Exercise in Chronic Disease: Cardiopulmonary and Metabolic.

Chap te r 1 3 Acu te C oro n ary S yn dro m es:

Unsta b le A ngin a P ecto ris a n d Acu te M yoca rd ia l I n fa rctio n Ray W . S quir e s, P hD , M AAC VPR, F AC SM , F AH A T he b urd en o f d is e ase s o f t h e c ard io vasc u la r s y ste m o n o ur s o cie ty i s h orre n dous. S in ce 1 900, c ard io vasc u la r d is e ase s ( C V Ds), su ch a s c o ro nary h eart d is e ase , s tr o ke, h eart f a ilu re , a n d h yperte n sio n, h av e b een t h e l e ad in g c au se o f d eath i n t h e U nite d Sta te s e v ery y ear w ith t h e e x cep tio n o f 1 918, t h e y ear o f t h e g re at i n flu en za e p id em ic ( 1 ). I n 2 013, C V Ds c au se d 5 4% o f a ll death s i n t h e U nite d S ta te s ( 1 28 d eath s p er 1 00,0 00 p ers o ns), 2 ,2 00 d eath s e ach d ay , a n a v era g e o f 1 d eath e v ery 4 0 s e co nds (2 ). I t i s t h e m ost c o m mon c au se o f d eath f o r b oth m en a n d w om en ( 2 , 3 ). A ppro xim ate ly 5 0% o f a ll c ard io vasc u la r d eath s a re a r e su lt o f c o ro nary h eart d is e ase ( C H D) ( 2 ).

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For 2 013, C H D c au se d a t o ta l o f 3 70,2 13 d eath s a n d a cco unte d f o r 1 o ut o f e v ery 7 d eath s. A cu te c o ro nary s y ndro m es ( m yocard ia l i n fa rc tio n, u nsta b le a n gin a p ecto ris , a n d s o m e f o rm s o f s u dden c ard ia c d eath ), f o rm s o f C H D, a re a lm ost a lw ay s t h e r e su lt of c o ro nary a rte ry a th ero sc le ro sis a n d s u bse q uen t t h ro m bosis . E ach y ear 5 50,0 00 A m eric an s w ill s u ffe r a n ew m yocard ia l i n fa rc tio n, an d 2 00,0 00 w ill s u ffe r a r e cu rre n t m yocard ia l i n fa rc tio n. S ile n t ( p ain le ss) m yocard ia l i n fa rc tio n w ill o ccu r i n 1 60,0 00 p ers o ns per y ear. E very 4 2 s s o m eo ne i n t h e U nite d S ta te s s u ffe rs a m yocard ia l i n fa rc tio n. T he a v era g e a g e a t t h e f ir s t m yocard ia l in fa rc tio n i s 6 5 y r f o r m en a n d 7 2 y r f o r w om en . T he n um ber o f A m eric an s w ho u nderw en t p erc u ta n eo us c o ro nary i n te rv en tio n (c o ro nary a n gio pla sty , s te n tin g, o r b oth ) o r c o ro nary b ypass g ra ft s u rg ery f o r t r e atm en t o f C H D i n 2 010 w as 9 54,0 00 a n d 3 97,0 00, re sp ectiv ely ( 2 ). A ppro xim ate ly 1 6,3 00,0 00 A m eric an s h av e a h is to ry o f m yocard ia l i n fa rc tio n, a n d 9 ,0 00,0 00 e x perie n ce a n gin a pecto ris ( c h est p ain ). E stim ate d t o ta l c o sts f o r C H D w ere $ 207.3 b illio n f o r 2 013 ( 2 ).

T his c h ap te r p ro vid es i n fo rm atio n r e g ard in g t h e f o llo w in g t o pic s:

444 1 .

The d is e ase p ro cess o f a th ero sc le ro sis a n d t h ro m bosis 2 .

Myocard ia l b lo od f lo w a n d i s c h em ia : a n gin a p ecto ris 3 .

Acu te c o ro nary s y ndro m es: d efin itio n, a cu te m yocard ia l i n fa rc tio n, clin ic al a sse ssm en t, d ia g nosis , c la ssif ic atio n b y E C G , man ag em en t str a te g ie s, p ote n tia l c o m plic atio ns, r ig ht v en tr ic u la r i n fa rc tio n 4 .

Facto rs a sso cia te d w ith p oor p ro gnosis 5 .

Str e ss t e stin g a fte r a cu te m yocard ia l i n fa rc tio n 6 .

Exerc is e t r a in in g a n d c ard ia c r e h ab ilita tio n f o r a cu te c o ro nary sy ndro m es Path op hysio lo gy The p ath olo gy o f a cu te c o ro nary s y ndro m es i s c o m ple x ; i t i n volv es t h e dev elo pm en t o f a th ero sc le ro tic l e sio ns i n t h e w alls of t h e c o ro nary a rte rie s with s u bse q uen t t h ro m bosis f o rm atio n r e su ltin g i n a n a b ru pt d ecre ase i n vesse l b lo od f lo w .

Ath ero sc le ro sis a n d T hro m bosis Ath ero sc le ro sis i s a d is e ase p ro cess t h at m ay r e su lt i n b lo od-flo w l im itin g le sio ns i n t h e e p ic ard ia l c o ro nary , c aro tid , i lia c, an d f e m ora l a rte rie s, a s well a s t h e a o rta . S om e a rte rie s a re r e sis ta n t t o a th ero sc le ro sis ( b ra ch ia l, in te rn al t h ora cic , i n tr a m yocard ia l) fo r u nknow n r e aso ns ( 4 ). T he p ro cesse s of a th ero sc le ro sis a n d t h ro m bosis a re i n te rre la te d , a n d t h e t e rm ath ero th ro m bosis h as b een a d opte d b y s o m e i n vestig ato rs t o e m phasiz e th is p oin t ( 4 ).

