rehabilita- 142. Hosenpud JD, Bennett LE, Keck BM, et al: The Registry of the tion after myocardial infarction in men of working age. Ann Clin International Society for Heart and Lung Transplantation: Fifteenth Res 1972;4(suppl 9):1–84. official report. J Heart Lung Transplant 1998;17:656–668. 121. Dorn J, Naughton J, Imamura D, Trevisan M: Correlates of com- pliance in a randomized exercise trial in myocardial infarction patients. Med Sci Sports Exerc 2001;33:1081–1089.

506 E X E R C I S E A N D T H E H E A R T 143 Stinson EB, Griepp RL, Schroeder IS, et al: Hemodynamic obser- 167. Maresh C, Harbrecht J, Flick B, Hartzler G: Comparison of reha- vations one and two years after cardiac transplantation in man. bilitation benefits after percutaneous transluminal coronary Circulation 1972;14:1181–1193. angioplasty and coronary artery bypass graft surgery. J Cardiac Rehabil 1985;5:124–130. 144. Gullestad L, Myers J, Edvardsen T, et al: Predictors of exercise capacity and the impact of angiographic coronary artery disease in 168. Waites T, Watt E, Fletcher G: Comparative functional and physio- heart transplant recipients. Am Heart J 2004;147:49–54. logic status of active and dropout coronary bypass patients of a rehabilitation program. Am J Cardiol 1983;51:1087–1090. 145. Borrelli E, Pogliaghi S, Molinello A, et al: Serial assessment of peak VO2 and VO2 kinetics early after heart transplantation. Med 169. Stevens R, Hanson P: Comparisons of supervised and unsuper- Sci Sports Exerc 2003;35:1798–1804. vised exercise training after coronary bypass surgery. Am J Cardiol 1984;53:1524–1528. 146. Shephard RJ: Responses of the cardiac transplant patient to exer- cise and training. Exerc Sport Sci Rev 1992;20:297–320. 170. Kappagoda CT, Greenwood PV: Physical training with minimal hospital supervision of patients after coronary artery bypass sur- 147. Marconi C, Marzorati M: Exercise after heart transplantation. Eur gery. Arch Phys Med Rehabil 1984;65:57–60. J Appl Physiol 2003;90:250–259. 171. Froelicher V, Jensen D, Sullivan M: A randomized trial of the 148. Williams MA, Maresh CM, Esterbrooks DJ, et al: Early exercise effects of exercise training after coronary artery bypass surgery. training in patients older than age 65 years compared with that in Arch Intern Med 1985;145:689–692. younger patients after acute myocardial infarction or coronary artery bypass grafting. Am J Cardiol 1985;55:263–266. 172. Holmes DR, Vliestra RE, Smith HC, et al: Restenosis after percu- taneous transluminal coronary angioplasty (PTCA): A report from 149. Ades P, Waldmann M, Poehlman E, et al: Exercise conditioning in the PTCA registry of the National, Heart, Lung, and Blood older coronary patients: Submaximal lactate response and Institute. Am J Cardiol 1989;53:77C–81A. endurance capacity. Circulation 1993;88:572–577. 173. Fitzgerald ST, Becker DM, Celentano DP, et al: Return to work after 150. Lavie CJ, Milani RV: Impact of aging on hostility in coronary percutaneous transluminal coronary angioplasty. Am J Cardiol patients and effects of cardiac rehabilitation and exercise training 1989;64:1108–1112. in elderly persons. Am J Geriatr Cardiol 2004;13:125–130. 174. Meier B, Gruentzig AR: Return to work after coronary artery bypass 151. Lavie CJ, Milani RV: Effects of cardiac rehabilitation programs in surgery in comparison to coronary angioplasty. In PJ Walter (ed.): very elderly patients ≥75 years of age. Am J Cardiol 1995;76: Return to Work After Coronary Bypass Surgery: Psychosocial and 177–179. Economic Aspects. New York, Springer-Verlag, 1995, pp 171–176. 152. Oldridge NB, Nagle FJ, Balke B, et al: Aortocoronary bypass sur- 175. Ben-Ari E, Rothbaum DA, Linnmeir TJ, et al: Benefits of a moni- gery: Effects of surgery and 32 months of physical conditioning on tored rehabilitation program versus physician care after percuta- treadmill performance. Arch Phys Med Rehabil 1978;59:268–275. neous transluminal coronary angioplasty: Follow-up of risk factors and rate of restenosis. J Cardiopulm Rehabil 1989;7:281–285. 153. Soloff PH: Medically and surgically treated coronary patients in cardiovascular rehabilitation: A comparative study. Int J Psychiatry 176. Ben-Ari E, Rothbaum DA, Linnmeier TA, et al: Return to work Med 1980;9:93–106. after successful coronary angioplasty: Comparison between a comprehensive rehabilitation program and patients receiving 154. Horgan JH, Teo KK, Murren KM, et al: The response to exercise usual care. J Cardiopulm Rehabil 1992;12:20–24. training and vocation counselling in post-myocardial infarction and coronary artery bypass surgery patients. Ir Med J 1980; 177. Kubo H, Yano K, Hirai H, et al: Preventive effect of exercise train- 74:463–469. ing on recurrent stenosis after percutaneous transluminal coro- nary angioplasty (PTCA). Jpn Circ J 1992;56:413–421. 155. Hartung GH, Rangel R: Exercise training in post-myocardial infarction patients: Comparison of results with high risk coronary 178. Hambrecht R, Walther C, Mobius-Winkler S, et al: Percutaneous and post-bypass patients. Arch Phys Med Rehabil 1981;62: coronary angioplasty compared with exercise training in patients 147–153. with stable coronary artery disease. A randomized trial. Circulation 2004;109:1371–1378. 156. Dornan J, Rolko AF, Greenfield C: Factors affecting rehabilitation following aortocoronary bypass procedures. Can J Surg 1982; 179. Haskell WL: Restoration and maintenance of physical and psy- 25:677–680. chosocial function in patients with ischemic heart disease. J Am Coll Cardiol 1988;12:1090–1121. 157. Fletcher BJ, Lloyd A, Fletcher GF: Outpatient rehabilitative train- ing in patients with cardiovascular disease: Emphasis on training 180. Dennis C, Houston-Miller N, Schwartz RG, et al: Early return to method. Heart Lung 1988;17:199–205. work after uncomplicated myocardial infarction: Results of a ran- domized trial. JAMA 1988;260:214–220. 158. Nakai Y, Kataoka Y, Bando M, et al: Effects of physical exercise training on cardiac function and graft patency after coronary 181. Picard MH, Dennis C, Schwartz RG, et al: Cost-benefit analysis of artery bypass grafting. J Thorac Cardiovasc Surg 1987;93: early return to work after uncomplicated acute myocardial infarc- 65–72. tion. Am J Cardiol 1989;63:1308–1314. 159. Perk B, Hedback E, Engvall G: Effects of cardiac rehabilitation 182. Engblom E, Korpilahti K, Hamalainen H, et al: Quality of life and after CABS on readmissions, return to work, and physical fitness. return to work 5 years after coronary artery bypass surgery. Long Scand J Soc Med 1990;18:45–53. term results of cardiac rehabilitation. J Cardiovasc Rehabil 1997; 17:29–36. 160. Robinson G, Froelicher VF, Utley JR: Rehabilitation of the coro- nary artery bypass graft surgery patient. J Cardiac Rehabil 183. Siegel D, Grady P, Browner WS, Hulley SB: Risk factor modifica- 1984;4:74–86. tion after myocardial infarction. Ann Intern Med 1988;109: 213–218. 161. Foster C: Exercise training following cardiovascular surgery. Exerc Sport Sci Rev 1986;14:303–323. 184. LaRosa JC, Cleary P, Muesing RA, et al: Effect of long-term mod- erate physical exercise on plasma lipoproteins: The National 162. Gohlke H, Schnellbacher K, Samek L, et al: Long-term improve- Exercise and Heart Disease Project. Arch Intern Med 1982;142: ment of exercise tolerance and vocational rehabilitation after 2269–2274. bypass surgery: A five-year follow-up. J Cardiac Rehabil 1982;2: 531–540. 185. Pekkanen J, Linn S, Meiss G, et al: Ten year mortality from cardio- vascular disease in relation to cholesterol level among men with 163. Ben-Ari E, Kellermann JJ, Fisman E, et al: Benefits of long-term and without preexisting cardiovascular disease. N Engl J Med physical training in patients after coronary artery bypass grafting–A 1990;332:1700–1707. 58 month follow-up and comparison with a non-trained group. J Cardiopulm Rehabil 1986;6:165–170. 186. Hamalainen H, Luurila OJ, Kallio V, et al: Long-term reduction in sudden deaths after a multifactorial intervention programme in 164. Dubach P, Litscher K, Kuhn M, et al: Cardiac rehabilitation in patients with myocardial infarction: 10-year results in a con- Switzerland: Efficacy of the residential approach following bypass trolled investigation. Eur Heart J 1989;10:55–62. surgery. Chest 1993;103:611–615. 187. Schell WD, Myers JN: Regression of atherosclerosis: A review. 165. Dubach P, Myers J, Dziekan G, et al: Effect of residential cardiac Prog Cardiovasc Dis 1997;39:483–496. rehabilitation following bypass surgery: Observations in Switzerland. Chest 1995;108:1434–1439. 188. Feeman WE, Niebauer J: Prediction of angiographic stabiliza- tion/regression of coronary atherosclerosis by a risk factor graph. 166. Hedbach B, Perk J, Engvall J, Areskog N-H: Cardiac rehabilitation J Cardiovasc Risk 2000;7:415–423. after coronary artery bypass grafting: Effects on exercise perfor- mance and risk factors. Arch Phys Med Rehabil 1990;71:1069–1073.

