Stroke Nursing Committee: addressing a special need of the Council of Cardiovascular Nursing.
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American Heart Association↗
Biomedical subjects
B J Fletcher
Publications and source records attributed to B J Fletcher.
Adherence in the training levels comparison trial.
In the Training Levels Comparison Trial, 197 male coronary heart disease patients were randomized to low or high intensity training with target heart rates, which corresponded to 50% and 85% of the VO2max achieved on the previous exercise test, respectively. Patients were to exercise at their assigned intensity level at three 1-h long supervised sessions per week for 2 yr. This paper reports on two components of adherence: attendance at exercise sessions and achievement of heart rates in the target range. During the first year of training, the average percent of exercise sessions attended (mean +/- SE) for the low intensity group (64.0 +/- 2.5%) was significantly higher than for the high intensity group (55.5% +/- 2.7%). At the end of 1 yr of training, 54% and 37% of the low and high intensity patients, respectively, achieved heart rates within 5 beats.min-1 of their target heart rates. Although the low intensity program was preferable to achieve maximum attendance, attenders on the high intensity program achieved higher heart rates. These results suggest that to maximize the achieved heart rate, it would be optimal to motivate a cardiac rehabilitation patient to train at the high intensity level for a prolonged period of time.
Adult↗
Efficacy of high-intensity exercise training on left ventricular ejection fraction in men with coronary artery disease (the Training Level Comparison Study).
The purpose of this study was to compare high- versus low-intensity exercise training on the change in echocardiographic left ventricular ejection fraction (LVEF) from rest to peak exercise. Sedentary men with coronary artery disease, aged 30 to 70 years, were randomized to dynamic exercise training of either low intensity, 50% of maximal oxygen consumption, n = 89; or high intensity, 85% of maximal oxygen consumption, n = 111. No other interventions were imposed and patients were evaluated at 6 months and 1 year. Both exercise groups significantly increased exercise capacity without adverse events, but the increase was greater (p = 0.02) in the high-intensity exercise group. The mean exercise test rest-peak LVEF in the high-intensity group rose from 6.20% at baseline to 6.54% in 6 months and to 6.73% at 12 months, while the low-intensity group showed no improvement at 6 months and a decrease at 12 months. Multivariate analyses revealed that treatment group (high versus low intensity) significantly contributed to the change in rest-peak LVEF. When the exercise groups were subdivided by initial baseline LVEF < or = 50% versus > 50%, those with the higher LVEF in the high-intensity group showed a greater (p = 0.05) increase in the rest-peak LVEF from baseline to 1 year. Over a 1-year period, exercise capacity improved in both exercise-intensity groups, but more so in the high-intensity group, with no adverse events. The high-intensity group, compared with the low-intensity, showed more improvement in the rest-peak LVEF, especially in those with a higher LVEF at baseline.
Adult↗
Effects of variable doses and formulations of cholestyramine on elevated serum low-density lipoprotein cholesterol.
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Adult↗
Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease.
A prospective, randomized, controlled clinical trial in patients with coronary artery disease (CAD) and a concurrent physical disability evaluated the effects of a home exercise training program on cardiovascular function and blood lipids. Eighty-eight men between the ages of 42 and 72 years (mean 62) with documented CAD and a physical disability with functional use of > or = 2 extremities including 1 arm were randomized to either a 6-month home exercise training program using wheelchair ergometry or to a control group that received usual and customary care. Both groups received dietary instructions and were requested to follow a fat-controlled diet. Exercise test variables with echocardiography and blood lipids were measured at baseline and at 6 months. The home exercise training group significantly improved both peak exercise left ventricular ejection fraction (p = 0.007) and fractional shortening (p = 0.01) between baseline to 6 months, whereas the control group showed no significant changes. Exercise training effects of decreased resting heart rate (p = 0.03) and decreased peak rate pressure product (p = 0.03) were also found in the treatment group. No exercise-related cardiac complications occurred. Both groups significantly (p < or = 0.01) increased high-density lipoprotein cholesterol levels. These results indicate that physically disabled men with CAD can safely participate in a home exercise training program which may result in intrinsic cardiac benefits. The metabolic cost of activities of daily living imposed on this disabled population may also have a positive effect on high-density lipoprotein cholesterol levels.
Adult↗
Design of the training levels comparison trial.
