Conclusions There is suggestive evidence that exercise training enhances subsequent exercise habits. A limitation of the scientific data relating to continued exercise habits as a result of rehabilitative exercise training is the self-report nature of the information, which was typically based on questionnaire or physical activity diary data. Information concerning the cardiovascular benefits of varied exercise and recreational physical activities is sparse in the cardiac rehabilitation literature. However, extensive studies and position statements in populations without apparent heart disease document that regular exercise, including a wide scope of physical activities with a broad range of intensity and duration, have beneficial effects on overall health, morbidity, and mortality.225-227 Patients should be encouraged to undertake exercise activities following cardiac exercise rehabilitation that are personally enjoyable and that can be sustained long-term. The panel endorses the position statement of the AHA regarding the beneficial role of physical activity, that “regular aerobic physical activity increases exercise capacity and plays a role in both primary and secondary prevention of cardiovascular disease."225 In addition, the recommendations from the Centers for Disease Control and Prevention and the American College of Sports Medicine (ACSM) are endorsed regarding the value of modest intensity habitual physical activity for all Americans.227 The panel also recognizes the need to encourage women, particularly older women, to participate in cardiac rehabilitation programs designed to enhance exercise capacity and physical activity. Symptoms RECOMMENDATION Exercise rehabilitation decreases angina pectoris in patients with coronary disease and decreases symptoms of heart failure in patients with left ventricular systolic dysfunction. Exercise training is recommended as an integral component of the symptomatic management of these patients. Scientific Evidence (Strength of Evidence = B) Twenty-six scientific studies reported the effect of cardiac rehabilitation exercise training on symptoms. Twelve were randomized controlled trials, seven were nonrandomized controlled studies, and seven were observational reports. Eight of the 12 randomized controlled trials reported statistically significant improvement in cardiovascular symptoms in intervention groups compared with control groups. Seven of these trials involved exercise training as the sole intervention, 10,16,42,43,50,147,220 and one trial was multifactorial.41 Four randomized controlled trials of exercise training reported no significant difference in cardiovascular symptoms between the exercise and control groups; 14,57,153,219 two of these trials were multifactorial,14,153 and two involved only exercise.57,219 Two of the 12 randomized controlled trials involved patients with symptomatic left ventricular dysfunction;42,43 all others dealt with patients with angina pectoris. Six of the seven nonrandomized controlled studies reported statistically significant improvements in cardiovascular symptoms favoring rehabilitation versus control groups; three involved exercise training as the sole intervention,28,78,165 and three were multifactorial. 163,167,221 One nonrandomized controlled study of exercise training in patients with baseline diminished left ventricular ejection fraction following a large anterior myocardial infarction reported worsening symptomatic status in the rehabilitation versus control patients.19 Six of the seven observational studies reported improved cardiovascular symptoms following exercise training,83,193,194,198,204,206 and one reported no improvement. 190 All but one of the observational studies involved patients with angina pectoris; one study involved patients with symptoms of heart failure.83 Conclusions There is moderate evidence for improvement in cardiovascular symptomatic status, both angina pectoris and heart failure symptoms, as a result of cardiac rehabilitation exercise training. Symptomatic outcomes in these scientific studies were confounded by inadequate information regarding changes in medication status, by differing levels of exercise or physical activity at baseline and at followup, as well as by nonrehabilitation exercise activities of control patients. Change in symptomatic status of cardiac patients often results in changes in medication regimens. The panel noted the relatively young age of patients studied; only two studies included patients who were older than 65 years of age. Only 8 of the 20 controlled trials included women; and in these studies, only a small proportion of the enrollees were women-less than 25 percent. No study reported symptomatic outcomes by gender or age. Smoking RECOMMENDATION Exercise training has little or no effect on smoking cessation. Smoking cessation is achieved by specific smoking cessation strategies. Scientific Evidence (Strength of Evidence = B) The data pertaining to the effect of exercise rehabilitation on smoking habits included 12 randomized controlled trials, 8 nonrandomized controlled studies, and 4 observational reports. Three of the 12 randomized controlled trials involved exercise training as the sole intervention. None of these studies reported statistically significant differences in self-reported smoking cessation rates between intervention and control patients. 