C H A P T E R 1 4 Cardiac Rehabilitation 507 189. Third Report of the National Cholesterol Education Program 204. Gordon NF, Salmon RD, Mitchell BS, et al: Innovative approaches to (NCEP) Expert Panel on Detection, Evaluation and Treatment, comprehensive cardiovascular disease risk reduction in clinical and High Blood Cholesterol in Adults (Adults Treatment Panel III) community-based settings. Curr Atheroscler Rep 2001;3:498–506. final report. Circulation 2002;106:3143–3421. 205. DeBusk RF, Haskell WL, Miller NH, et al: Medically directed at- 190. Pierson LM, Miller LE, Herbert WG: Predicting exercise training home rehabilitation soon after clinically uncomplicated acute outcome from cardiac rehabilitation. J Cardiopulm Rehabil myocardial infarction: A new model for patient care. Am J Cardiol 2004;24:113–118. 1985;55:251–257. 191. Hammond KH, Kelly TL, Froelicher VF, Pewen W: Use of clinical 206. Ades P, Pashkow F, Fletcher G, et al: A controlled trial of cardiac data in predicting improvement in exercise capacity after cardiac rehabilitation in the home setting using electrocardiographic and rehabilitation. J Am Coll Cardiol 1985;6:19–26. voice transtelephonic monitoring. Am Heart J 2000;139:543–548. 192. Van Dixhoorn E, Duivenvoorden H, Pool G: Success and failure of 207. DeBusk RF, Houston-Miller N, Superko HR, et al: A case- exercise training after myocardial infarction: Is the outcome pre- management system for coronary risk factor modification after dictable? J Am Coll Cardiol 1990;15:974–980. acute myocardial infarction. Ann Intern Med 1994;120:721–729. 193. European Heart Failure Training Group: Experience from con- 208. Levknecht L, Schriefer J, Schriefer J, Maconis B: Combining case trolled trials of physical training in chronic heart failure. Protocol management, pathways, and report cards for secondary cardiac and patient factors in effectiveness in the improvement in exercise prevention. Jt Commun Qual Improv 1997;23:162–174. tolerance. Eur Heart J 1998;19:466–475. 209. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH: Improved 194. Myers J, Froelicher VF: Predicting outcome in cardiac rehabilita- treatment of coronary heart disease by implementation of a tion. J Am Coll Cardiol 1990;15:983–985. Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819–822. 195. Ades PA, Balady GJ, Berra K: Transforming exercise-based cardiac rehabilitation programs into secondary prevention centers: A 210. West JA, Miller NH, Parker K, et al: A comprehensive management national imperative. J Cardiopulm Rehabil 2001;21:263–272. system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol 1997;79:58–63. 196. Balady G, Ades P, Comoss P, et al: Core components of cardiac rehabilitation/secondary prevention programs: A statement for 211. Froelicher VF, Herbert W, Myers J, Ribisl P: How cardiac rehabili- healthcare professions from the American Heart Association and tation is being influenced by changes in healthcare delivery. the American Association of Cardiovascular and Pulmonary J Cardiopulm Rehabil 1996;16:151–159. Rehabilitation Writing Group. Circulation 2000;102:1069–1073. 212. Ries AL, Kaplan RM, Limberg TM, Prewitt LM: Effects of pul- 197. Wee CC, McCarthy EP, Davis, et al: Physician counseling about monary rehabilitation on physiologic and psychosocial outcomes exercise. JAMA 1999;282:1583–1588. in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995;122:823–832. 198. Sherman SE, Hershman WY: Exercise counseling: How do gen- eral internists do? J Gen Intern Med 1993;8:243–248. 213. Drummond M, Brandt A, Luce B, Rovira J: Standardizing method- ologies for economic evaluation in health care. Int J Technol 199. Damush TM, Stewart AL, Mills KM, et al: Prevalence and corre- Assess Health Care 1993;9:26–36. lates of physician recommendations to exercise among older adults. J Gerontol A Biol Sci Med Sci 1999;54:M423–M427. 214. Oldridge N, Furlong W, Feeny D, Guyatt GH: Economic evalua- tion of cardiac rehabilitation soon after acute myocardial infarc- 200. Sueta C, Chowdhury M, Boccussi S: Analysis of the degree tion. Am J Cardiol 1993;72:154–161. of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease. Am J Cardiol 1999;83: 215. Ades PA, Huang D, Weaver SO: Cardiac rehabilitation participa- 1303–1307. tion predicts lower rehospitalization costs. Am Heart J 1992; 123:916–921. 201. Schrott H, Bittner V, Vittinghoff E, et al: Adherence to national cholesterol education program treatment goals in postmenopausal 216. Bondestam E, Breikss A, Hartford M: Effects of early rehabilita- women with heart disease: The heart and estrogen/progestin tion on consumption of medical care during the first year after replacement study (HERS). JAMA 1997;277:1281–1286. acute myocardial infarction in patients 65 years of age or older. Am J Cardiol 1995;75:767–771. 202. Ribisl PM: Exercise: The unfilled prescription. Am J Med Sports 2001;3:13–21. 217. Levin LA, Perk J, Hedback B: Cardiac rehabilitation: A cost analy- sis. J Intern Med 1991;230:427–434. 203. Ribisl PM: The inclusive chronic disease model: Reaching beyond cardiopulmonary patients. In Jobin J, Maltais F, Poirier P, Leblanc P, 218. Ades PA, Pashkow FJ, Nestor JR: Cost effectiveness of cardiac Simard C (eds): Advancing the Frontiers of Cardiopulmonary rehabilitation after myocardial infarction. J Cardiopulm Rehabil Rehabilitation. Champaign, Ill, Human Kinetics, 2002, pp 29–36. 1997;17:222–231.



index A Aircrewmen, asymptomatic, exercise-induced changes in ST-segment depression, predictive value of, 147, 147t Absolute spatial vector velocity (ASVV), in Sunnyside biomedical exercise electrocardiography program, 84–85 Algorithms, computer, evaluation of, in computerized electrocardiographic analysis, 70 as transformation function, 65 formula for, 66 Altitude, effects of, maximal heart rate and, 112 mathematical constructs, 68t, 85 Ambulation, during cardiac rehabilitation, 464, 464t ACC/AHA exercise testing guidelines. See American College animal studies of, 464 of Cardiology (ACC)/American Heart Association (AHA) Ambulatory monitoring, in preoperative evaluation, for exercise testing guidelines. ACE (Angiotensin-converting enzyme), during noncardiac surgery, 403–404 transplantation, 334 in prognostic studies, treadmill testing vs., 282 Activity, progressive, during cardiac rehabilitation, 465–467 in screening, 367–368, 367t Activity counseling, after myocardial infarction, 324 American College of Cardiology (ACC)/American Heart Adenosine, in nuclear perfusion imaging, 35 Adenosine diphosphate, 2 Association (AHA) exercise testing guidelines, for Adenosine triphosphate, production of, for muscular diagnostic use of standard exercise test, 237–239 contraction, 2–3 for noncardiac surgery, 401 Aerobic capacity, after myocardial infarction, spontaneous coronary angiography indications and, 404–405 improvement in, 478 for prognostic use, 283–286 Aerobic exercise program, features of, 419 in asymptomatic screening, 358–361 hemodynamic consequences of, 420, 420t in cardiac rhythm disorders, 407–408 metabolic consequences of, 420, 420t in pre- and postrevascularization, 394–395 morphologic consequences of, 420, 420t in recovery from myocardial infarction, 292–293 Aerobic training, maximal oxygen uptake in, 93 in valvular heart disease, 412 Afterload, 5, 6 Anaerobic threshold, definition of, 52 Age, definition of, in multivariable analysis, 224 Analog-to-digital conversion, advantages, 64, 64t effect of, on athletic sudden death, 452–453 Anaphylaxis, exercise-induced, 454 on heart rate, 4–5 Aneurysm, ventricular, ST-elevation and, 137 on maximal heart rate, 109–112, 110t, 111 Angina, antianginal agent testing and, 387–389, 388t maximal heart rate vs., 101, 103 atypical, as indicator of coronary artery disease, 198, 198t in United States Air Force School of Aerospace Medicine during bicycle ergometry, 19 effort. See Effort angina pectoris. (USAFSAM) study of, 111–112, 112 exercise-induced, as cause of chronotropic incompetence, metabolic equivalent vs., 101–102, 102 nomograms for, effect on exercise capacity and, 100–101, 112–114 prognostic importance of, 307 101, 102 Frank vector lead system in, computerized study of, 70 predicting metabolic equivalents, 102–104, 105t in asymptomatic screening, 362t relationship to maximal oxygen uptake, 55, 56, 95, 95 long-acting nitrates for, 389–391 vs. disease effects on, maximal cardiac output, 107–108 oxygen uptake in, vs. treadmill time, 45, 45t maximal heart rate and, 109 oxygen uptake slopes in, vs. work rate in, 23t, 44t safety of placebo in studies of, 287 spontaneous, effort angina pectoris vs., 389 Note: Page numbers in italics refer to illustrations; page numbers followed by the letter t refer to tables. 509

510 Index Angina, antianginal agent testing and (Continued) Atherosclerotic calcification, 371 ST-segment depression in, 70–72 Atherosclerotic plaque, incidence of, 374 variant, 134, 135t Athletes, echocardiographic studies of, 426t–427t, 455 definition of, 135 history of, 135 orthopedic injuries in, 454 screening of, 452, 455 Angiography. See Coronary angiography. sudden death of, causes of, 448–454 Angiotensin-converting enzyme (ACE), during environmental impact on, 452 transplantation, 334 ATP (adenosine triphosphate), production of, for muscular Antianginal agents, evaluation of, 387–389 contraction, 2–3 and variable anginal threshold, 389 Atrial fibrillation, evaluation of, 409–412 reproducibility of exercise variables in, 387–388 Aortic stenosis, 412–415 drug effect on, 410–412 congenital, 413 exercise response to, 410 effort syncope in, 413 maximal exercise testing in, 410 exercise testing in, 413–415, 414t prevalence of, 409 Arithmetic mean, 87 Atrial repolarization, exercise-induced ST-segment Arm ergometry, 17–19 depression and, 153–154 Arm exercise, vs. leg exercise, 18–19 Atypical angina, as indicator, of coronary artery disease Arrhythmia(s), exercise-induced, 250 (CAD), 198, 198t evaluation of, 394 Australian studies, of exercise testing prognostic value, 302 in asymptomatic screening, 369 Averaging, for maximal heart rate determination, 108 prognostic importance of, 307 a-VO2 difference, as response to exercise, 5, 9 malignant ventricular, evaluation of, 408 Arterial pulse, for maximal heart rate (HRmax) B determination, 108 Artery(ies), hemoglobin content of, during exercise, 8–9 Bags, Douglas, in gas exchange measurement, 46 oxygen content of, determinants of, 8–9 Balke protocol, 21t in pulmonary disease, 8–9 Ascoop (the Netherlands) studies, of computerized oxygen uptake slopes in, vs. work rate in, 23t, 44t electrocardiographic analysis, 77 Balloon(s), weather, in gas exchange measurement, 46 ASVV (absolute spatial vector velocity), in Sunnyside Baltimore Longitudinal Study of Aging, 147, 366 biomedical exercise electrocardiography program, 85–86 Baseline wander, cubic spine filter effect on, 65, 67 Asymptomatic Cardiac Ischemia Pilot protocol, 21t Asymptomatic screening, 351–384 in computerized electrocardiographic analysis, reduction ACC/AHA guidelines for, 358–361 of, 65, 67, 86 ancillary techniques for, 368–370, 369t coronary artery calcification in, 371–372 Bayes’ Theorem, 73, 196 electron-beam computed tomography for, 372–377 formula for, 197 costs of, 373–374 nomograms for, 197 follow-up after, 375–376 sensitivity and specificity of, 198–199 risks of, 373–374 vs. multivariate diagnostic techniques, 234 vs. coronary angiography, 373 exercise testing in, 367–368 Beat(s), in computerized electrocardiographic analysis, cardiokymography in, 370–371 alignment of, 86 electrocardiographic criteria for, 369 averaging of, 68, 68, 83 exercise-induced dysrhythmias in, 369 classification of, 68 follow-up studies of, 361–367, 362t, 364t, 367t extraction of, 86 improvement of, 368–377, 369t nuclear perfusion exercise testing in, 369–370 Bed rest, during cardiac rehabilitation, 462t, 464, 465 predictors of, 364, 364t effect of, on maximal heart rate (HRmax), 111–112 fluoroscopy for, 372 recommendations for, after acute myocardial infarction, for left ventricular hypertrophy, criteria for, 357 461 in prevention of coronary artery disease, 352–353 sensitivity and specificity of, 353 Bernoulli’s law, 46 maximal vs. submaximal testing in, 361 Beta-blockers, during exercise testing, 14, 205–206, 310 multivariable prediction in, 377–379 computer probability estimates for, 378–379 during exercise training, 484–486, 487t in patients with angiographically significant effect of, on computerized electrocardiographic analysis, coronary artery disease, 379 84–85 procedures for, 380 on maximal oxygen uptake, 411 resting electrocardiography in, 354–357 on multivariable analysis, 205–206, 233 abnormal angiographic findings in, 357–358 on QRS score, 73 abnormalities of, 357 on ST-segment, 205–206 outcome prediction with, 357–358, 358t for atrial fibrillation, 410–412 silent ischemia and, 367, 367t for myocardial infarction, 471 Atherosclerosis, aerobic exercise program effect on, 420 Bicycle ergometry, protocol(s) for, 20–22, 21t cardiac rehabilitation effect on, 496, 497t oxygen uptake slopes in, vs. work rate in, 23t exercise effects on, 423, 435, 455 regression equations for, 57 supine, cardiac output changes during, 482t physiologic response to, 115 stroke volume changes during, 482t vs. upright, 19 vs. Bruce protocol, maximal ST/HR slope in, 74 vs. treadmill testing, 17, 19 maximal oxygen uptake in, 22