The Training Levels Comparison (TLC) trial was a grant-supported, multicenter, randomized, controlled clinical trial designed to determine whether cardiac rehabilitation patients would benefit from supervised exercise for a prolonged period (2 years) and whether subjecting patients to a more vigorous exercise program than currently recommended would provide additional cardiac benefit. If high-intensity exercise does not enhance the cardiac benefit, then physical activity should be limited to low-intensity levels that are safer, easier to implement and more adaptable to a greater number of patients. Patients were randomly assigned to either a low-intensity or high-intensity training program. All patients were to attend three 1-hour supervised exercise sessions per week for a period of 2 years. Attendance at exercise sessions and adherence to assigned treatments were monitored throughout the study. Patients were evaluated for outcome measures at 3, 6, 12, and 24 months. This paper reports the study design and methodology for the TLC trial, and should be useful in providing methodologies to facilitate comparison of data from other studies with different levels of exercise as an intervention.
Adult↗
Cardiac precautions for non-acute inpatient settings.
Activity progression of persons with physical disabilities and accompanying cardiovascular disease in medical rehabilitation centers is traditionally based on cardiac precautions derived from acute care settings. Concern that these guidelines were too conservative and restrictive led to exercise testing and evaluation of 64 physically disabled male patients with a history of coronary artery disease. The sample had a mean age of 62.4 years. The exercise test was an adaptation of the Schwade Arm Ergometer Protocol with blood pressure measured at baseline, immediately after each 2 minutes of exercise, peak exercise and each minute for 6 minutes after peak exercise. Heart rate was monitored continuously. Patients achieved a mean peak heart rate of 115 beats per minute, mean peak systolic pressure of 169 mm Hg and mean peak diastolic pressure of 89 mm Hg. Ischemic electrocardiographic changes occurred in four of the 64 patients. Based on the achieved ranges of values of heart rate, systolic and diastolic pressures and comparison of these results with baseline (pre-exercise) values, more liberal guidelines for prescribing activity in the non-acute inpatient setting are provided.
Adult↗
Blood magnesium and potassium alterations with maximal treadmill exercise testing: effects of beta-adrenergic blockade.
To test alterations in plasma potassium and magnesium levels with maximal exercise, 15 sedentary, healthy men (mean age 29 years) participated in a double-blind crossover study for 11 weeks with propranolol, atenolol, and placebo. Maximal exercise tests were done at baseline and after placebo and beta-blockade phases. Blood for analysis was collected via indwelling brachial vein angiocatheters at baseline and during and after testing. Plasma potassium and magnesium levels increased at peak exercise with atenolol, propranolol, and placebo. There was no difference among groups in baseline recovery for magnesium (mean 28 minutes, range 24 to 30 minutes). Potassium levels returned to baseline more rapidly (compared with magnesium) in the placebo and atenolol groups (mean 10 minutes); however, recovery time was prolonged with propranolol (26 minutes) compared with placebo and atenolol (p less than 0.01). In conclusion, plasma magnesium and potassium levels increased significantly with maximal exercise and are unaffected by atenolol or propranolol beta-blockade. Propranolol, however (compared with atenolol and placebo), prolongs the time of return to baseline of plasma potassium after exercise.
Adrenergic beta-Antagonists↗
Efficacy and compliance with cholestyramine bar versus powder in the treatment of hyperlipidemia.
PURPOSE: The purpose of the study was to compare the powder and the bar forms of cholestyramine to determine efficacy and patient compliance. SUBJECTS AND METHODS: A prospective, randomized trial was conducted that included 83 healthy men and women with hyperlipidemia greater than the 90th percentile for low-density lipoprotein (LDL) or total cholesterol. Patients were randomly assigned to receive either cholestyramine powder, two packets (8 g), twice daily, or cholestyramine confectionery bar, in maple or mint flavors, two bars (8 g), twice daily. Fasting serum total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were measured at baseline, after 6 to 8 weeks of following the American Heart Association Step I diet alone, and after 8 weeks of taking either the cholestyramine bar or powder. RESULTS: Total cholesterol decreased significantly (p less than 0.01) by 16% in the bar group and 17% in the powder group. LDL cholesterol decreased by 28% and 29% in the bar and powder groups, respectively (p less than 0.01). There was no significant change in HDL cholesterol. Triglycerides increased in both groups, by 29% in the bar group and by 25% in the powder group. There was no difference between bar and powder in the effect on blood lipids. The majority of the lipid-lowering effect was seen within 14 days. Mean patient endpoint compliance with the therapy was 91.8 +/- 3.6% in the bar group and 94.8 +/- 2.1% in the powder group. There was no difference between groups. CONCLUSION: The cholestyramine confectionery bar is as effective as cholestyramine powder in the treatment of hyperlipidemia. The majority of the lipid-lowering effect is seen within 14 days of therapy. Although patient compliance is comparable between the two forms, gastrointestinal side effects were slightly greater with the bar form. Therefore, although the bar offers an alternative form of therapy, there appears to be no advantage with regard to patient compliance or palatability.
