reduction in the absence of these management strategies is not known. Although some reports describe a greater magnitude and earlier improvement in physical work capacity with supervised exercise training, all training regimens increased functional capacity more than “spontaneous activity” in a variety of coronary patients. 13,39,42,43,62,69 Because economic constraints and logistics often limit the availability of supervised exercise training, the safety and effectiveness of unsupervised rehabilitative physical activity must be determined in various populations of coronary patients. Patients with prior exercise experience and those with family and social support are more likely to adhere to unsupervised exercise; cigarette smokers, overweight patients, blue-collar workers, those with sedentary occupations and low leisure-time activities, and patients who perceive their health status to be poor are less likely to do so.55 These patients should be encouraged to participate in structured cardiac rehabilitation programs. Recent studies have shown that mild-to-moderate resistive exercise training can safely and effectively improve both strength and cardiovascular endurance in low-risk coronary patients who can perform adequate levels of aerobic exercise.70-73 This approach to exercise training can improve performance in a variety of tasks of daily living, in the workplace, and at leisure activities. Resistance training provides diversity in the exercise regimen and may increase patient interest and adherence. Increased Scope of Patients Eligible for Exercise Rehabilitation In the early years of exercise rehabilitation, this modality was considered suitable predominantly for patients recovering from uncomplicated myocardial infarction.9-17 Many categories of patients who, in prior years, were arbitrarily excluded from exercise rehabilitation, now constitute a large percentage of the enrollees in structured exercise rehabilitation programs. These include elderly coronary patients:23-26,30,31 high-risk coronary patients with combinations of myocardial ischemia, arrhythmia, or compensated heart failure;43,74,75 and a variety of other medically complex patients.76-85 This limits the applicability of earlier data to contemporary cardiac rehabilitation. Exercise regimens for these latter patients are characterized by lower intensity, longer duration, and often an initial requirement for supervision and ECG monitoring. The goal of exercise for these latter categories of patients is typically an improvement in functional status so as to enable maintenance of independent living, in contrast to the goal of improvement of functional capacity to permit a return to remunerative work, which is frequently the desired outcome for younger and less impaired coronary patients. Return to Work CHD is the leading diagnosis in the United States for which patients receive premature disability benefits under the Social Security system. Almost one-fourth of the men and women receiving Social Security disability allowances are considered permanently disabled by CHD.86 More than 750,000 patients under 65 years of age currently survive myocardial infarction or myocardial revascularization in the United States each year. The indirect health care costs of disability, including lessened productivity, loss of income, welfare payments, and unemployment insurance costs, must be considered when the cost-effectiveness of rehabilitative interventions is ascertained.87 Symptomatic and functional improvement in survivors of myocardial infarction and myocardial revascularization procedures correlate poorly with return to work and general resumption of preillness lifestyle; psychosocial status appears to be a more important determinant.88 Because only about 15 percent (and the percentage decreases with older age) of the U.S. labor force currently performs heavy manual labor, the severity of angina or heart failure in patients with marginal residual cardiac function only rarely precludes or delays the return to work. Most studies of return to work involved predominantly or exclusively men, but one report identified working women with CHD as having a longer convalescence and a lower rate of return to work;89 whether this is gender related or reflects the older age or greater occurrence of comorbid illnesses and depression among women warrants further study. Education, Counseling, and Behavioral Interventions Education, counseling, and behavioral interventions are important elements of cardiac rehabilitation. In this guideline, “education" is defined as systematic instruction, and "counseling" is defined as providing advice, support, and consultation. “Behavioral interventions" refer to systematic instruction in techniques to modify health-related behaviors. Patients with cardiovascular disease have to learn to manage their illness and prevent or retard progression or induce regression of atherosclerosis. This management focuses on techniques of lifestyle changes, guided by health professionals. Approaches to teach