Index 511 Bipolar lead(s), 25–26, 26 Cardiac output, changes in, during supine bicycle Frank lead system vs., in ST-segment depression, 70 exercise (Continued) vs. vector leads, in computerized electrocardiographic analysis, 70 during bicycle ergometry, 19 maximal, age vs. disease effects on, 107–108 Blood catecholamine, aerobic exercise program Cardiac rehabilitation, 461–503 effect on, 420 after percutaneous transluminal coronary angioplasty, 493 age-related benefits of, 491–492 Blood flow, in chronic heart failure, 9 as standard of care, 503 Blood pressure, exercise training effect on, 434 bedrest during, 462t cardiac changes during, 479–483 high, evaluation of, 406 exercise-induced ST-segment depression and, 154–155 radionuclide assessment of, 479–480 in multivariable analysis, 224 cardiac changes in, radionuclide assessment of, 479–483, measurement of, during exercise testing, 15 481, 482t normal, 121 chair treatment in, 464–465 response to exercise, 116–121 cost-effectiveness of, 494 resting systolic, response to long-acting nitrates, 391 early ambulation in, 462t, 464 systolic, aerobic exercise program effect on, 420 animal studies of, 464 as criteria for exercise-induced hypotension, 117 effect on risk-factor modification, 495, 495, 497t exercise-recovery ratio for, 121 exercise prescription in, 467 response to exercise, 116 circuit weight training in, 468 prognostic importance of, 307 principles of, 467 Body surface mapping, in electrocardiography, 32–33 exercise programs for post-CABS patients in, 492–493, 493t exercise testing in, pre-hospital discharge, 467 in coronary artery disease, 32–33 risks of, 476, 477t in normal patients, 32 exercise training for, beta-blocker effect on, 484–486, 487t Body weight, exercise training effect on, 434 compliance with, 486 Borg scale of perceived exertion, 24t, 115, 115t complications during, 477–478 Breathing reserve, definition of, 52 exercise electrocardiography in, 483 formula for, 49t left ventricular dysfunction in, 487, 490, 488t–491t Brody effect, 132 post-infarct remodeling in, 490–491 Bruce protocol, 20, 23t post-transplant patients and, 491 bicycle ergometer vs., maximal ST/HR slope in, 74 ventilatory threshold in, 483 Naughton treadmill protocol vs., for post-myocardial exertion-related cardiac arrest during, 478 future directions of, 500 exercise testing, 294 documenting cost efficacy of, 502 oxygen uptake in, during chronic heart failure, 20–22, 21 expanding utilization of, 501 highlighting mortality reduction in, 502 related to maximal treadmill time, 42, 43 including underserved populations, 501 oxygen uptake slopes in, vs. work rate in, 23t, 44t increasing patient diversity for, 500–501 Burdick Instruments, computerized exercise systems, of, 89 increasing physician awareness of, 501 Bypass surgery. See Coronary artery bypass surgery (CABS). initiating patient contact for, 500 home-based model of, 500 C intervention studies of, 468–478, 469t meta-analytical studies of, 473, 474t Cable(s), in exercise testing, 25 outcome of, prediction of, 496–498 CABS (coronary artery bypass surgery). See Coronary artery progressive activity during, 465–467 recommendations for, 462t bypass surgery (CABS). return to work after, 494 Calcification, atherosclerotic, 371 World Health Organization definition of, 467 Cardiac rhythm disorders, ACC/AHA guidelines for, exercise of coronary arteries. See Coronary artery calcification. testing in, 407–408 Calcium, role of, in muscular contraction, 2 evaluation of, 407–409 Calcium channel blockers, effect of, on exercise testing, 222 Cardiac risk factors, exercise training effect on, in heart Calibration, in multivariable analysis, 223 disease patients, 433–434 Capillaries, changes in, from chronic exercise, 421 Cardiokymography (CKG), exercise testing vs., 233 Capillary blush, for maximal heart rate determination, 108 in asymptomatic screening, 370–371 Carbohydrate(s), as energy source in muscular contraction, 3 Cardiotachometer(s), for maximal heart rate determination, Carbon dioxide, production of, formula for, 49t 108 Cardiovascular death, spectrum of, 259, 260 ventilatory equivalents of, 50–51 Cardiovascular disease(s), disability related to, economic Cardiac arrest, exertion-related, during cardiac impact of, 462 CASS (Coronary Artery Surgery Study), 252 rehabilitation, 478 ST-elevation and, 138 Cardiac catheterization, in prediction of coronary artery Catheter(s), intracardiac, in exercise testing, 19–20 for differentiation of cardiac vs. pulmonary dyspnea, 20 disease, 266 for differentiation of left ventricular systolic vs. diastolic Cardiac death, as cardiac endpoint, 259 dysfunction, 20 noninvasive testing for, predictive value of, 317t for quantitation of valvular disease, 20 summary odds ratio for, 317–322, 318t, 319, 320 Cardiac dyspnea, vs. pulmonary dyspnea, 20 Cardiac endpoints, prediction of, in coronary artery disease, 252–257, 257t–258t, 261 Cardiac fluoroscopy, of coronary artery calcifications, 372 Cardiac function, exercise capacity and, 96–99, 98 Cardiac output, changes in, during supine bicycle exercise, 482t determinants of, 4–9

512 Index Celiprolol, for atrial fibrillation, 411 Coronary artery calcification, 371–372 Censoring, 251, 311–312 electron-beam computed tomography of, 372–373 Chair treatment, in cardiac rehabilitation, 464–465 costs of, 373 Chest pain. See also Angina. risks of, 373 vs. coronary angiography, 373 as indicator of coronary artery disease, 198t epidemiology of, 374 definition of, in multivariable analysis, 224 fluoroscopy of, 372 ST segment and, 159 in vivo imaging of, 372 Children, regression equations for, 57 Cholesterol, definition of, in multivariable analysis, 224 Coronary artery disease (CAD), body surface mapping in, 32–33 total, cardiac rehabilitation effect on, 495–496, 495 calcium deposition in. See Coronary artery calcification. Chronic heart failure, definition of, in exercise testing, 329 diagnosis of, 380–381 Chronic obstructive pulmonary disease (COPD), vs. left-sided angiographic correlative studies in, 219t arm ergometry in, 19 heart disease, 20 by electrocardiography, 199–203 Chronotropic incompetence (CI), 111–114 computer-derived criteria for, 68t, 72t, 77–85 Chronotropic index, 113 flow diagram for, 200 CI (chronotropic incompetence), 111–114 in exercise program(s), 379–380 Circuit weight training, in cardiac rehabilitation, 468 in pilots, 381 CKG (cardiokymography), exercise testing vs., 235 ST-segment analysis in, 76–77 diagnostic exercise testing in, 191–248 in asymptomatic screening, 370–371 ACC/AHA guidelines for, 237–238 Classification, functional, exercise capacity vs., 93–96, 95 by electrocardiogram, 199–202 digoxin effect on, 211 questionnaire assessment in, 96, 96t, 97t Feinstein’s methodologic standards for, 216–217 Climate, impact on sudden death of athlete, 452 for electrocardiography abnormalities, 206–209 Collateral circulation, coronary, changes in, 421 for left bundle branch block, 206–207 Computer algorithms, evaluation of, in computerized for left ventricular hypertrophy with strain, 207 for one additional millimeter depression with baseline electrocardiographic analysis, 70 ST depression, 207–208 Confidence, of patients and spouses, after post-myocardial for resting ST-segment depression, 207 for right bundle branch block, 207 infarction exercise testing, 294 gender effect on, 208, 212t, 213 Congenital aortic stenosis, exercise testing in, 413 left ventricular hypertrophy effect on, 211 Congestive heart failure, definition of, in exercise testing, 329 limited challenge in, 216 Congestive heart failure, in noncardiac surgery, 401 medication effect on, 205–206 multivariable techniques for, 219–225 incidence of, 487 probability analysis in, 197–198, 198t oxygen uptake slopes in, vs. work rate in, 23t, 44t resting ST depression effect on, 211 Congestive Heart Failure (Modified Naughton) protocol, 21t studies of, 216, 247–248 Consensus, in multivariable analysis, 228, 274–275 left main, diagnosis of, 271–272 Consent, for exercise testing, 15 multivariable prediction of, 233–234 Contractility, myocardial, 6 oxygen uptake slopes in, vs. work rate, 23t, 43, 43t, 44t COPD (chronic obstructive pulmonary disease), pathophysiology of, 250 prediction of. See Coronary artery disease (CAD), differentiation from left-sided heart disease, through prognostic exercise testing in. exercise testing, 20 pretest probability of, by symptoms, gender, and age, 238t Copenhagen studies, of exercise testing prognostic value, 303 prevention of, asymptomatic screening for, 352–353 Coronary angiography, after acute myocardial infarction, probability for, calculation of, 198t 295–297, 296t prognostic exercise testing in, 249–287 and exercise testing, in asymptomatic screening, 367–368 ACC/AHA guidelines for, 283–286 exercise testing vs., in prognostic determination, 249 as part of patient evaluation, 249 for noncardiac surgery, 401 cardiac catheterization in, 250 indications for, 404 cardiac death in, 259 in asymptomatic screening, with resting consensus in, 274–275 Duke Treadmill Score in, 254–255 electrocardiography (ECG) abnormalities, 357–358 follow-up studies of, 253–254, 257–259, 257t limitations of, 199 for silent ischemia, 278–282 of silent ischemia, 281–282, 284t–285t Long-Beach VA Treadmill Score studies of, 260–262 predictions from, 271–275 meta-analytic studies of, 273 multivariable equations for, 273 consensus in, 274 myocardial infarction history in, 274 meta-analytical studies of, 273 pathophysiology of, 250 multivariable equations for, 273 predicting angiographic findings in, 271–275 predictors for, 274 predicting cardiac endpoints in, 252–262, 257t–258t, statistical methods for, 273 261–262 using clinical variables, 271 prediction equations vs. clinicians’ predictions in, 270–271 using exercise test responses, 271–272 predictors for, 274 vs. electron-beam computed tomography, of coronary artery calcification, 372–373 Coronary artery(ies), changes in, from chronic exercise, 421 stenosis of, ST-elevation and, 138 Coronary artery bypass surgery (CABS), evaluation of, 397 exercise program(s) for, 492–493, 493t prognostic implications of, 275–276, 276t vs. medical treatment, for exercise-induced hypotension, 119 vs. percutaneous transluminal coronary angioplasty, 399, 400t