Adult↗
Effects of exercise testing, training and beta blockade on serum potassium in normal subjects.
To evaluate the effects of exercise testing, training and beta blockade on serum potassium, 40 normal subjects (24 men, 16 women, mean age 33 years) had 4 maximal exercise tests with venipuncture for serum potassium before and less than or equal to 40 seconds after each test. After initial exercise testing, they were randomized to atenolol 50 mg daily, atenolol 100 mg daily, propranolol 80 mg twice daily or placebo. All began a 9-week dynamic exercise program for 8 weeks followed by a 1-week drug-free washout period. Tests were done after weeks 1, 8 and 9. A significant mean increase (p less than 0.05) in serum potassium occurred with maximal exercise in the atenolol 50 mg and propranolol groups after 1 week of treatment (mean +/- standard deviation, 4.78 +/- 0.29 to 5.09 +/- 0.43 mEq/liter and 4.81 +/- 0.55 to 5.30 +/- 0.33 mEq/liter). By week 8 after training, all beta blockade groups showed an increase in postmaximal exercise test serum potassium (atenolol 50 mg, 4.78 +/- 0.29 to 5.11 +/- 0.26 mEq/liter; atenolol 100 mg, 4.95 +/- 0.41 to 5.16 +/- 0.36 mEq/liter; propranolol, 4.81 +/- 0.55 to 5.05 +/- 0.29 mEq/liter). After washout, only the placebo group showed an increase in postmaximal test serum potassium (4.99 +/- 0.46 to 5.35 +/- 0.27 mEq/liter). Data indicate that hyperkalemia with maximal exercise testing increases after training with atenolol and propranolol compared to placebo and that this effect resolves once treatment is discontinued.
Adult↗
Cardiac rehabilitation in the workplace. Current concepts and methodology.
Identification and modification of risk factors for cardiovascular disease can be carried out effectively in the workplace. Coronary artery disease is multifactorial. A cardiac exercise program conducted by the occupational health nurse should serve as a catalyst for modification of all coronary risk factors. Employers have begun to value and support worksite cardiac rehabilitation programs because of the benefits of health care cost avoidance, increased attendance and productivity at work, and improved employee relations. It is the responsibility of the occupational health nurse and other health care providers to see that this continues.
Cardiac Rehabilitation↗
Exercise testing and training with beta-adrenergic blockade: role of the drug washout period in "unmasking" a training effect.
To determine whether or not a training effect can be achieved with beta-adrenergic blockade and whether there is a difference between selective and nonselective therapy, we recruited 40 healthy subjects (16 women, 24 men) to participate in a 9-week exercise training program. After a baseline exercise treadmill test, subjects were randomized to oral therapy groups of atenolol, 50 mg daily (AT 50), atenolol, 100 mg daily (AT 100), propranolol, 80 mg twice a day (Prop), or placebo. Repeat exercise tests were performed at week 1, week 8, and at week 9, with week 8 to 9 being a 1-week drug-free washout period. At week 8, maximal oxygen consumption (Max VO2), when compared with baseline levels, was increased slightly in AT 50 (4.2%) and Prop (2.4%), decreased in AT 100 (5.3%), and increased significantly in the placebo group (12.7%). After washout, Max VO2 increased significantly compared with baseline in AT 50, AT 100, and Prop (9.8%, 10.8%, and 9.8%, respectively). We conclude that there is no significant difference between selective and nonselective beta-blockade therapy in the development of a training effect. This effect, however, may not become apparent until the drug is withdrawn.
Adrenergic beta-Antagonists↗
Effect of maximal exercise testing on serum cholesterol in healthy subjects undergoing exercise training and on beta-adrenergic blockade.
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Adrenergic beta-Antagonists↗
Exercise testing in patients with musculoskeletal handicaps.