The N orm al A rte ry The c h an nel f o r t h e f lo w o f b lo od w ith in t h e a rte ry i s t h e lu m en . T he i n ner, sin gle -c ell l a y er o f t h e a rte ry i s t h e en doth eliu m . T he e n doth eliu m p la y s a critic al r o le i n m ain ta in in g v aso m otio n ( th e d eg re e o f v aso co nstr ic tio n) an d r e g ula tin g h em osta sis (b ala n cin g p ro – a n d a n tith ro m botic p ro pertie s).

When i n ta ct, t h e e n doth eliu m p ro duces n itr ic o xid e, a v aso dila to r, a n d su bsta n ces su ch a s p la sm in ogen t h at i n hib it t h ro m bosis f o rm atio n. V ario us re cep to rs , s u ch a s t h ose f o r l o w -d en sity l ip opro te in a n d g ro w th fa cto rs , a re lo cate d o n t h e e n doth elia l c ells ( 5 ). U nder n orm al c ir c u m sta n ces, t h e en doth eliu m p ro te cts a g ain st t h e d ev elo pm en t of a th ero th ro m bosis , b ut 445 when d am ag ed i t p la y s a c en tr a l r o le i n t h e d ev elo pm en t o f t h e d is e ase ( 5 ).

Undern eath t h e e n doth elia l b ase m en t m em bra n e i s t h e in tim a , c o nsis tin g of a t h in l a y er o f c o nnectiv e t is su e w ith a n o ccasio nal s m ooth m usc le c ell.

The l e sio ns o f a th ero sc le ro sis f o rm in t h e i n tim a ( 5 ).

The med ia c o nta in s m ost o f t h e s m ooth m usc le c ells o f t h e a rte ria l w all, i n ad ditio n t o e la stic c o nnectiv e t is su e, a n d i s l o cate d u ndern eath th e i n tim a betw een t h e i n te rn al a n d e x te rn al e la stic l a m in ae. T he s m ooth m usc le c ells main ta in a rte ria l t o ne ( p artia l v aso co nstr ic tio n).

Sm ooth m usc le c ells h av e re cep to rs f o r l o w -d en sity l ip opro te in , i n su lin , a n d g ro w th f a cto rs . W hen ap pro pria te ly s tim ula te d , sm ooth m usc le c ells a re c ap ab le o f f u nctio nin g as s y nth etic t is su e, p ro ducin g c o nnectiv e t is su e ( 6 ).

The o ute rm ost l a y er o f t h e a rte ria l w all i s t h e adven titia , c o nsis tin g o f co nnectiv e t is su e ( c o lla g en , e la stin ), f ib ro bla sts ( c ells c ap ab le o f sy nth esiz in g c o nnectiv e t is su e), a n d a f e w s m ooth m usc le c ells . T his t is su e is h ig hly v asc u la riz ed ( its b lo od s u pply i s p ro vid ed b y s m all v esse ls c alle d th e v asa vaso ru m ) a n d p ro vid es t h e m ed ia a n d i n tim a w ith o xygen a n d nutr ie n ts ( 5 ).

Ath ero gen esis Our u nders ta n din g o f t h e d ev elo pm en t a n d p ro gre ssio n o f a th ero sc le ro sis (a th ero gen esis ) i s i n co m ple te . H ow ev er, i t i s c le ar th at en doth elia l i n ju ry re su ltin g i n en doth elia l d ysfu nctio n a n d a s u bse q uen t in fla m mato ry re sp onse p la y c ritic al r o le s ( 7 ). T he d is e ase p ro cess m ay b eg in i n ch ild hood a n d p ro gre ss f o r d ecad es b efo re a c lin ic al e v en t o ccu rs .

The r a te of p ro gre ssio n o f a th ero sc le ro sis m ay n ot b e c o nsis te n t o ver t im e a n d im possib le t o p re d ic t.

Under n orm al c o nditio ns, t h e e n doth eliu m m ay e x perie n ce p erio dic min im al a m ounts o f i n ju ry . I n t h ese s itu atio ns, t h e i n here n t re p air pro cesse s o f t h e e n doth eliu m a re a d eq uate t o r e sto re n orm al f u nctio n.

How ev er, c h ro nic , e x cessiv e i n ju ry t o e n doth elia l cells i n itia tin g t h e pro cess o f a th ero gen esis m ay r e su lt f ro m m ultip le c au se s, s u ch a s t h e fo llo w in g ( 6 , 7 , 8 , 9 , 1 0, 1 1, 12, 1 3):

Tobacco s m oke a n d o th er c h em ic al i r rita n ts f ro m t o bacco Low -d en sity l ip opro te in c h ole ste ro l ( L D L-C ) Hyperte n sio n 446 Gly cate d s u bsta n ces r e su ltin g f ro m h yperg ly cem ia a n d d ia b ete s mellitu s Pla sm a h om ocy ste in e In fe ctio us a g en ts ( e .g ., Chla m yd ia pneu m onia e , h erp es v ir u se s) Endoth elia l d ysfu nctio n m ay r e su lt f ro m t h ese p ote n tia lly i n ju rio us f a cto rs , le ad in g t o t h e f o llo w in g a b norm alitie s c h ara cte ris tic of a n i n fla m mato ry re sp onse :

1 .

In cre ase d a d hesiv en ess r e su ltin g i n p la te le t d ep ositio n, m onocy te ad hesio n 2 .

In cre ase d p erm eab ility t o l ip opro te in s a n d o th er s u bsta n ces i n t h e blo od 3 .

Im pair e d v aso dila tio n, i n cre ase d v aso sp asm Pla te le ts a d here t o t h e d am ag ed e n doth eliu m ( p la te le t a g gre g atio n), f o rm sm all b lo od c lo ts o n t h e v esse l w all ( m ura l t h ro m bi) , an d r e le ase g ro w th fa cto rs a n d v aso co nstr ic to r s u bsta n ces, s u ch a s t h ro m boxan e A 2 ( 5 , 6 ).

These c h an ges i n dic ate a s w itc h in e n doth elia l f u nctio n f a v orin g a pro th ro m botic , v aso co nstr ic tiv e s ta te .