Index 513 Coronary artery disease (CAD), body surface Digitalis, effect of, on exercise-induced ST-segment mapping in (Continued) depression, 149 statistical methods for, 250–251 studies of, 287t Digoxin, effect of, on computerized electrocardiographic using exercise test responses, 271–272 analysis, 85 vs. coronary angiography, 249 on exercise-induced ST-segment depression, 149, 310 vs. radionuclide techniques, 267 on meta-analytical studies, 211 with coronary artery bypass surgery, 275–276 on multivariable analysis, 205 work-up bias in, 259–260 on ST-segment depression, 205 R wave changes in, 131–132 for atrial fibrillation, 411 silent ischemia with, 160 Diltiazem, for atrial fibrillation, 411–417 stable, cardiac catheterization in, 250 Dipyridamole nuclear perfusion imaging, 35 ST-elevation and, 135–138 ST-segment depression, 142–143 in preoperative evaluation, for noncardiac surgery, 404 Coronary artery stenosis, diagnosis of, by exercise Dipyridamole stress testing, for ischemia evaluation, in left electrocardiography, 199 bundle branch block, 404 Coronary Artery Surgery Study (CASS), 160 Dipyridamole thallium stress testing, in preoperative ST-elevation and, 138 evaluation, for noncardiac surgery, 403–404 Coronary atherosclerosis, in joggers and marathon runners, Discriminant analysis, 312 Discriminant function analysis, definition of, 72t 448–450 Discriminate function, 273 Coronary collateral circulation, changes in, from chronic Discriminate value, 191–193 Dobutamine stress echocardiography, 35 exercise, 421–422 Coronary collateral vessels, effect on exercise in preoperative evaluation, for noncardiac surgery, 403 Double product, exercise-induced ST-segment depression electrocardiography, 202–203 Coronary flow reserve, effect on exercise electrocardiography, and, 154–155 Douglas bags, in gas exchange measurement, 46 199–202 Downsloping ST-segment, depression of, during recovery, Coronary heart disease, asymptomatic. See Asymptomatic 205 screening. Drugs. See Medication(s). cardiac changes in, during cardiac rehabilitation, Duke Activity Status Index (DASI), 96, 97t Duke meta-analysis, of stress testing, after acute myocardial 479–483 radionuclide assessment of, 479–480 infarction, 314–322, 317t, 318t prediction of, activity level vs. maximal oxygen uptake, Duke Treadmill Score (DTS), 232, 254–255 420–421 equation for, 262 Coronary regression, studies of, 497t for Veterans Affairs prognostic score, 261, 262 Corwin hemostat, for atrial fibrillation, 411 nomogram(s) for, 255 Cost effectiveness, of asymptomatic screening, 294 Dynamic exercise, definition of, 17, 419 maximal heart rate during, 108, 108t of cardiac rehabilitation, 494 types of, 115–116 of electron-beam computed tomography, for coronary Dynamic work, 467 Dyspnea, cardiac vs. pulmonary, 20 artery calcification, 373 Dysrhythmias. See Arrhythmia(s). Cubic spine filter, effect on baseline wander, 65, 67 Cycle ergometry. See Bicycle ergometry. D E Dalhousie square, 26 EBCT (electron-beam computed tomography), exercise DASI (Duke Activity Status Index), 96, 97t testing vs., 235 Death, cardiac, as cardiac endpoint, 241 ECG (electrocardiography). See Electrocardiography (ECG). noninvasive testing for, 317t Echocardiographic stress test, in preoperative evaluation, for summary odds ratio for, 317–322, 318t, 319, 320 cardiovascular, spectrum of, 260 noncardiac surgery, 403 exertion-related. See Sudden death. Echocardiography, dobutamine, 35 from exercise-induced hypotension, 119 from myocardial infarction, 291 exercise testing vs., 235 reduction of, animal studies of, 421t of normal individuals, before and after exercise training, through cardiac rehabilitation, 502 related to physical activity, 435 425–432, 426t–430t sudden. See Sudden death. Effort angina pectoris, vs. spontaneous angina pectoris, 389 Dekers (Rotterdam) studies, of computerized Effort syncope, in aortic stenosis, 412–413 electrocardiographic analysis, 80 EIH (exercise-induced hypotension). See Exercise-induced Detrano (Cleveland Clinic) studies, of computerized electrocardiographic analysis, 80 hypotension (EIH). Detry (Belgium) studies, of computerized EIVA (exercise-induced ventricular arrhythmias), evaluation electrocardiographic analysis, 80 Diabetes, definition of, in multivariable analysis, 224 of, 408–409 silent ischemia with, 160–163 Ejection fraction (EF), 7 in prognostic studies, 278 during bicycle ergometry, 19 resting, vs. measured maximal oxygen uptake, 98, 98 Elderly, cardiac rehabilitation for, 491–492 Electrocardiography (ECG), blood composition shifts in, 128–131 body surface mapping in, 32–33

514 Index Electrocardiography (ECG), blood composition Electron-beam computed tomography (EBCT), exercise shifts in (Continued) testing vs. (Continued) in coronary artery disease, 32–33 follow-up after, 375 in normal patients, 32 risks of, 373 vs. coronary angiography, 373 clinical studies of, 127–128 historical, 127–128 End-diastolic volume, determinants of, 6 during bicycle ergometry, 19 computerized analysis of, 63–90 response to exercise, 6–8 comparison criteria for, 77–85 Ascoop (Netherlands), 77, 78t Endurance performance, determinants of, 3 Deckers (Rotterdam), 79t, 80 Energy, definition of, 2 Detrano (Cleveland Clinic), 78t, 80 Detry (Belgium), 78t, 80 for muscular contraction, 2–3 Pruvost (France), 78t, 80 Environment, impact on sudden death of athlete, 452 QUEXTA, 80–81 Ergometry, arm, 17–18 Simoons (Rotterdam), 77–80 Veterans’ Affairs Medical Centers and Hungarian bicycle. See Bicycle ergometry. Heart Institute. See Veterans’ Affairs Medical Exercise, acute cardiopulmonary response to, 4–9 Centers-Hungarian Heart Institute studies. computer algorithms in, 70 animal studies of, atherosclerosis in, 421t data reduction in, 64 coronary artery size changes in, 421, 421t exercise testing in, 87–89, 90 coronary collateral circulation in, 421, 421t Burdick Instruments, 89 morphologic and capillary changes in, 421, 421t Marquette Electronics, 89 mortality in, 423 Mortara Instruments, 89 ventricular fibrillation threshold in, 421t, 422–423 Quinton Instruments, 89 Schiller, 89–90 arm, vs. leg, 18 Hollenberg treadmill exercise score for, 73 dangers of, 448–454 ischemia in, 70–74, 71, 72t leads in, 76–77 in athletes, 450–452 mathematical concepts of, 68 in joggers and marathon runners, 448–450 noise reduction in, 64–68 definition of, 1 principles of, 62–63 dynamic, definition of, 17, 419 ST60 or ST0 in, 76 environmental impact on, in athletes, 452 ST/HR index in, 74–75 health benefits of, animal studies of, 421–423, 421t ST/HR slope in, 74 maximal heart rate during, 108–109, 108t ST/HR studies of, 75 types of, 115–116 Sunnyside biomedical program for, 85–87 vs. fitness benefits of, 447 absolute spatial vector velocity in, 85–86 isometric, dangers of, 424 baseline removal in, 86 definition of, 17, 419 beat classification and alignment in, 86 isotonic, definition of, 419 leg, vs. arm, 18 criteria for, in asymptomatic screening, 371 volume response to, 7, 7t exercise test-induced silent ischemia, 160–163 Exercise capacity, and cardiac function, 95–99, 98 exercise test-induced arrhythmias interpretation of, and ventilatory gas exchange analysis, in normal patients, 163–180, 169t–175t 101–102, 103, 107t for diagnosis of coronary artery disease (CAD), 199–203 and ventricular function, 98 for maximal heart rate determination, 108 epidemiologic studies of, 440, 441t in exercise testing, 15–17 evaluation of, 412 measurement of, through nomograms, 100–107, 101–104, paper recorders for, 16–17 waveform averaging during, 16 105t, 106t, 107t interpretation of, observer agreement about, 182 myocardial damage and, 99–100 leads for. See Lead(s). normal values for, 56–58, 56t, 59 pre-exercise, 29–31 artifacts in, 29 nomogram applications in, 57–58 response to exercise, 127–128 regression equations for, 56–57 skin preparation for, 25 prognostic importance of, 307 subjective responses to, 158–159 response to long-acting nitrates, 391 supine, exercise testing electrode(s) vs., 28t, 29 spontaneous improvement in, after myocardial infarction, treadmill test response to, reproducibility of, 182–183, 183t Electrode(s), in exercise testing, 25 295 Mason-Likar placement of, 26–27, 27 vs. functional classification, 93–96, 95 UCSD (University of California, San Diego) placement questionnaire assessment in, 96, 96t, 97t of, 27–29, 28 Exercise electrocardiography (ECG), changes in, with visual interpretation of, vs. supine electrocardiogram, 28t Electron-beam computed tomography (EBCT), exercise exercise training, 483–484 testing vs., 235 in preoperative evaluation, for noncardiac surgery, 403–404 of coronary artery calcification, 372 test characteristics of, in women, 212t costs of, 373 Exercise habits, relationship to maximal oxygen uptake, 95, 95 Exercise intensity, individualized, 424 Exercise physiologist(s), role of, during exercise testing,12–13 Exercise physiology, 1–10 afterload in, 6 and muscle fiber types, 3 and muscular contraction, 2–3