patients effective health management techniques 90-114 and the effectiveness of the educational messages95,100,115 have been based on educational models. Some studies used principles of education, counseling, 116 and behavioral psychology as interventions; most studies were unable to separate these elements in patient education. Because of the substantial morbidity and mortality of CHD and the role of behavior in rehabilitation, patient education is an integral part of cardiac rehabilitative care. The conclusions of a meta-analysis of 28 controlled trials of patient education were that "education programs have demonstrated a measurable impact on blood pressure, mortality, exercise, diet, and other parameters are positively affected, although less consistently."117 Type of communication did not influence outcome; adherence to educational principles did. Thus, cardiac rehabilitation programs should use reinforcement, provide feedback, offer opportunity for individualization, facilitate behavioral change through the development of skills and resources, and be relevant to patients' needs and abilities. Education alone does not change behavior, although it can reduce anxiety and alleviate depression. 95,97 A combination of education, counseling, and behavioral intervention strategies seems most effective in promoting health, reducing risk, and favorably altering lifestyle. 101,102,115 Specific behavioral interventions using social learning theory have been advocated. 112,113,115,118 Whether the same approaches in patient education, counseling, and behavioral interventions are equally effective for men and women and across the age span remains unanswered because most studies enrolled middle-aged men. Minimal information on patients 70 years and older is available,119,120 and few studies included women.94,103,108 Most early studies of education involved patients recovering from myocardial infarction and focused on the ideal content for an education program. 94,95,97,101,103,104,106,108,110,115 These studies took place in the hospital; later studies focused on education after hospital discharge, pertinent to contemporary practice where early discharge limits or obviates comprehensive hospital-based education, counseling, or behavioral interventions. Educational programs were subsequently extended to patients following CABG, PTCA, cardiac transplantation, and valve surgery. Educational needs and outcomes depend on the specific cardiovascular disease and intervention. Definitive studies are lacking that address educational needs and opportunities for patients with advanced cardiac problems such as heart failure, including those awaiting cardiac transplantation. Studies of educational programs in the outpatient setting are few and not well described. The home education 101,108 delivered either via telephone or visits by public health nurses and/or physicians is a model more common in the United Kingdom. Combinations of these approaches (e.g., weekly outpatient clinic appointments plus telephone followup) are becoming more common. 101,103 Other forms of home-based educational programs such as the visiting nurse service have not been fully utilized in the United States. These approaches warrant further investigation, especially as the population ages. Most education about the disease and treatment is provided by physicians, nurses, physical therapists, exercise physiologists, and dietitians. (Some scientific reports use the terms “dietitian” and “nutritionist" interchangeably; this guideline uses "dietitian.") Other health professionals play a role in providing specific health education interventions in the patient's care and knowledge of disease, treatment, adjustment to illness, and expected outcomes. The focus of education in the reported studies was the patient, the couple (such as the patient and spouse or partner),92,96,112 and groups of patients. 55,107,108,115 The interventions included smoking cessation and relapse prevention;113,121 ambulation and activity progression; 101,106 energy conservation (particularly important in patients with advanced heart disease);106 exercise prescription;99,101,109 resumption of sexual activity;122 and return to work. 108,122 Dietary interventions included management of diet and medication to control hypertension and hyperlipidemia. 107,108,115 The extent of adherence to medication regimens has been extensively reported in the adherence literature. 93,95,98,118,120 This literature also addresses adherence to exercise training interventions, 120 Psychosocial Aspects The importance of psychosocial variables in the development of CHD and in the prognosis of patients with established CHD has received increased attention during the past decade. In particular, Type-A behavior pattern and hostility, depression, vital exhaustion, social isolation, and lack of social resources have been identified as important targets for education, counseling, and behavioral interventions. Type-A Behavior Pattern and Hostility Type-A behavior pattern has received more attention than any other behavioral or psychological variable as a risk factor for CHD. Individuals who exhibit Type-A behavior pattern display a variety of traits and behavioral dispositions, including hard-driving competitiveness, a persistent sense of time urgency, and easily evoked hostility. A relative absence of these behavioral features characterizes the converse, Type-B behavior pattern. In 1981, a review panel assembled by NHLBI concluded that Type-A behavior pattern is an independent risk factor for CHD in employed, middle-aged U.S. citizens. 