Monocy te s, a t y pe o f w hite b lo od c ell, a ls o a d here t o t h e i n ju re d en doth eliu m a n d m ig ra te i n to t h e i n tim a. L D L-C e n te rs t h e arte ria l w all an d u nderg oes t h e p ro cess o f o xid atio n. M onocy te s a ccu m ula te L D L-C , au gm en tin g t h e o xid atio n p ro cess, a n d b eco m e tr a n sfo rm ed i n to a dis tin ctly d if fe re n t t y pe o f c ell, t h e m acro phag e ( 5 , 7 ).

Gro w th f a cto rs e x pre sse d b y p la te le ts , m onocy te s, a n d d am ag ed en doth eliu m r e su lt i n g ro w th a n d p ro lif e ra tio n ( in cre ase i n cell n um bers an d c ell s iz e) o f c erta in t y pes o f c ells ( m ito gen ic e ffe ct) a s w ell a s t h e mig ra tio n o f c ells i n to t h e a re a o f in ju ry ( c h em ota ctic e ffe ct) ( 5 , 7 ). I n re sp onse t o t h e g ro w th f a cto rs , s m ooth m usc le c ells a n d f ib ro bla sts (u ndif fe re n tia te d co nnectiv e t is su e c ells t h at c an s y nth esiz e f ib ro us t is su e) mig ra te f ro m t h e m ed ia t o t h e i n tim a. S m ooth m usc le p ro gen ito r cells f ro m bone m arro w a ls o m ig ra te t o t h e i n tim a ( 1 4). S om e o f t h ese c ells , i n ad ditio n t o m onocy te s, a ccu m ula te c h ole ste ro l, fo rm in g f o am c ells t h at may r e le ase t h eir c h ole ste ro l i n to t h e e x tr a cellu la r s p ace, g iv in g r is e t o fa tty s tr e ak s, t h e e arlie st vis u ally d ete cta b le ( y ello w m acro sc o pic ap peara n ce) l e sio n o f a th ero sc le ro sis ( 1 1, 1 5). I m mune s y ste m c ells , T ly m phocy te s, are a ls o p re se n t i n f a tty s tr e ak s a n d a re p art o f t h e in fla m mato ry s ta te i n t h e a rte ria l w all ( 1 6).

447 With c o ntin ued m ig ra tio n, p ro lif e ra tio n, a n d g ro w th o f t is su e, t h e l e sio n pro gre sse s i n c o m ple x ity a n d s iz e a n d b eco m es a fib ro m usc u la r p la q ue (1 5). T he c o m positio n o f t h e p la q ue n ow i n clu des a f ib ro us c ap , co nnectiv e t is su e e x tr a cellu la r m atr ix , lip id s, i n fla m mato ry c ells s u ch a s macro phag es a n d T l y m phocy te s, s m ooth m usc le c ells , t h ro m bus, a n d calc iu m . T he t y pic al pla q ue i s f ir m i n t e x tu re a n d p ale g ra y i n c o lo r, a n d i t may c o nta in a y ello w c h ole ste ro l c o re .

As t h e i n tim al l e sio ns o f a th ero sc le ro sis p ro gre ss a n d t h ic k en t h e v esse l wall, a c o m pen sa to ry o utw ard e x pan sio n o f t h e v esse l occu rs ( to a p oin t) an d l u m en s iz e r e m ain s u nch an ged . T his i s c alle d a rte ria l r e m odelin g an d may b e e ffe ctiv e i n c o m pen sa tin g f o r p la q ues w hose b ulk m ay r e p re se n t up t o 4 0% o f t h e v esse l d ia m ete r ( 1 7). W ith c o ntin ued pro gre ssio n i n pla q ue b ulk , t h e a re a o f t h e l u m en d ecre ase s, w hic h m ay u ltim ate ly r e su lt in a r e d uctio n i n b lo od f lo w .

The p ro gre ssio n o f t h e s iz e a n d v olu m e o f a th ero sc le ro tic l e sio ns i s h ig hly varia b le . S om e l e sio ns a p pear r e la tiv ely s ta b le over m an y y ears , o th er pla q ues m ay s lo w ly p ro gre ss i n s iz e, w hile s till o th er a re as o f ath ero sc le ro sis m ay e n la rg e v ery r a p id ly (6 ). T he s lo w ly p ro gre ssin g pla q ues a re t h ought t o g ra d ually i n te rn aliz e m onocy te s a n d l ip id s, w hile ra p id ly p ro gre ssin g l e sio ns in co rp ora te t h ro m bus i n to t h e p la q ue ( 4 ). L ocal str e sso rs ( e .g ., f ro m t u rb ule n t b lo od f lo w o r v aso co nstr ic tio n) o r c h em ic al fa cto rs ( e n zy m es s u ch a s m eta llo pro te in ase s t h at w eak en t h e f ib ro us c ap ) with in t h e l e sio n m ay r e su lt i n p la q ue r u ptu re o r fis su rin g of t h e f ib ro us cap , e x posin g t h e i n te rn al c o nte n ts o f t h e p la q ue t o t h e b lo od ( 6 , 1 8).

Vario us a m ounts o f t h ro m bus f o rm i n re sp onse t o t h is p ro th ro m botic en vir o nm en t a n d m ay b e i n co rp ora te d i n to t h e p la q ue. T he s c en ario o f pla q ue r u ptu re , s u bse q uen t th ro m bus f o rm atio n, a n d i n co rp ora tio n i n to t h e arte ria l w all m ay r e p eate d ly o ccu r, g iv in g a l a y ere d a p peara n ce t o t h e le sio n an d r e su ltin g i n r a p id p ro gre ssio n i n t h e s iz e o f t h e p la q ue. T hese le sio ns, w hic h i n clu de o rg an iz ed t h ro m bus, a re c alle d ad van ced ath ero sc le ro tic p la q ues.

Ath ero sc le ro sis a ffe cts a rte rie s i n a n e x tr e m ely d if fu se m an ner, w ith occasio nal d is c re te , l o caliz ed a re as o f m ore p ro nounced narro w in g o f t h e vesse l l u m en ( 1 9). S ele ctiv e c o ro nary a n gio gra p hy i s t h e g old s ta n dard (b est a v aila b le t e st) f o r d ete rm in atio n of t h e s e v erity o f c o ro nary l e sio ns.