Index 515 Exercise physiology (Continued) Exercise testing. See also specific tests (Continued) contractility in, 6 nomogram measurement of, 100–107, 101–104, 105t, definition of, 1 106t, 107t filling pressure in, 6 vs. functional classification, 93–96, 95, 96t, 97t heart rate in, 4–5 principles of, 1, 2t for antianginal agent evaluation, 387–389, 388t stroke volume in, 5 reproducibility of exercise variables in, 387 ventricular compliance in, 6 variable anginal threshold in, 389 volume response in, 6–7 for atrial fibrillation evaluation, 409–411 Exercise prescription, 424–425 drug effects on exercise performance in, 410–413 for cardiac rehabilitation, 467 response to exercise in, 410 circuit weight training in, 468 with maximal exercise testing, 410 principles of, 467 with submaximal exercise testing, 410 Exercise program(s), aerobic. See Aerobic exercise program. for cardiac rehabilitation, risks of, 476, 477t cardiac adaptations from, 423–424 for evaluation, of cardiac rhythm disorder, 407–412 effect on ventilatory threshold, 483 exercise testing for, 379–380 of coronary artery bypass surgery, 397–398 for post-CABS patients, 492–493, 493t of coronary artery bypass surgery vs. PCI, 399, 400t human studies of, cross-sectional vs. longitudinal, of high blood pressure, 406 423–424 of individualized exercise programs, 415 individualized, evaluation for, 415 of treatment, 387 of valvular heart disease, 412–415, 414t Exercise stress myocardial perfusion imaging, summary odds for exercise programs, 379–380 ratio (OR) for cardiac death, 317–322 for pilots, 381–382 graded, 424 Exercise technician(s), role of, during exercise testing, 12–13 guidelines for. See American College of Cardiology Exercise testing. See also specific tests. (ACC)/American Heart Association (AHA) exercise ACC/AHA guidelines for. See American College of testing guidelines. Cardiology (ACC)/American Heart Association (AHA) heart rate in, normal, 121, 122 exercise testing guidelines. hemodynamic responses to, 93–122 chronotropic incompetence in, 112–114 advantages of, 11 dynamic exercise in, 115–116 angiotensin-converting enzyme, evaluation by, 345–346 exercise capacity in, 96–107 arm ergometry in, 17–19 in asymptomatic screening. See Asymptomatic screening, as predictor of coronary angiography results, after acute exercise testing in. in myocardial oxygen consumption, estimate of, 121–122 myocardial infarction, 295–297, 296t leads for. See Lead(s), in exercise testing. beta-blocker, evaluation by, 346 legal implications of, 15 bicycle ergometry vs. treadmill in, 19 maximal, in atrial fibrillation, 410, 410t blood pressure measurement during, 15 maximal cardiac output in, 101–108 blood pressure response to, 116–121 maximal effort during, assessment of, 12, 13t maximal effort measures in, 114–115, 115t in exertional hypotension, 117–119, 118t maximal heart rate in, 108–112, 108t, 110t, 111 of systolic blood pressure, 121 multivariable techniques for, Bayesian vs. multivariate cables in, 25 diagnostic techniques as, 234 cardiac-resynchronization therapy, evaluation by, 347 calibration in, 223 computerized systems in, 89–90 characteristic prevalence effect in, 222 interpretation of, 87 clinical studies of, 225 consent for, 15 clinical variable definitions in, 224 contraindications to, 12, 13t clinical vs. exercise test variables in, 221 diagnostic applications of. See Coronary artery disease consensus among, 228 coronary artery disease prediction in, 233–234 (CAD), diagnostic exercise testing in. discriminate value in, 192–193 differentiating ischemia from left ventricular dysfunction downsloping ST-segment depression in, 205 drug administration effects in, 222 during, 1 Duke Treadmill Score in, 234 disadvantages of, 11 gender differences in, 223–224 during recovery from myocardial infarction. See Guyatt’s criteria for, 215–216 Long Beach-Palo Alto-Hungarian Multivariable Myocardial infarction, exercise testing during recovery from. Prediction Study of, 231 echocardiographic, 35 over-fitting in, 222–223 electrocardiogram for, 16–17 population effect in, 193–194, 233 skin preparation for, 25 prediction equation in, 232–233, 232t waveform averaging of, 16 predictive accuracy in, 195 electrocardiographic response to. See Electrocardiography predictive value in, 195 (ECG), response to exercise. prevalence effect on, 233 electrode(s) for, 25 QUEXTA in, 231 Mason-Likar placement of, 26–27 R wave changes in, 204 University of California, San Diego placement of, 27, range of characteristic curves in, 194–195, 195 27–29 visual interpretation of, vs. supine electrocardiogram, 28, 28t exercise capacity in, and cardiac function, 96–99, 98 and myocardial damage, 99–100

516 Index Exercise testing. See also specific tests (Continued) Exercise-induced ST-segment, shifts of, prognostic ST-segment depression in, 205 importance of, 306 ST-segment depression leads in, 203–204 ST-segment elevation in, 204 Exercise-induced ST-segment depression, and left ventricular ST-segment interpretation issues in, 203–205 hypertrophy, 154–155 test performance definitions for, 191 upsloping ST-segment depression in, 204 Exercise-induced ventricular tachycardia, flecainide vs. cardiokymography, 235 associated with, 206 vs. nuclear perfusion and echocardiography, 234 work-up bias in, 216–219 Exertion, Borg scale of, 115, 115t differences in, 221–222 Exertional hypotension. See Exercise-induced hypotension nuclear perfusion. See Nuclear perfusion exercise testing. (EIH). patient preparation for, 14 Exertion-related cardiac arrest, during cardiac rehabilitation, placebo evaluation, in angina studies, 393–394 postexercise period in, 33–34 478 preoperative. See Noncardiac surgery, preoperative risk transient ischemia in, 453 Exertion-related death. See Sudden death. assessment of. Expert systems, in computerized exercise testing, 87, 88 prognostic applications of. See Coronary artery disease EXTRA, in computerized exercise testing, 87, 88 (CAD), prognostic exercise testing in. F protocols for, 20–22, 21. See also individual protocols. radionuclear ventriculography with, 31–32 Face masks, in gas exchange measurement, 46 ramp, 22–23, 22, 24 FAI (Functional aerobic impairment), nomograms for, 57–58 Family history, of coronary artery disease, definition of, 224 maximal, thirty-second moving averages in, 47, 48t Fasting glucose, aerobic exercise program effect on, 420 response to, due to myocardial ischemia, 250 Fast-twitch (Type II) muscle fibers, 3–4 risk of, 12–13 Feinstein’s methodologic standards, for studies of diagnostic safety precautions for, 12–13 submaximal. See Submaximal exercise testing. test performance, 213–215 supine vs. upright, 19 Fibrinolytic system, aerobic exercise program effect on, 420 termination of, 13, 13t, 34 Fiducial point, identification of, in computerized treadmill for, 14–15 12-lead, sensitivity of, 31 electrocardiographic analysis, 69 with intracardiac catheters, 19–20 Filling pressure, 6 with long-acting nitrates, 389–394 Filter(s), for absolute spatial vector velocity curve, 85 correlation of resting systolic blood pressure changes for noise reduction, 65 with exercise capacity, 391 notched, 66 source consistency, 67 transdermal nitroglycerin, 390 time-varying, 67 with percutaneous transluminal coronary angioplasty, 395 Flecainide, associated with exercise-induced ventricular restenosis prediction with, 396 tachycardia, 206 Exercise training. See also Exercise prescription; Exercise effect of, on multivariable analysis, 206 program(s). Fleisch pneumotacometer(s), in gas exchange measurement, compliance with, 486 definition of, 419–420 46 echocardiographic studies of, in normal individuals, Flowmeter(s), in gas exchange measurement, 46 Fluoroscopy, cardiac, of coronary artery calcification, 372 425–432, 426t–431t Force, definition of, 2 effect of, on beta-blockers, 484–486 Framingham offspring study, 177, 323, 439 Framingham score, 382 on cardiac risk factors, 433 Frank lead system, 28, 64 on coronary heart disease, 479 on exercise electrocardiography, 483–484 computerized study of, in angina, 70 on post-infarct remodeling, 490–491 vs. bipolar lead system, in ST-segment depression, 70 on post-transplant patients, 491 Frank-Starling mechanism, 6, 329 on propranolol, 485 Free fatty acids, as energy source in muscular contraction, 2 for cardiac rehabilitation, complications during, 477–478 Functional aerobic impairment nomogram(s) for, 57–58 for left ventricular dysfunction, 487–488, 488t–490t Functional classification, exercise capacity vs., 93–96, 95 Exercised-induced left bundle branch block, 207 questionnaire assessment in, 96, 96t, 97t Exercise-induced anaphylaxis, 454 Exercise-induced angina, as cause of chronotropic G incompetence (CI), 112–114 prognostic importance of, 307 Gas exchange, 41–59 Exercise-induced arrhythmia(s), evaluation of, 407 and exercise capacity, 101–102, 103–104 prognostic importance of, 307 breathing reserve and, 52 Exercise-induced dysrhythmias, in asymptomatic screening, carbon dioxide production and, 50 369 formulas for, 49t Exercise-induced hypotension (EIH), 117–121, 118t instrumentation for, 43–47 clinical studies of, 117, 118t maximal oxygen uptake and, 47–48 Long Beach VA Medical Center study of, 117, 119–120 minute ventilation and, 48–50 definition of, 117–120, 118t normal values for, 56–58 mortality of, 119 oxygen kinetics and, 54–55

Index 517 Gas exchange (Continued) Hungarian Heart Institute-Veterans’ Affairs Medical Centers oxygen pulse and, 50 studies. See Veterans’ Affairs Medical Centers- plateau in, 55–56 Hungarian Heart Institute studies. prediction of, 41–45 respiratory exchange ratio and, 50 Hypertension, definition of, in multivariable analysis, 224 ventilatory dead space to tidal volume ratio and, 51–52, 51 evaluation of, 406 ventilatory equivalents and, 50–51 exercise-induced ST-segment depression and, 154–155 ventilatory threshold and, 52–54, 53 Hypertension Detection and Follow-up Program, 357 Gas exchange anaerobic threshold, 52, 53 Hyperventilation, abnormalities of, exercise-induced Gaussian-distributed noise, 87 Gender, definition of, in multivariable analysis, 224 ST-segment depression and, 154 Hypotension, exertional. See Exercise-induced hypotension during arm ergometry, differences in maximal heart rate (HRmax), 17–19, 18t (EIH). differences in maximal oxygen uptake , 17–19 I effect of, on exercise-induced ST-segment depression, 149 Incremental averaging, in computerized electrocardiographic on multivariable analysis, 203, 208, 212t, 213 analysis, 67 Glycolysis, terminology of, 3 Goldman specific activity scale, 96–97, 96t Individualized exercise intensity, 423 Graded exercise test, 424 Individualized exercise program, evaluation for, 415 Guyatt’s criteria, for studies of diagnostic test performance, Infarction, myocardial. See Myocardial infarction. Informed consent, for exercise testing, 15 215 Insulin sensitivity, aerobic exercise program effect on, 420 Intraclass correlation coefficient, definition of, 182 H Ischemia, computer-derived criteria for, 70–74, 71, 72t Handrails, holding onto, in treadmill testing, 14–15 differentiation from left ventricular dysfunction, during HDL (high-density lipoprotein), aerobic exercise program exercise testing, 1 effect on, 420 dobutamine echocardiography in, 35 cardiac rehabilitation effect on, 495 echocardiographic exercise testing in, 35 exercise training effect on, 434 exercise test responses due to, 250 Heart failure, chronic, blood flow in, 8 nuclear perfusion imaging in, 35 silent. See Silent ischemia. outcomes prediction of, through gas exchange, 47–48 ST-segment normalization in, 140–142 VD/VT (ventilatory dead space to tidal volume ratio) in, ST-segment shift in, 155 transient, in exertion-related cardiac arrest, 453 51–52, 51 wall motion abnormality vs., 138–140, 141–142 cardiac transplantation, treatment for severe, 330 Isometric exercise, dangers of, 424 congestive. See Congestive heart failure. definition of, 17, 419 exercise testing, role of, for decision-making in, 330 Isometric work, 467 Isonitrile (Sestimibi) nuclear perfusion imaging, with cardiopulmonary, for decision-making in, 333, 334–336 oxygen uptake in, during ramp vs. Bruce protocol(s), 22, 24 exercise testing, 35 prevalence in, 330 Isotonic exercise, definition of, 419 prognosis in, 330, 334–336 Heart rate, aerobic exercise program effect on, 419 J impairment of, 112–113 normal, 121 J junction, alterations in, during maximal treadmill exercise, response to exercise, influences on, 4–5 128 resting, aerobic exercise program effect on, 420 Heart rate reserve, 424 Joggers, coronary atherosclerosis in, 448–449 Heat cramps, 452 Junctional ST-segment depression, exercise-induced changes Heat exhaustion, 452 Heat injury, 452 in, 134 Heat stroke, 452 avoidance of, 454 K Hematuria, in runners, 454 Hemoglobin, arterial, during exercise, 8–9 Kaplan-Meier survival curve, for Veterans’ Affairs prognostic High blood pressure, definition of, in multivariable analysis, score, 261 224 Karvonen formula, 426\\4 evaluation of, 406 Krebs cycle, 3 exercise training effect on, 433 High-density lipoproteins (HDLs), aerobic exercise program L effect on, 420 Lactate, accumulation of, 52 cardiac rehabilitation effect on, 495 as determinant of endurance performance, 3 Hollenberg treadmill exercise score, 73 Holter monitoring, treadmill testing vs., in prognostic Lactate shuttle, 52 Law of Laplace, 33 studies, 282 LBBB (left bundle branch block), 206–207 Home-based model, of cardiac rehabilitation, 500 HRmax (maximal heart rate). See Maximal heart rate exercise-induced, 207 (HRmax).