123 This conclusion was based on a number of studies investigating the development of CHD in healthy persons, as well as studies of patients with documented CHD, prior myocardial infarction, or cardiac risk factors. Type-A men in the Western Collaborative Group Study (WCGS) were five times more likely to have had a recurrent myocardial infarction compared with Type-B men. This strong association was significant even after considering the contribution of elevated levels of cholesterol, blood pressure, and cigarette smoking. 124 However, subsequent studies failed to support these findings. 125-127 One explanation for inconsistent findings related to Type-A behavior and CHD is that global Type-A measures are too broad and nonspecific to identify the components of Type-A behavior pattern relevant to CHD events. Just as not all components of cholesterol are detrimental, and indeed, some components are beneficial (e.g., the high-density lipoprotein [HDL] fraction), the hostility component of Type-A behavior pattern currently is regarded as the most “toxic" component. Evidence is accumulating that high levels of anger and hostility are associated with CHD and other adverse health outcomes. One instrument that has been used to measure hostility-the Cook Medley Hostility Scale (derived from the Minnesota Multiphasic Personality Inventory [MMPI])—has shown hostility to be related to the extent of CHD in coronary patients, 128,129 and prospectively to an increased risk of cardiac morbidity and all cause mortality in nonclinical populations.130,131 More myocardial ischemia was observed in women and middle-aged men with CHD who had high hostility scores than in those with low scores. 132 Depression Depression is reported to precede myocardial infarction in 33-50 percent of patients. Higher rates of myocardial infarction have been reported among depressed than nondepressed psychiatric patients. Examination of 283 hospitalized patients with myocardial infarction showed that 18 percent had major depression and an additional 27 percent had symptoms of depression.133 Depression is associated with increased mortality and medical morbidity after myocardial infarction and cardiac surgery. 134-138 In a recent study, patients who met the modified Diagnostic and Statistical Manual for Mental Disorders139 criteria for major depressive disorder (16 percent of the sample of 272 patients) were more than five times more likely to die during the first 6 months following myocardial infarction than nondepressed patients.135 The effect of depression was independent of Killip class, ejection fraction, and other clinical indicators of disease severity. Depressive affect short of major depressive disorder also conferred higher risk in this population.140 Another factor possibly related to depression is a constellation of symptoms known as "vital exhaustion." Vital exhaustion is characterized by excessive fatigue, decreased energy, feelings of dejection or defeat, loss of libido, and increased irritability. The proportion of individuals experiencing this syndrome prior to a coronary event has been estimated at 30-50 percent. Several studies investigating the association of vital exhaustion and CHD found it to be positively associated with stable and unstable angina pectoris. 141-144 Vital exhaustion was also associated with future angina pectoris and nonfatal myocardial infarction (but not with fatal myocardial infarction) and with an increased risk of coronary events following PTCA.145 Social Isolation and Low Socioeconomic Status The prognostic value of level of education and psychosocial characteristics (life stress, social isolation, Type-A behavior, depression) was studied in male patients after myocardial infarction. 142 Depression may be associated with social isolation, which may serve as an independent risk factor. For example, a 6-month mortality of 15.8 percent occurred among patients after myocardial infarction living alone (16.4 percent of total sample) versus 8.8 percent among those living with others. In a followup study of patients with angiographically documented coronary disease, a 50-percent 5-year mortality rate occurred among those who were most socially isolated (unmarried with no confidant, 26 percent of total sample) versus 17 percent among those not so isolated. 142 In both studies, the impact of social isolation on prognosis was independent of left ventricular ejection fraction and other physiologic prognostic factors. |