How ev er, b ase d o n c o m paris o ns o f a n gio gra p hic a n d a u to psy f in din gs, with t h e e x cep tio n of c o m ple te o cclu sio n o f t h e v esse l i n q uestio n ( 1 00% ste n osis ), t h e d eg re e o f s te n osis i s g re atly u ndere stim ate d b y a n gio gra p hy 448 becau se o f t h e d if fu se n atu re o f t h e d is e ase p ro cess ( 2 0). O bstr u ctiv e co ro nary l e sio ns ( s e v ere e n ough t o r e d uce b lo od f lo w ) occu r m ost fre q uen tly i n t h e f ir s t 4 t o 5 c m o f t h e e p ic ard ia l c o ro nary a rte rie s, alth ough m ore d is ta l d is e ase m ay a ls o b e se en . O bstr u ctiv e l e sio ns a t t h e orig in ( o stia l l e sio ns) o f t h e l e ft m ain a n d r ig ht m ain c o ro nary a rte rie s m ay als o o ccu r.

For r e aso ns n ot f u lly u nders to od, w om en g en era lly l a g 5 t o 2 0 yr b eh in d m en i n t h e e x te n t a n d s e v erity o f c o ro nary a th ero sc le ro sis (2 1).

Ris k F acto rs f o r A th ero sc le ro sis Ris k f a cto rs a re a sso cia te d w ith a n i n cre ase d l ik elih ood t h at ath ero sc le ro sis w ill d ev elo p o ver t im e. S uch f a cto rs h av e b een id en tif ie d on t h e b asis o f o bse rv atio nal s tu die s e v alu atin g c o m mon c h ara cte ris tic s o f pers o ns w ith t h e d is e ase ( 2 2, 2 3). P ossib le mech an is m s o f a th ero gen ic effe ct h av e b een i d en tif ie d f o r s o m e r is k f a cto rs . T he e ffe cts o f r e d ucin g th e s e v erity o f s o m e ris k f a cto rs , e sp ecia lly L D L-C , h av e b een dem onstr a te d t o r e d uce p ro gre ssio n o f t h e d is e ase . P re d ic tin g w heth er a n in div id ual patie n t w ill o r w ill n ot d ev elo p a th ero sc le ro sis b ase d o n t h e pre se n ce a n d s e v erity o f r is k f a cto rs i s v ery i m pre cis e , h ow ev er.

Less t h an half o f f u tu re c ard io vasc u la r e v en ts c an b e p re d ic te d u sin g c o nven tio nal ris k f a cto rs ( 2 4):

Tobacco u se Dyslip id em ia , e sp ecia lly e le v ate d L D L-C a n d l o w l e v els o f h ig h- den sity l ip opro te in c h ole ste ro l ( H DL-C ) Hyperte n sio n Sed en ta ry l if e sty le Obesity Dia b ete s m ellitu s Meta b olic s y ndro m e ( a c o m bin atio n o f c o nven tio nal r is k f a cto rs asso cia te d w ith o besity a n d i n su lin r e sis ta n ce) Fam ily h is to ry o f p re m atu re c o ro nary d is e ase ( m ale f ir s t- d eg re e re la tiv es < 55 y r o f a g e, f e m ale f ir s t- d eg re e r e la tiv es < 65 yr o f a g e) Male s e x Obstr u ctiv e s le ep a p nea Psy ch oso cia l f a cto rs , s u ch a s d ep re ssio n, a n xie ty , s o cia l i s o la tio n, co ro nary p ro ne p ers o nality ( ty pe A ), l o w er s o cio eco nom ic sta tu s, a n d ch ro nic l if e s tr e sso rs Less w ell- e sta b lis h ed r is k f a cto rs , t e rm ed e m erg in g r is k f a cto rs , a re b ein g 449 in vestig ate d , i n clu din g t h e f o llo w in g ( 2 4, 2 5, 26):

Ele v ate d p la sm a h om ocy ste in e, a n i n te rm ed ia ry i n t h e m eta b olis m o f th e e sse n tia l a m in o a cid m eth io nin e Fib rin ogen , a p ro te in f a cto r i n t h e b lo od c o ag ula tio n c asc ad e Lip opro te in (a ) LD L p artic le c o ncen tr a tio n Hig h-s e n sitiv e C -re activ e p ro te in , a m ark er f o r s y ste m ic in fla m matio n Myoca rd ia l B lo od F lo w , M eta b olis m , a n d I sc h em ia Norm al c o ntr a ctio n a n d r e la x atio n o f c ard ia c m yocy te s r e q uir e s t h e pre se n ce o f a d eq uate a m ounts o f a d en osin e t r ip hosp hate (A TP; a h ig h- en erg y p hosp hate m ole cu le ) i n t h e m yocard iu m . T he h eart i s a h ig hly aero bic o rg an w ith a n e x te n siv e c ir c u la to ry sy ste m a n d a b undan t mito ch ondria ( 2 7).

Fig ure 1 3.1 i llu str a te s t h e e p ic ard ia l c o ro nary a rte rie s.

The c o ro nary a rte ria l s y ste m i n clu des e p ic ard ia l a rte rie s t h at b if u rc ate i n to in tr a m yocard ia l a n d e n dom yocard ia l b ra n ch es. A t r e st, c o ro nary b lo od flo w a v era g es 6 0 t o 9 0 m L · m in −1 · 1 00 g −1 o f m yocard iu m a n d m ay in cre ase f iv e- t o s ix fo ld d urin g e x erc is e ( 2 8). U nder u su al c o nditio ns, t h e heart r e g en era te s A TP a ero bic ally , an d m yocard ia l c ells a re n ot w ell ad ap te d t o a n aero bic e n erg y p ro ductio n. A t r e st, m yocard ia l o xygen upta k e i s a p pro xim ate ly 8 t o 1 0 m L p er 1 00 g o f t is su e p er m in ute . D urin g in te n se e x erc is e , t h e o xygen r e q uir e m en t m ay i n cre ase b y 2 00% t o 3 00% (2 9).