518 Index LBBB (left bundle branch block) (Continued) LVH (left ventricular hypertrophy), asymptomatic screening exercise-induced ST-segment depression and, 150 of, criteria for, 357 R wave changes in, 131–132 effect of, on meta-analytical studies, 211 LBVAMC study. See Long Beach Veterans’ Affairs Medical exercise-induced ST-segment depression and, 154–155 Center (LBVAMC) study. M LDLs (low-density lipoproteins), cardiac rehabilitation effect Malignant ventricular arrhythmia(s), evaluation of, 408 on, 495 Mapping, body surface, in electrocardiography (ECG), 32–33 exercise training effect on, 434 Lead(s), in computerized electrocardiographic analysis, in normal patients, 32 Marathon runners, coronary atherosclerosis in, 448–450 bipolar vs. vector, 73 Marquette Electronics, computerized exercise systems of, 89 in exercise testing, 25–32 Masks, face, in gas exchange measurement, 46 Mason-Likar lead systems, 26–27, 27, 77 bipolar, 25–26, 26, 70 Maximal cardiac output, age vs. disease effects on, 107–108 Frank, 26, 70 Maximal effort, measures of, 114–115, 115t Mason-Likar, 26–27, 27 Maximal exercise testing, in atrial fibrillation, 410, 410t recording of, number required for, 33 Maximal heart rate (HRmax), age effects on, 109–111, 110t, 111 sensitivity of, 31–32 ST-segment analysis in, 32 age vs. disease effects on, 109 University of California, San Diego, 27–29, 28 altitude effects on, 112 vectorcardiographic (VCG), 26–27 bed rest effects on, 111 in ST-segment, depression of, 203–204 during arm ergometry, gender differences in, 18, 18t selection of, in ST-segment analysis, 76–77 during bicycle ergometry, 19 Left bundle branch block (LBBB), 206–207 during dynamic exercise, 108–109, 109t exercise-induced, 207 factors limiting, 108–109, 109t exercise-induced ST-segment depression and, 150 motivation effects on, 112 R wave changes in, 131–132 recording methods for, 108 Left ventricular dysfunction, differentiation from ischemia, vs. age, 101, 102 during exercise testing, 1 Maximal oxygen uptake (VO2 max), aerobic exercise program exercise training for, 487–488, 488t systolic vs. diastolic, 20 effect on, 419 Left ventricular filling, during bicycle ergometry, 19 age factors in, 54, 56, 95–96, 95 Left ventricular function, assessment of, during exercise, 8 beta-adrenergic blockade effect on, 411 R wave changes in, 131–132 determinants of, 5, 4–9 Left ventricular hypertrophy (LVH), asymptomatic screening during arm ergometry, gender differences in, 18 of, criteria for, 357 during bicycle ergometry, 19 effect of, on meta-analytical studies, 211 during treadmill testing, vs. bicycle ergometry, 19 exercise-induced ST-segment depression and, 154–185 measured, nomograms of, 104 with strain, 207 Leg exercise, vs. arm exercise, 18–19 resting ejection fraction vs., 98, 98 Legal issues, in exercise testing, 15 minimal level of, for physical fitness, 95, 411 Likelihood ratio, calculation of, 192t definition of, 197 in aerobic training, 95 Limited challenges, in diagnostic test studies, 216, 217–218 of normal sedentary adults, 95 Linear Borg scale, of perceived exertion, 24 peak, 48 Linear phase high-pass filter, for noise reduction, 67 resting ejection fraction vs., 98, 98 Line-frequency noise, reduction of, in computerized Maximal ramp exercise test, thirty-second moving averages electrocardiographic analysis, 65 Lipid(s), cardiac rehabilitation effect on, 495, 495 in, 46–47, 48t exercise training effect on, 434 Maximal ST/HR slope, in computerized electrocardiographic Lipid Research Clinics Coronary Primary Prevention Trial, 366 analysis, 74 Lipid Research Clinics Mortality Follow-up Study, 442 bicycle ergometer vs. Bruce protocol, 74 Lipoprotein(s). See High-density lipoproteins (HDLs); Maximal testing, vs. submaximal testing, in asymptomatic Low-density lipoproteins (LDHs). screening, 363 Logistic regression, 273, 312 Maximal treadmill testing, in PERFEXT, 480, 482t Long Beach–Palo Alto–Hungarian Multivariable Prediction waveform alterations in, 128, 129 Study, 231 Maximal voluntary ventilation (MVV), 52 Long Beach VA Medical Center (LBVAMC) study, 260–262 McHenry protocol, 21 of blood pressure response, to exercise testing, 117, 118t Mean, trimmed, 87 of exercise-induced hypotension, 117, 119 Measured maximal oxygen uptake, nomograms of, 104 of exercise-induced ST-segment depression, 142–143, resting ejection fraction vs., 98, 98 Medication(s), effect of, on exercise testing, 14 145t on exercise-induced ST-segment depression, 149 of prognostic exercise testing, in coronary artery on multivariable analysis, 205, 233 Men. See Gender. disease (CAD), 260–262, 260, 262, 262t Metabolic equivalent(s), definition of, 2, 93, 100 Long-acting nitrates. See Nitrates, long-acting. prediction of, from age, 104, 105t Low-density lipoproteins (LDLs), cardiac rehabilitation effect vs. age, 102, 102 Minute ventilation (VE), definition of, 48, 50 on, 495 formula for, 49t exercise training effect on, 434

Index 519 Modified Naughton (Congestive Heart Failure) protocol, 21 Myocardial infarction, acute, enzymatic marker of (Continued) Montreal Heart Institute studies, of exercise testing history of, and silent ischemia, 280 in multivariable analysis, 225 prognostic value, 302–303 mortality of, 291 Mortality. See Death. non-Q wave, 309, 463 Mortara Instruments, computerized exercise systems of, 89 Q wave anterior, 463 Motivation, effect on, maximal heart rate, 112 Q wave inferior, 463 MRFIT (Multiple Risk Factor Intervention Trial), 367, 440 rehabilitation following. See Cardiac rehabilitation. Multiple Risk Factor Intervention Trial (MRFIT), 367, 440 risk determination after, 292 Multivariable analysis, 220, 273 spontaneous improvement in, 478 ST-elevation and, 135–138, 143 vs. ST diagnostic criteria, 225 subendocardial, 463 Multivariable prediction, 203 transmural, 463 Muscle(s), contraction of, 2–3 Muscle fiber(s), Type I (slow-twitch), 3 Myocardial ischemia. See Ischemia. Myocardial oxygen consumption, estimation of, through Type II (fast-twitch), 3 MVV (maximal voluntary ventilation), 52 hemodynamic measurements, 121–122 Myocardial contractility, 6 in exercise prescription, for cardiac rehabilitation, 467 Myocardial damage, 329 Myocardial oxygen uptake, 1, 2t Myocardial dysfunction, 329 Myocardial perfusion imaging, in preoperative evaluation, for Myocardial infarction, acute, enzymatic marker of, 463 noncardiac surgery, 407 and exercise capacity, 99–100 Myoglobin, effect on endurance, 3 as clinical predictor, of coronary artery disease, 274 Myosin ATPase, effect on muscular contraction, 3 pathophysiology of, 463–464 risk prediction for, 462t, 463–464 N complicated, classification of, 461, 462t exercise testing during recovery from, 291–325 N (newton), 2 activity counseling in, 324 National Exercise and Heart Disease Project (NEHDP), 471 AHA/ACC exercise testing guidelines for, 292–293 National Institutes of Health (NIH) report on Physical angiography and, 295–297, 296t benefits of, 324–325, 324t Activity and Health, 447 clinical study design features of, 298t–301t, 308–310 Naughton treadmill protocol, vs. Bruce treadmill protocol, cardiac events in, 309 for post-myocardial exercise testing, 294 electrocardiography leads in, 309 Nearest-neighbor procedure, 312 endpoints in, 309 NEHPD (National Exercise and Heart Disease Project), 471 exclusion criteria for, 310 New Zealand studies, of exercise testing prognostic value, 304 exercise protocol for, 309 Newton (N), 2 follow-up of, 310 Newton meter (Nm), 2 gender in, 310 Nitrates, long-acting, evaluation of, in exercise testing, 389–391 medication(s) in, 310 Q wave location and, 309 resting systolic blood pressure changes correlated with timing of, 309 exercise capacity, 391 effect of Q wave location on ST-segment shifts, 295 effect on patient and spouse confidence, 294 Nm (newton meter), 2 exercise capacity in, 310 Noise, causes of, during computerized electrocardiography, 65t exercise data vs. clinical data in, 307 exercise-induced angina in, 307 definition of, 64 exercise-induced arrhythmia(s) in, 307 Gaussian distribution of, 87 exercise-induced ST-segment shifts in, 306–307 reduction of, during computerized electrocardiography, meta-analytical studies of, 312–314 prognostic indicators from, 306–307 64–65 prognostic studies of, 297–322 absolute spatial vector velocity curve filtering, 85–86 Australia, 302 during electrocardiography, 16 Copenhagen, 303 during exercise testing, through skin preparation, 25 Montreal Heart Institute, 303 Nomogram(s), for Bayes’s Theorem, 197 New Zealand, 304–305 for Duke Treadmill Score, 255 Royal Melbourne Hospital, 306 for exercise capacity, 100–107, 101–104, 105–107t Spain, 304 in normal patients, 101–102, 103–104, 107t Stanford, 302 for functional aerobic impairment, 57–58 statistical critique of, 310–312 Noncardiac surgery, cardiac risk stratification by, 402t UCSD SCOR, 312 patient selection for, 402 Wilford Hall USAF Medical Center (WHUSAFMC), 303 with coronary artery disease, 400t protocol comparison in, 294 preoperative risk assessment of, ambulatory safety of, 293 spontaneously improved exercise capacity in, 295 electrocardiography monitoring in, 403–404 ST elevation in, 306–307 clinical predictors of, 402t, 404–405 studies of, 294 dobutamine stress echocardiography in, 403 submaximal testing in, 293–294 indications for coronary angiography in, 405 systolic blood pressure in, 307 myocardial ischemia and exercise capacity in, 402–403 myocardial perfusion imaging in, 403 nonexercise stress testing in, 403 recommendations for, 405–406 test selection in, 404