10,50,219 One randomized controlled trial evaluated exercise training versus exercise training plus education/counseling versus a control group of patients after myocardial Eight randomized controlled trials involved multifactorial cardiac rehabilitation, which made it impossible to ascertain an independent effect on smoking cessation attributable to exercise training. Two trials reported statistically significant reduction in smoking rates favoring rehabilitation versus control groups, one by self-report228 and the other using biochemically confirmed smoking cessation data;36 the latter used nicotine gum or patch in addition to behavioral approaches for smoking cessation. Another randomized controlled trial reported no difference in self-reported smoking cessation rates in intervention patients compared with control patients, although the self-reported daily cigarette consumption averaged 11 in the exercise compared with 22 in the nonexercise group (p < .03).113 Five trials reported no significant difference in self-reported smoking cessation rates between intervention and control groups 14,16,22,49 or in biochemically verified smoking cessation rates.39 All eight nonrandomized controlled studies described smoking cessation rates that were based on self-report; five of these reported significantly greater cessation rates favoring rehabilitation versus nonrandomized control patients; 20,28,167,169,221 all but one were multifactorial rehabilitation interventions.28 Three involved exercise training and psychological counseling.20,169,221 Two studies reported no significant difference between groups. 175,212 A final nonrandomized controlled study reported equal smoking cessation rates by self-report, whether or not patients were classified as depressed at baseline, 172 All four observational studies reported statistically significant reductions in self-reported smoking habits at the completion of cardiac rehabilitation. 196,205,223,229 Conclusions Little or no evidence was found of beneficial outcome in smoking cessation resulting from exercise training as a sole intervention. Given the documented benefit of smoking cessation in decreasing coronary risk, specific techniques of proven value in effecting smoking cessation should be incorporated into multifactorial cardiac rehabilitation; studies reporting changes in smoking habits should include biochemical confirmation.230 Most of the smoking cessation studies that were reviewed involved patients who were younger than 65 years of age, predominantly patients following myocardial infarction. No study included more than 25 percent female patients. None of the trials reported smoking cessation outcomes by gender or by age. Lipids RECOMMENDATION Cardiac rehabilitation exercise training is not recommended as a sole intervention for lipid modification because of its inconsistent effect on lipid and lipoprotein levels. Optimal lipid management requires specifically directed dietary and, as medically indicated, pharmacologic management, in addition to cardiac rehabilitation exercise training. Scientific Evidence (Strength of Evidence = B) Thirty-seven reports in the scientific literature describe changes in various lipid levels and/or lipoprotein levels resulting from exercise-based cardiac rehabilitation. Eighteen were randomized controlled trials, 6 were nonrandomized controlled studies, and 13 were observational reports. The randomized controlled trials are described in Table 4. Twelve of these trials involved multifactorial rehabilitation, with nine reporting improvement in total cholesterol levels favoring intervention versus control patients. 16.22,36,37,39,41,149,160,231 One study did not report a test of statistical significance for cholesterol lowering,160 and one reported favorable reduction in cholesterol levels only in patients who were provided cholesterol-lowering medication.49 Two trials did not report significant differences between intervention and control patients.68,232 Two of the six studies that used exercise training as the sole intervention documented statistically significant improvement in total cholesterol levels favoring exercise-trained versus control patients,14,50 and four studies reported no significant difference between exercise-trained and control patients. 10,17,152,233 Six of eight randomized controlled trials that reported changes in lowdensity lipoprotein (LDL) cholesterol levels documented significant lowering of LDL levels in rehabilitation patients compared with control patients. All six involved multifactorial interventions, that is, exercise training and behavioral counseling and/or dietary instruction and counseling.22,36,37,39,41,231 Two of these trials used lipid-lowering medications in addition to exercise training, education, and behavioral strategies.36.39 The intervention program was homebased in three trials. 36,37,39 Two multifactorial cardiac rehabilitation trials reported no significant difference in LDL cholesterol levels in intervention patients compared with control patients.68,232 Nine randomized controlled trials reported changes in HDL cholesterol levels. Two documented statistically significant increases in HDL levels favoring intervention versus control patients; both were multifactorial studies.39,149 Seven trials reported no significant differences in HDL cholesterol levels between groups. 22,36,37,41,68,152,231 All but one study were multifactorial.152 Twelve randomized controlled trials reported changes in triglyceride levels. Seven documented significantly lower triglyceride levels in rehabilitation versus control patients; five of these were multifactorial studies.39,49,149,231,232 |