The m yocard iu m e x tr a cts n early a ll i ts o xygen f ro m t h e c ap illa ry blo od f lo w ( u nlik e s k ele ta l m usc le ), a n d c o ro nary b lo od f lo w must b e clo se ly r e g ula te d t o t h e n eed s o f t h e m yocard iu m f o r o xygen ( 3 0). W ith a n in cre ase i n m yocard ia l w ork , o xygen d em an d in cre ase s, a n d c o ro nary blo od f lo w m ust a ls o i n cre ase t o p ro vid e t h e n ecessa ry a m ount o f o xygen .

450 Fig u re 1 3.1 The e p ic ard ia l c o ro nary a rte rie s.

(a ) A nte rio r v ie w .

(b ) Poste rio r v ie w . B la ck s e g m en ts a re p rim e s ite s f o r t h e d ev elo pm en t o f o bstr u ctiv e a th ero sc le ro tic p la q ues. A o = a o rta ; I V C = i n fe rio r v en a c av a; SV C = s u perio r v en a c av a; P A = p ulm onary a rte ry .

Rep rin te d b y p erm is sio n f ro m J .T . L ie , P ath olo gy o f C oro nary A rte ry D is e ase , i n Card io lo gy:

Fundam en ta ls a nd P ra ctic e, 2 nd e d ., e d ite d b y E .R . G iu lia n i e t a l. ( C hic ag o: M osb y Y earb ook, 1991).

B lo od f lo w t h ro ugh a n y r e g io nal c ir c u la tio n, i n clu din g t h e c o ro nary s y ste m , i s d ete rm in ed b y t h e b lo od p re ssu re a n d t h e v asc u la r re sis ta n ce ( 3 0). D urin g s y sto le , i n tr a m yocard ia l p re ssu re i s i n cre ase d ( a s i s v asc u la r r e sis ta n ce) a n d t h e i n tr a m ura l v esse ls are c o m pre sse d . T here fo re , m ost c o ro nary b lo od f lo w o ccu rs d urin g d ia sto le , w hen i n tr a m yocard ia l p re ssu re i s l o w er ( lo w er vasc u la r r e sis ta n ce).

B efo re a d ecre ase i n f lo w c an b e m easu re d d is ta l t o a n arro w ed , a th ero sc le ro tic c o ro nary a rte ry s e g m en t, a s u bsta n tia l r e d uctio n in v esse l l u m in al d ia m ete r m ust o ccu r. W hen p la q ue b ulk r e d uces t h e l u m in al c ro ss- s e ctio nal a re a b y 7 5% o r m ore , f lo w i s r e d uced under r e stin g c o nditio ns ( a h em odynam ic ally s ig nif ic an t l e sio n) ( 2 8). B ey ond t h is a m ount o f c ritic al s te n osis , f u rth er s m all decre ase s i n c ro ss-s e ctio nal a re a o f t h e v esse l r e su lt i n l a rg e r e d uctio ns i n f lo w .

A r e d uctio n i n t h e l u m en d ia m ete r m ay b e c au se d b y s e v era l f a cto rs ( 3 1, 3 2):

Sig nif ic an t a th ero sc le ro tic p la q ue Vaso sp asm w ith out u nderly in g p la q ue Vaso sp asm s u perim pose d o ver a p la q ue 451 Thro m bus a sso cia te d w ith p la q ue r u ptu re Coro nary v aso sp asm m ay r e su lt f ro m s e v era l f a cto rs , s u ch a s e n doth elia l dysfu nctio n, s y m path etic n erv ous s y ste m a ctiv atio n (e .g ., v aso sp asm re su ltin g f ro m e x posu re t o v ery c o ld a m bie n t t e m pera tu re s), a n d blo odborn e s u bsta n ces s u ch a s e p in ep hin e (3 3).

Myocard ia l i s c h em ia r e su lts w hen m yocard ia l b lo od f lo w i s i n ad eq uate t o pro vid e t h e r e q uir e d a m ounts o f o xygen f o r A TP r e g en era tio n (o xygen su pply < o xygen d em an d) ( 2 7, 2 8). I s c h em ia m ay r e su lt i n p ro gre ssiv e ab norm alitie s i n c ard ia c f u nctio n, t e rm ed t h e is c h em ic c asc ad e (3 4). T he fir s t a b norm ality i s s tif fe n in g o f t h e l e ft v en tr ic le , w hic h i m pair s d ia sto lic fillin g o f t h e h eart ( d ia sto lic d ysfu nctio n).

Seco nd, s y sto lic e m pty in g o f t h e le ft v en tr ic le b eco m es i m pair e d ( s y sto lic d ysfu nctio n). L ocaliz ed a re as o f th e m yocard iu m dev elo p a b norm al c o ntr a ctio n p atte rn s s u ch a s hypokin esis ( re d uced s y sto lic c o ntr a ctio n).

Left v en tr ic u la r e je ctio n fr a ctio n ( L V EF) m ay d ecre ase . T hir d , e le ctr o card io gra p hic a b norm alitie s asso cia te d w ith a lte re d r e p ola riz atio n ( S T -s e g m en t c h an ges, T w av e in vers io n) o r a rrh yth m ia s m ay o ccu r. F in ally , s y m pto m s o f a n gin a p ecto ris may d ev elo p.

Angin a p ecto ris i s t r a n sie n t r e fe rre d c ard ia c p ain r e su ltin g f ro m myocard ia l i s c h em ia ( 3 5). A m in ority o f p atie n ts w ith s u bsta n tia l am ounts of i s c h em ia d o n ot r e p ort p ain ( s ile n t i s c h em ia ). T he p ain o f a n gin a m ay b e lo cate d i n t h e s u bste rn al r e g io n, j a w , neck , o r a rm s, a lth ough p ain m ay als o o ccu r i n t h e e p ig astr iu m a n d i n te rs c ap ula r r e g io ns. I t i s u su ally desc rib ed a s a f e elin g of p re ssu re , h eav in ess, f u lln ess, s q ueezin g, b urn in g, ach in g, o r c h okin g. T he p ain m ay v ary i n i n te n sity a n d m ay r a d ia te .