520 Index Nonexercise stress testing, in preoperative evaluation, of Percutaneous transluminal coronary angioplasty (PTCA), noncardiac surgery, 403 cardiac rehabilitation after, 493–494 Nonlinear Borg scale, of perceived exertion, 24 vs. medical treatment, for exercise-induced Non–Q wave myocardial infarction, 463 hypotension, 119 Notched filter, for noise reduction, 65, 66 Nuclear perfusion, exercise testing vs., 235 PERFEXT, 480–483 Nuclear perfusion exercise testing, in asymptomatic in post-by pass patients, 492 in post-infarct remodeling, 490–491 screening, 369–370 in radionuclide assessment, during cardiac rehabilitation, Nuclear perfusion imaging, 33 480–483, 481, 482t isonitrile (Sestimibi), 33 Pharmacologic stress myocardial perfusion imaging, technetium, 33 summary odds ratio for cardiac death, 318, 318t, thallium, 33 319–320 Nurse(s), role of, during exercise testing, 13 Phosphate, 2 O Phosphorus, serum, alterations in, during exercise, 128–130 Physical activity. See Physical fitness. Orthopedic injuries, in athletes, 454 Physical examination, role of, in exercise testing, 12–13 Overfitting, in multivariable analysis, 222 Physical fitness, epidemiologic studies of, 445–447, 436t, Oxidative phosphorylation, role of, in muscular 438t contraction, 3 relating exercise capacity to cardiac events, 440–443, Oxygen, arterial, determinants of, 8–9 441t in pulmonary disease, 8 relating physical activity to cardiac events, 435–440, venous, determinants of, 9 ventilatory equivalents of, 50–51, 51 436t, 438t Oxygen consumption, myocardial, estimation relating physical activity to mortality, 436t, 438t relating physical inactivity to cardiac events, 445, 447 of, 121–122 maximal oxygen uptake in, 95 Oxygen kinetics, measurement of, 44t, 54–55 recommendations for, 447 Oxygen pulse, definition of, 50 Physician(s), competency requirements of, during exercise testing, 15 ventilatory equivalents and, 50–51 role of, during exercise testing, 12–13 Oxygen uptake (VO2), breathing reserve and, 52 Physiology, exercise. See Exercise physiology. Pilots, exercise testing for, 381 carbon dioxide production and, 50 Plaque, atherosclerotic, incidence of, 374 factors affecting, 42, 43t Plateau, as measure of maximal effort, 115 formula for, 45, 49t Pneumotacometers, Fleisch, in gas exchange in chronic heart failure, during ramp vs. Bruce protocol(s), measurement, 46 Population, effect of, on multivariable analysis, 233 22–23, 24 on test variables, 193–194, 193, 233 in coronary artery disease, vs. normal patients, 42, 43 POSCH (Program of Surgical Control of Hyperlipidemia), instrumentation for, 45–47 147, 281 Positive predictive value, definition of, 195 in data sampling, variability in, 46–47, 47, 48t Postexercise period, in exercise testing, 33 in expired ventilation collection, 46 Potassium, serum, alterations in, during exercise, 128–130 maximal. See Maximal oxygen uptake (VO2 max). Power, definition of, 2 minute ventilation and, 48–50 Practitioners, for exercise testing, 500 myocardial, 1, 2t Prediction equation, development of, 232 oxygen pulse and, 50 performance and validation of, 232, 232t plateau in, 55 vs. clinicians’ predictions, 272–273 prediction of, 41–45 Predictions, clinicians’ vs. equation, 229–230 respiratory exchange ratio and, 50 Predictive accuracy, calculation of, 192t slopes of, vs. work rate, 22–23, 23t, 43, 44t definition of, 195 ventilatory threshold and, 52–53, 53 Predictive modeling, 196 vs. treadmill time, 45, 45t Predictive value, calculation of, 192, 195 Oxygen uptake drift, 43 definition of, 195, 196t, 271 Oxygen uptake lag, 43 Pre-exercise electrocardiogram (ECG), 29 Pre-hospital discharge, exercise testing in, 467 P Preload, 5 Preoperative exercise testing. See Noncardiac surgery, Paroxysmal supraventricular tachycardia (PSVT), ST-segment preoperative risk assessment of. depression in, 179–180 Prevalence, effect on multivariable analysis, 233 Prinzmetal’s angina, 134, 135t Patient(s), inclusion of, in cardiac rehabilitation, 500 Probability analysis, of coronary artery disease (CAD), Patient history, role of, in exercise testing, 12–13 196–199 Patient instruction, for exercise testing, 14 Program of Surgical Control of Hyperlipidemia (POSCH), Peak maximal oxygen uptake (VO2max), 47 147, 281 Progressive activity, during cardiac rehabilitation, 465–467 cut points for, 341 Prolapsing mitral valve syndrome, exercise-induced ST- with EF, 336 segment depression and, 154–155 role of, in HF patients, 335 with plasma biomarkers, in predicting risk, 343 vs. hemodynamic variables, 341–343

Index 521 Proportional hazard model, 314 Respiratory exchange ratio (RER), definition of, 50, 115 Propranolol, exercise training effect on, 484, 487t production of, formula for, 49t Protocol(s), for exercise testing, 20–22, 21. See also Restenosis, prediction of, with exercise test, 396 individual protocols. Resting, definition of, in multivariable analysis, 224 Pruvost (France) studies, of computerized Resting ejection fraction, vs. measured maximal oxygen electrocardiographic analysis, 80 uptake, 98, 98 PSVT (paroxysmal supraventricular tachycardia), ST-segment Resting electrocardiography, abnormalities of, effect on depression in, 179 multivariable analysis, 233 PTCA (percutaneous transluminal coronary angioplasty). in asymptomatic screening, 357–358 in asymptomatic screening, 354–356 See Percutaneous transluminal coronary angioplasty outcome prediction with, 357–358, 358t (PTCA). Resting ST-segment, depression of, 207 Pulmonary disease, arterial oxygen saturation in, 8 Resting systolic blood pressure, response to long-acting Pulmonary dyspnea, cardiac dyspnea vs., 20 nitrates, 391 Return to work, of cardiac patient, 494 Q Rhythm disorders, cardiac, ACC/AHA guidelines for, exercise testing in, 407–408 Q wave, effect on ST-segment shifts, 295 evaluation of, 407–412 exercise-induced changes in, 128 Right bundle branch block, 207 respiration effect on, 30 exercise-induced ST-segment depression and, 151, 152–153 standing effect on, 31 Risk(s), during exercise testing, 12–13 of electron-beam computed tomography, for coronary Q wave anterior myocardial infarction, 463 Q wave inferior myocardial infarction, 463 artery calcification, 373 QRS axis, computer analysis of, 29, 30t following myocardial infarction, 463 QRS complex, misalignment of, 67 Risk factor(s), estimation of, in asymptomatic screening, 352 QRS score, beta blockade effect on, 73 exercise training effect on, in heart disease patients, 434 QUEST, 89 modification of, through cardiac rehabilitation, 495–496, QUEXTA studies, 231 495, 497t of computerized electrocardiographic analysis, 80–81 preoperative assessment of, 403–404 Quinton Instruments, computerized exercise systems of, 89 through dobutamine stress echocardiography, 403 R through exercise testing for myocardial ischemia and R wave, changes in, 204–205 exercise capacity, 403–404 effect of, on exercise-induced ST-segment depression, 148 through myocardial perfusion imaging, 403 exercise-induced changes in, 131–132, 133 through nonexercise stress testing, 403 RNV (radionuclide ventriculography), prognostic applications Radionuclide ventriculography, 6–7, 7t of, in coronary artery disease, 267 assessment of coronary patients by, after exercise training, ROC curve, for Veterans Affairs prognostic score, 261, 262 479 Royal Melbourne Hospital studies, of exercise testing vs. exercise electrocardiography, in ST/HR slope, 74 prognostic value, 302 Runners, marathon, coronary atherosclerosis in, 448–450 Radionuclide ventriculography (RNV), prognostic applications of, in coronary artery disease, 267 S Ramp exercise test, maximal, thirty-second moving averages S wave, exercise-induced changes in, 128, 133 in, 46–47, 48t Safety, during exercise testing, 12–13 oxygen uptake in, during chronic heart failure, 22–23, 24 during early post myocardial infarction, 293 oxygen uptake slopes in, vs. work rate in, 23t, 44t Sampling, in gas exchange, 46–47, 47, 48t Ramp protocols, 22, 24 SAS (specific activity scale) of Goldman, 96t Receiver operating characteristic curve (ROC), calculation of, Schiller, computerized exercise systems of, 89–90 Screening, asymptomatic. See Asymptomatic screening. 192t definition of, 194–195, 195 criteria for, procedure selection, 351 Recorders, paper, for electrocardiography, 16–17 definition of, 351 with inadequate frequency response, exercise-induced efficacy of, 351 for athletes, 452 ST-segment depression and, 155 guidelines for, performance of, 351 Recovery, ST-segment depression during, 143–146, 145t Holter study of, 367, 367t Recursive partitioning, 312 of apparently healthy individuals. See Asymptomatic Regression equation(s), 56–57 Rehabilitation. See Cardiac rehabilitation. screening. Reperfusion, prognostic effect of post-myocardial infarction Seattle Heart Watch study, ST-elevation and, 138 Sensitivity, 210 exercise testing, 322–324 Repolarization, atrial, exercise-induced ST-segment calculation of, 192t definition of, 191 depression and, 153–154 Serum phosphorus, alterations in, during exercise, 128–130 RER (respiratory exchange ratio), definition of, 50, 115 Serum potassium, alterations in, during exercise, 130 Serum triglycerides, aerobic exercise program effect on, 420 production of, formula for, 49t cardiac rehabilitation effect on, 494, 495 Respiration, effect of, on Q wave, 30 on vectorcardiographic lead systems, in exercise testing, 30