To determine safe and effective exercise testing techniques for musculoskeletally handicapped individuals, 20 patients (mean age, 61 years) were studied. Types of handicaps included various degrees of paralysis of arms and legs, and leg amputations. Seventeen of the 20 patients had concurrent cardiovascular problems. All were currently hospitalized, engaged in various physical therapy exercises, and referred for exercise testing to increase rehabilitation therapy or for cardiovascular evaluation. Of 20 tests, arm ergometry was used in 15, leg or combination arm-leg ergometry in four, and treadmill in one. All patients completed testing with mean increases in heart rate (82 to 106 bpm arm, 88 to 125 other) and systolic blood pressure (114 to 127 mmHg arm, 118 to 146 other). Low-grade atrial and ventricular ectopy occurred in eight patients, decrease or plateauing of systolic blood pressure in three, increased diastolic blood pressure in two, and significant (greater than or equal to 1mm) ECG S-T segment displacement in one. With the use of appropriate equipment for each patient, exercise testing can be done safely and effectively in musculoskeletally handicapped individuals.
Adult↗
Outpatient rehabilitative training in patients with cardiovascular disease: emphasis on training method.
As our ability to evaluate cardiovascular patients expands and direct oxygen consumption measurements are available, exercise prescriptions can be better individualized for each patient. By using basic principles of frequency and duration and specifically basing intensity and progression on percent of maximum oxygen consumption, protocols using various modes of exercise may be defined so that each patient entering cardiovascular training programs will gradually progress. This methodology discussion presents concise progressions for both phase II monitored and phase II nonmonitored medically supervised exercise training. The phase II monitored protocol consists of levels 1 through 6 and is designed to be completed within a minimum of six 1-hour sessions. The phase II nonmonitored protocol consists of levels 7 through 12 and is designed to be completed within 12 weeks. The ultimate goal is for each patient to safely progress to a training level that can be maintained safely and effectively by the patient. A total of 192 patients enrolled in our phase II programs have safely completed both components and are in long-term maintenance programs.
Cardiac Rehabilitation↗
Phase II intensive monitored cardiac rehabilitation for coronary artery disease and coronary risk factors--a six-session protocol.
To evaluate phase II intensive monitored cardiac rehabilitation using a 6-level, 6-session protocol, 31 patients were placed in a progressive 6-level exercise protocol with careful supervision and assessment of heart rate, rhythm, blood pressure and perceived exertion. Duration after the cardiac event ranged from 12 days to 8 years (median 10 months). Each exercise prescription was based on exercise testing with oxygen consumption determinations. Exercise activities were individually prescribed according to percentages of maximal MET level achieved on the exercise test. Each exercise session incorporated calisthenics, treadmill exercise, and bicycle and arm ergometry with progressively greater workloads on the various stations. All patients completed the 6 levels within 6 sessions of approximately 1 hour each, and achieved their designated 50 to 75% target heart rate with perceived exertion level 13 or less. There were no critical cardiac events, i.e., high-grade ventricular arrhythmias or myocardial infarction. All completed the 6-level protocol and progressed to a nonmonitored exercise program with no difficulty. The results of this short-term method of telemetry-monitored rehabilitation suggest benefits of proper exercise instruction, successful achievement of the 50 to 75% exercise target heart rate, detection of minor new arrhythmias and alterations of blood pressure response, adequate use of the perceived exertion scale, and a safe and effective transition to subsequent exercise programs.
Adult↗
Training level comparison study. Effect of high and low intensity exercise on ventilatory threshold in men with coronary artery disease.
PURPOSE: To determine whether exercise at low intensity (LO; 50% of peak VO2) or high intensity (HI; 85% of peak VO2) results in improvement of the ventilatory threshold (VT), 186 men with coronary artery disease (CAD) were enrolled in an exercise study for 1 year. METHODS: A symptom-limited exercise test was performed at baseline and the heart rate corresponding to 50% and 85% of peak VO2 was determined. Subjects were randomized to LO or HI intensity exercise. Exercise sessions included 45 minutes of walking/jogging and/or stationary cycling at the appropriate target heart rate and were conducted 3 days per week. The exercise test was repeated at 3 and 6 months. Target heart rates were revised to adjust for training. RESULTS: Both LO and HI resulted in improved VO2 at VT and peak. However, HI resulted in greater improvement than LO. CONCLUSION: Among this population, both HI and LO improve the VO2 at VT and peak, but the improvement is greater with HI. The VT can be a useful adjunct to heart rate and peak oxygen uptake when prescribing exercise.
Anaerobic Threshold↗