The patie n t m ay e x perie n ce d ysp nea ( a n gin al e q uiv ale n t) , i f t h e i s c h em ia re su lts i n i n cre ase d l e ft v en tr ic u la r e n d-d ia sto lic pre ssu re a n d i n cre ase d pulm onary v asc u la r p re ssu re .

Typic al a n gin a i s p ro voked b y e x ertio n, em otio ns, c o ld a n d h eat e x posu re , m eals , a n d s e x ual i n te rc o urs e ; a n d i s re lie v ed b y re st, n itr o gly cerin , o r b oth . A ty pic al a n gin a i n volv es s im ila r sy m pto m s b ut h as f e atu re s t h at s e t i t a p art f ro m t y pic al a n gin a, su ch a s n o re la tio nsh ip w ith e x ertio n. S ta b le a n gin a i s r e p ro ducib le a n d p re d ic ta b le i n onse t, s e v erity , a n d m ean s o f r e lie f.

Unsta b le a n gin a is d efin ed a s n ew onse t o f t y pic al a n gin a; i n cre asin g f re q uen cy , i n te n sity , o r d ura tio n o f pre v io usly s ta b le a n gin a; o r a n gin a th at o ccu rs a t r e st o r i n t h e f ir s t f e w day s a fte r a cu te m yocard ia l i n fa rc tio n.

If a n e p is o de o f i s c h em ia i s b rie f, t h e c o ntr a ctile a b norm alitie s d esc rib ed 452 pre v io usly a re q uic k ly r e v ers ib le . B rie f p ostis c h em ic le ft v en tr ic u la r dysfu nctio n i s c alle d s tu nned m yocard iu m (3 6). C hro nic , s u bsta n tia l, nonle th al i s c h em ia m ay r e su lt i n p ro lo nged b ut r e v ers ib le l e ft v en tr ic u la r dysfu nctio n c alle d hib ern atin g m yocard iu m . M yocy te s r e m ain v ia b le b ut ex hib it d ep re sse d c o ntr a ctile f u nctio n. E lim in atio n o f c h ro nic i s c h em ia with r e v asc u la riz atio n r e su lts i n a g ra d ual r e tu rn o f n orm al c o ntr a ctile fu nctio n, a lth ough r e so lu tio n m ay r e q uir e u p t o a year ( 3 7). P ro lo nged , se v ere i s c h em ia r e su lts i n m yocy te n ecro sis ( ir re v ers ib le d am ag e, myocard ia l i n fa rc tio n).

Defin it io n o f A cu te C oro n ary S yn dro m es Unsta b le a n gin a p ecto ris , a cu te m yocard ia l i n fa rc tio n, a n d s o m e i n sta n ces of s u dden c ard ia c d eath c o m pris e t h e a cu te c o ro nary sy ndro m es (A CS) (4 ). T he u nderly in g m ech an is m r e su ltin g i n t h ese s y ndro m es i s ath ero sc le ro tic p la q ue e ro sio n, r u ptu re , o r o th er t y pe of p la q ue d is ru ptio n re su ltin g i n t h ro m bus f o rm atio n a n d p ossib ly v aso co nstr ic tio n, w ith su bse q uen t v esse l o cclu sio n a n d a cu te myocard ia l i s c h em ia .

The t y pe o f a cu te c o ro nary s y ndro m e t h at o ccu rs i s r e la te d t o t h e d ura tio n of v esse l o cclu sio n. U nsta b le a n gin a i s p ro bab ly th e r e su lt o f t r a n sie n t vesse l o cclu sio n ( < 10 m in ) f o llo w ed b y s p onta n eo us th ro m boly sis ( c lo t dis so lu tio n) a n d v aso re la x atio n. V esse l o cclu sio n p ers is tin g f o r m ore t h an 60 m in r e su lts i n a cu te m yocard ia l i n fa rc tio n.

Is c h em ia r e su ltin g f ro m ath ero th ro m botic v esse l o cclu sio n m ay t r ig ger v en tr ic u la r t a ch ycard ia o r ven tr ic u la r f ib rilla tio n an d s u dden c ard ia c d eath ( 4 ).

Why d o s o m e p la q ues r u ptu re a n d t h ro m bose ? A ppro xim ate ly t w o-th ir d s of p atie n ts w ith A CS h av e h ig h-ris k o r v uln era b le a th ero sc le ro tic le sio ns with t h in f ib ro us c ap s o verly in g a l ip id -ric h c o re w ith a n a b undan ce o f macro phag es ( 4 ). I n fla m matio n m ed ia te d b y vario us c y to kin es, i n clu din g pro te ase s a n d t u m or n ecro sis f a cto r, e ro des t h e p la q ue f ro m w ith in . T he physic al f o rc es a ssis tin g with p la q ue d is ru ptio n i n clu de i n cre ase d b lo od pre ssu re o r h eart r a te , l o cal v aso co nstr ic tio n, a n d n ic o tin e o r i m mune co m ple x es.

Afte r p la q ue r u ptu re , c ir c u la tin g b lo od p la te le ts c o m e i n d ir e ct co nta ct w ith t h e t h ro m bogen ic i n te rn al e n vir o nm en t o f t h e pla q ue, re su ltin g i n c lo t f o rm atio n ( 3 8).

Angio gra p hic s tu die s h av e d em onstr a te d t h at m ost o f t h ese r u ptu re -p ro ne le sio ns a re l e ss t h an 5 0% o cclu siv e b efo re t h ey b eco m e dis ru pte d (3 9).