522 Index Seven Countries Coronary Artery Disease Study, 437 ST-segment, amplitude of, for ST/HR index (Continued) Sign testing, 313 in Frank lead vs. bipolar lead systems, 70 Silent ischemia, and asymptomatic screening, 367, 367t in meta-analytical studies, 211 in paroxysmal supraventricular tachycardia, 179 coronary angiography of, 281–282, 284t–285t in recovery, 143, 145t, 146–149, 205 effect on exercise testing, 2 leads in, 203–204 exercise test-induced, 160–163 R wave influence on, 148 shift location and ischemia and, 155 angiographic studies of, 281–282 slope considerations in, 76 prevalence of, during treadmill testing, 162 prognosis of, 161 downsloping, depression of, 205 elevation of, 134–140, 204 in diabetics, with chest pain, 162 screening for, 160–161 cause of, 136t Simoons (Rotterdam) studies, of computerized measurement of, 138, 138t, 139 electrocardiographic analysis, 77, 80 prevalence of, 135–138, 136t Sitting, effect on vectorcardiographic lead systems, in prognostic importance of, 308–309 exercise testing, 30 exercise-induced changes in, 134–155 Skin, preparation of, for electrocardiography, in exercise normalization of, 140–142 testing, 25 resting, depression of, 207 Slope, definition of, 22 shifts in, in asymptomatic screening, 368 Slow-twitch (Type I) muscle fibers, 3 Q wave effect on, 295 Smoking, definition of, in multivariable analysis, 224 upsloping, depression of, 204 Smoking cessation, exercise training effect on, 434 ST-segment slope, alterations in, during maximal treadmill SnNout, 191 exercise, 128 Specific activity scale (SAS) of Goldman, 96, 96t definition of, 72t Specificity, 191 Subendocardial myocardial infarction, 463 definition of, 191, 353 Submaximal exercise testing, after myocardial infarction, Spontaneous angina pectoris, effort angina pectoris vs., 389 293–294, 324t SpPin, 1 in atrial fibrillation, 410 ST area, 70 indications for, 24 ST index, 70, 73 Sudden death, causes of, in athletes, 448–454 definition of, 72 environmental impact on, 452 ST integral, 70, 73 joggers and marathon runners, 450–452 definition of, 72t definition of, 297, 448 Standing, effect on Q wave, 30 incidence of, 448 Stanford protocol, 21t Sunnyside biomedical exercise electrocardiography (ECG) Stanford studies, of exercise testing prognostic value, 302 program, 85–87 ST/HR index, definition of, 72t absolute spatial vector velocity in, 85–86 ST amplitude for, 75–76 baseline removal in, 85–86 studies of, meta-analysis of, 75 beat classification and alignment in, 86 vs. ST/HR slope, 74, 75 beat extraction in, 86–87 ST/HR slope, definition of, 72t Supine bicycle exercise, cardiac output changes during, 482t in computerized electrocardiographic analysis, 74 stroke volume changes during, 482t maximal, 74 Surgeon General’s Report on Physical Activity and Health, ST/HR index vs., 74–75 435 studies of, meta-analysis of, 75 Surgery, noncardiac. See Noncardiac surgery. Stress echocardiography, dobutamine, in preoperative Survival analysis, 250 evaluation, for noncardiac surgery, 403 of prognostic studies, after myocardial infarction, 250, 312 Stress myocardial perfusion imaging, summary odds ratio Syncope, effort, in aortic stenosis, 412–413 (OR) for cardiac death, 318, 318t, 319–320 Systolic blood pressure, aerobic exercise program effect on, Stress testing, adenosine, 403 420 dipyridamole, 403 as criteria for exercise-induced hypotension, 116 dipyridamole thallium, 404 exercise-recovery ratio for, 121 dobutamine, 403 response to exercise, 116–117 Duke meta-analysis of, 314, 315t–316t prognostic importance of, 307 nonexercise, 403 resting, response to long-acting nitrates, 391–392 Stroke volume, 5 changes in, during supine bicycle exercise, 482t T during bicycle ergometry, 19 ST-segment, amplitude of, for ST/HR index, 75–76 T wave, exercise-induced changes in, 128 analysis of, in lead systems, 26, 32–33, 76–77 inversion of, pseudo-normalization of, during exercise beta-blockers effect on, 205–206 testing, 142 depression, digoxin effect on, 205 depression of, criteria for, 143–146, 144 Tachycardia, definition of, 297 definition of, 72t TES (treadmill exercise score), definition of, 72t exercise-induced changes in, 134 false-positive responses to, 149–150, 150t Hollenberg, 73 in angina, 70–73 Thallium nuclear perfusion imaging, with exercise in asymptomatic aircrewmen, 147, 147t testing, 35

Index 523 Thallium scintigraphy, assessment of coronary patients, after V exercise training, 479 Valvular disease, quantitation of, through exercise testing, 20 Thermoregulation, 452 Valvular heart disease, ACC/AHA guidelines for, exercise Threshold, anaerobic, definition of, 52 testing in, 412 gas exchange anaerobic, 52–53 evaluation of, 412–415 ventilatory, 52–53 Thrombolytic therapy, for myocardial infarction, 462 aortic stenosis, 412–413 summary odds ratio for cardiac death, 317–320, 320 Valvular stenosis, exercise testing in, 413 Time-varying filter, for noise reduction, 67 Variant angina, 134–135, 135t Total cholesterol, cardiac rehabilitation effect on, 495–496, VASQ (Veterans Specific Activity Questionnaire), 96, 97t VCG (vectorcardiographic) lead systems, 26 495 TRACE (TRAndlapril Cardiac Evaluation) study, 345 respiration effect on, 30 Transient ischemia, in exertion-related cardiac sitting effect on, 30 VD/VT (ventilatory dead space to tidal volume ratio), 51–52, 51 arrest, 463 VE/CO2, 50–51 Transmural myocardial infarction, 463 Vector leads, bipolar leads vs., in computerized Treadmill exercise, maximal, waveform alterations in, electrocardiographic analysis, 73 127–128 Vectorcardiographic (VCG) lead systems, 26 Treadmill exercise score (TES), definition of, 72t respiration effect on, 30 Hollenberg, 73 sitting effect on, 30 Treadmill testing, bicycle ergometry vs., 19 Veins, oxygen content of, determinants of, 8–9 Venous pressure, determinants of, 6 holding onto handrails in, 14–15 Ventilation perfusion ratio, definition of, 48 in normal patients, 121 Ventilatory dead space to tidal volume ratio (VD/VT), 51, 51 maximal, in PERFEXT, 481, 482t Ventilatory gas exchange. See Gas exchange. maximal oxygen uptake in, vs. bicycle ergometry, 22 to predict outcomes, in Chronic Heart Failure, 331t–333t protocols for, 20–22, 21 Ventilatory oxygen uptake (VO2), 1, 2t requirements of, 14–15 and exercise capacity, 101–102 silent ischemia during, in diabetics, 161 in exercise prescription, for cardiac rehabilitation, 467 systolic blood pressure response to, 116 Ventilatory threshold, exercise program effect on, 483 termination of, 12, 13t, 34 Ventilatory threshold (VT), 52–53, 53 variables in, reproducibility of, 182, 183t Ventricle(s), exercise training effect on, 425–432, 426t–431t vs. ambulatory monitoring, in prognostic left. See Left ventricular entries. Ventricular aneurysm, ST-elevation and, 137 studies, 282 Ventricular arrhythmia(s), exercise-induced, evaluation of, Trimmed mean, 87 Tropomyosin, role of, in muscular contraction, 2 408–409 Troponin, role of, in muscular contraction, 2 Ventricular compliance, 6 Type I (slow-twitch) muscle fibers, 3 Ventricular damage, 329 Type II (fast-twitch) muscle fibers, 3 Ventricular fibrillation threshold, changes in, from chronic U exercise, 422–423 Ventricular filling, determinants of, 6 U wave, exercise-induced changes in, 133 Ventricular function, after myocardial infarction, UCSD (University of California, San Diego) electrode(s), spontaneous improvement in, 479 placement of, in exercise testing, 27–29, 28 exercise capacity and, 98 UCSD (University of California, San Diego) lead systems, Ventricular tachycardia, during exercise testing, 178–179 28–29, 28 Baltimore Aging Study, 179 UCSD (University of California, San Diego) R-wave study, Long Beach Veterans’ Affairs Medical Center study, 129, 132–133 153–155, 154 UCSD SCOR studies, of exercise testing prognostic value, exercise-induced, evaluation of, 409 Ventricular volume, as response to exercise, 7–8, 7t 305–306 radionuclide studies of, 7 United States Air Force School of Aerospace Medicine Veterans’ Affairs Medical Centers–Hungarian Heart Institute (USAFSAM), protocol, 21 studies, of computerized electrocardiographic analysis, University of California, San Diego (UCSD) electrode(s), 81–85 beta-blocker effect on, 84–85 placement of, in exercise testing, 27–29, 28 computer analysis of, 81 University of California, San Diego (UCSD) lead systems, leads of, 83 population characteristics of, 81, 82t 28–29, 28 post-exercise test results, 81–82, 82t University of California, San Diego (UCSD) R-wave study, R wave adjustment in, 84 recovery measurements for, 83 129, 132–133 resting electrocardiography effect on, 84–85 Upsloping ST-segment, depression of, 204 ST criteria for, 82–83, 82t, 84 U.S. Army Cardiovascular Screening Program, 380 Veterans’ Affairs score, equation for, 262 USAFMC Normal Aircrewmen study, 128 Kaplan-Meier survival curve in, 261 USAFSAM, asymptomatic screening, 369 ROC curve in, 262 USAFSAM (United States Air Force School of Aerospace Veterans Specific Activity Questionnaire (VASQ), 97, 97t Medicine). See United States Air Force School of Aerospace Medicine (USAFSAM). USAFSAM study, serial electrocardiography screening, of asymptomatic individuals, 358

524 Index VE/VCO2 slope, 339–340 WHUSAFMC (Wilford Hall United States Air Force Medical VE/VO2 50–51, 51 Center) studies, of exercise testing prognostic value, 303 VO2. See Oxygen uptake. VO2 kinetics, 340 Wilford Hall United States Air Force Medical Center VO2 (ventilatory oxygen uptake), 1, 2t (WHUSAFMC) studies, of exercise testing prognostic VO2 max (maximal oxygen uptake), 5, 4–9 value, 303 determinants of, 5, 4–9 Wolff-Parkinson-White syndrome, exercise-induced ST- VT (ventilatory threshold), 52–53, 53 segment depression and, 154 W Women. See Gender. Work, definition of, 2 Wall motion, abnormality of, vs. ischemia, 138–140, 141–142 averaging of, of electrocardiogram signals, during exercise dynamic, 467 testing, 16 isometric, 467 recognition of, in computerized electrocardiographic return to, 469t, 494 analysis, 69 Work capacity, aerobic exercise program effect on, 420 after myocardial infarction, spontaneous improvement in, Weather balloons, in gas exchange measurement, 46 Weight, body, exercise training effect on, 434 478 White collar rhabdomyolysis, 454 Work-up bias, differences in, in exercise test/angiographic WHO (World Health Organization), definition of correlation studies, 221–222 cardiac rehabilitation, 467 in diagnostic test studies, 216–219, 218 in prediction of, coronary artery disease, 261 World Health Organization (WHO), definition of cardiac rehabilitation, 467