This e x pla in s w hy m an y p atie n ts w ho e x perie n ce a n A CS d o n ot h av e 453 warn in g s y m pto m s. H ow ev er, a n gio gra p hic ally s e v ere co ro nary ath ero sc le ro sis d oes i n cre ase t h e l ik elih ood o f a c o ro nary e v en t b y s e rv in g as a m ark er f o r t h e p re se n ce o f e x te n siv e dis e ase , i n clu din g r u ptu re -p ro ne le sio ns. A uto psy s tu die s h av e a ls o d em onstr a te d t h at m an y p atie n ts h av e dis ru pte d p la q ues but n o h is to ry o f a n A CS. T hus, n ot a ll p la q ue d is ru ptio n re su lts i n c lin ic al e v en ts . I n a p pro xim ate ly o ne-th ir d o f c ase s, an A CS re su lts f ro m o nly s u perfic ia l e ro sio n o f a s e v ere ly s te n otic a n d f ib ro tic pla q ue, w ith c lo t f o rm atio n d ue t o a h yperth ro m botic sta te c au se d b y fa cto rs s u ch a s s m okin g, h yperg ly cem ia , o r e le v ate d L D L-C ( 4 ).

Acu te M yoca rd ia l I n fa rctio n Acu te m yocard ia l i n fa rc tio n i s t h e n ecro sis ( d eath ) o f c ard ia c m yocy te s re su ltin g f ro m p ro lo nged i s c h em ia c au se d b y c o m ple te vesse l o cclu sio n (4 0). T he k ey e v en t i n d is tin guis h in g r e v ers ib le f ro m i r re v ers ib le (in fa rc tio n) i s c h em ia i s d is ru ptio n o f th e m yocy te m em bra n e ( a l e th al ev en t) . T he m yocy te c an not r e co ver i f m em bra n e d is ru ptio n o ccu rs a n d cy to pla sm ic c o nte n ts s p ill in to t h e c ir c u la tio n.

In s o m e p atie n ts , a p re cip ita tin g e v en t, o r t r ig ger, f o r t h e m yocard ia l in fa rc tio n m ay b e d ete rm in ed , s u ch a s p hysic al e x ertio n, em otio nal s tr e ss, or a n ger ( 4 1, 4 2). I t m ay a ls o o ccu r i n t h e s e ttin g o f s u rg ery a sso cia te d with s u bsta n tia l l o ss o f b lo od.

There i s e v id en ce f o r c ir c ad ia n v aria tio n, with s lig htly m ore m yocard ia l i n fa rc tio ns o ccu rrin g i n t h e e arly m orn in g hours th an a t o th er t im es, s u ggestin g a r o le f o r s y m path etic n erv ous s y ste m activ atio n a s a t r ig ger ( 4 0, 4 2).

Clin ic a l A sse ssm en t When a p atie n t p re se n ts t o a m ed ic al f a cility a n d t h ere i s s u sp ic io n o f ACS, t h e f o llo w in g a sse ssm en t i s w arra n te d .

His to ry o f s y m pto m s: S ym pto m s o f m yocard ia l i n fa rc tio n i n clu de ch est p ain o r o th er a n gin al s e n sa tio ns, g astr o in te stin al u pse t, dysp nea, sw eatin g, a n xie ty , o r s y nco pe. I t m ay b e p ain le ss ( s ile n t m yocard ia l in fa rc tio n) i n a p pro xim ate ly 2 5% o f c ase s ( 4 3).

Pain i s o fte n s e v ere , but a ll i n te n sitie s o f d is c o m fo rt m ay b e e x perie n ced . E ld erly p atie n ts re p ort m ore d ysp nea, w hile w om en are m ore l ik ely t o r e p ort a ty pic al sy m pto m s, s u ch a s s h ould er, m id dle b ack , o r e p ig astr ic p ain ; f a tig ue; 454 an d g en era l w eak ness (4 4).

Physic al e x am in atio n: P atie n ts w ith A CS m ay d em onstr a te t h e fo llo w in g f in din gs o n p hysic al e x am in atio n ( 4 5):

Systo lic h ypote n sio n Dia p hore sis Sin us t a ch ycard ia Tach ypnea New m urm ur o f m itr a l r e g urg ita tio n Thir d , f o urth h eart s o unds Pulm on ary r a le s Ele ctr o card io gra m : T he E C G m ay s h ow S T -s e g m en t e le v atio n o r nonsp ecif ic S T -T w av e a b norm alitie s ( s e e E C G C la ssif ic atio n o f Myocard ia l I n fa rc tio n).

Chest r a d io gra p h: T his i s u se fu l f o r p atie n ts w ith e v id en ce o f hem odynam ic i n sta b ility o r p ulm onary e d em a.

Lab ora to ry r e su lts : T he b io m ark er c ard ia c t r o ponin ( c T n) i s m easu re d tw ic e, 6 t o 1 2 h a p art. A n E C G i s p erfo rm ed o n a d m is sio n an d re p eate d s e ria lly , a s n eed ed . A b lo od l ip id p ro file s h ould b e o bta in ed with in 2 4 h o f s y m pto m o nse t.

Dia gn osis o f A cu te M yoca rd ia l I n fa rctio n The d ia g nosis o f m yocard ia l i n fa rc tio n i s b ase d o n t h e p re se n ce o f ele v ate d c ard ia c n ecro sis b io m ark ers p lu s a t l e ast o ne ad ditio nal f a cto r (4 6):

Sym pto m s o f i s c h em ia EC G e v id en ce o f m yocard ia l i s c h em ia ( S T -s e g m en t e le v atio n o r dep re ssio n, o r n ew l e ft b undle b ra n ch b lo ck ) New p ath olo gic al Q w av es o n t h e E C G Im ag in g e v id en ce ( u su ally e ch ocard io gra p hy) o f i n fa rc tio n cT n i s t h e p re fe rre d b io m ark er f o r t h e d ete ctio n o f c ard io m yocy te n ecro sis .

It i s h ig hly s e n sitiv e a n d s p ecif ic f o r c ard ia c necro sis . E le v atio n o ccu rs 2 to 3 h a fte r t h e o nse t o f i n fa rc tio n a n d r e m ain s e le v ate d f o r 1 t o 2 w k ( 4 7).

It s h ould b e n ote d th at c T n i s e le v ate d a fte r p erc u ta n eo us i n te rv en tio n o r card ia c s u rg ery . T he p rio r s ta n dard c ard ia c b io m ark er w as t h e M B f ra ctio n of c re atin e k in ase ( C K -M B) ( 4 8). W hile n ot a s s p ecif ic a n d s e n sitiv e a s cT n, i t i s s till a n a ccep ta b le d ia g nostic t e st i f cT n i s n ot a v aila b le .

Afte r m yocard ia l i n fa rc tio n, m yocard ia l c ells d o n ot r e g en era te , a n d healin g o ccu rs v ia s c ar f o rm atio n. D ep en din g o n t h e e x te n t of i n fa rc tio n, 455 sc ar f o rm atio n m ay t a k e d ay s t o w eek s f o r c o m ple tio n. T he l a rg er t h e s iz e of t h e i n fa rc tio n, t h e l a rg er t h e sc ar.

ECG C la ssif ic a tio n o f M yo ca rd ia l I n fa rc tio n In fa rc tio ns a re c la ssif ie d a s S T -s e g m en t e le v atio n ( S T EM I) o r n on-S T – se g m en t e le v atio n ( N ST EM I) ( 4 6).

Ele ctr o card io gra p hic c rite ria f o r ST EM I a n d N ST EM I a re a s f o llo w s:

ST EM I: S T -s e g m en t e le v atio n o f a t l e ast 1 m V i n t w o c o ntig uous le ad s o r n ew l e ft b undle b ra n ch b lo ck NST EM I: S T -s e g m en t d ep re ssio n o r T w av e i n vers io n p ers is tin g a t le ast 2 4 h ST EM I a re t h e r e su lt o f a n o cclu ded e p ic ard ia l c o ro nary a rte ry w ith m ore ex te n siv e m yocard ia l d am ag e a n d a w ors e p ro gnosis .

NST EM I h av e l e ss myocard ia l d am ag e b ecau se o f s p onta n eo us t h ro m boly sis ( c lo t dis so lu tio n).

Fig ure 1 3.2 s h ow s t h e e v olu tio n o f t h e e le ctr o card io gra m afte r S T EM I, w ith t h e f o rm atio n o f a Q w av e i n dic atin g i n fa rc tio n o f a ll o r most o f t h e t h ic k ness o f t h e v en tr ic u la r w all. T he S T -s e g m en t e le v atio n re su lts f ro m i s c h em ic i n ju ry , a n d i n verte d T w av es are d ue t o i s c h em ia aro und t h e o uts id e b ord ers o f t h e i n fa rc t. A nato m ic l o caliz atio n o f myocard ia l i n fa rc tio ns i s p ossib le if Q w av es a re f o rm ed , a s s h ow n i n Crite ria f o r A nato m ic L ocaliz atio n o f M yocard ia l I n fa rc tio n ( M I) b y Q Wav e A ppeara n ce.

456 F ig u re 1 3.2 The e v olu tio n o f t h e e le ctr o card io gra m i n a cu te S T -s e g m en t ele v atio n m yocard ia l i n fa rc tio n r e su ltin g i n Q w av e f o rm atio n.

Rep rin te d b y p erm is sio n f ro m G .T . G au , S ta n dard E le ctr o card io gra p hy, V ecto rc ard io gra p hy a n d Sig nal- A vera g ed E le ctr o card io gra p hy, in C ard io lo gy: F undam en ta ls a nd p ra ctic e, 2nd e d . e d ite d by E .R . G iu lia n i e t a l. ( S t. L ouis : M osb y Y ear B ook, 1 991).

Crit e ria f o r A nato m ic L oca liz a tio n o f M yoca rd ia l In fa rctio n ( M I) b y Q W ave A ppea ra n ce 1 .

In fe rio r w all M I ( u su ally r ig ht c o ro nary a rte ry o cclu sio n): Q wav e ( > 40 m s d ura tio n, a m plitu de > 25% o f t h e R w av e) i n le ad s II, I II, a n d a V F 2 .

Ante rio r w all M I ( le ft a n te rio r d esc en din g c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s V 1 t h ro ugh V 3 ( a n te ro se p ta l) , Q S patte rn in l e ad s V 1 t h ro ugh V 3 ( a n te ro se p ta l) , Q w av e i n le ad s V 2 t h ro ugh V 4 ( a n te rio r), Q S p atte rn i n l e ad s V 2 th ro ugh V 4 ( a n te rio r) 457 3 .

Late ra l w all M I ( u su ally c ir c u m fle x c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s V 4 t h ro ugh V 6 o r Q S p atte rn i n le ad s V 4 t h ro ugh V6 4 .

Poste rio r w all M I ( u su ally r ig ht c o ro nary a rte ry o cclu sio n):

pro m in en t R w av e i n l e ad s V 1 t h ro ugh V 2 w ith p ositiv e T wav es 5 .

Hig h l a te ra l w all M I ( u su ally c ir c u m fle x c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s I a n d a V L o r Q S p atte rn i n l e ad s I an d aV L Mech an is tic C la ssif ic a tio n o f M yo ca rd ia l I n fa rc tio n In fa rc tio ns a re a ls o c la ssif ie d b ase d o n t h e p re su m ed c au se o f t h e myocard ia l i s c h em ia ( 4 6):

Type 1 : D ue t o p ath olo gy o f t h e w all o f t h e c o ro nary a rte ry , co m monly p la q ue r u ptu re ; r a re ly d ue t o s p onta n eo us c o ro nary dis se ctio n Type 2 : D ue t o i n cre ase d o xygen d em an d o r d ecre ase d s u pply , s u ch as h yperth yro id is m , f e v er, p heo ch ro m ocy to m a, a rrh yth m ia s, hyperte n sio n, c o ro nary a rte ry s p asm , m ic ro vasc u la r s p asm , c o ro nary arte ry e m bolu s, a n em ia , h ypote n sio n Type 3 : S udden u nex pecte d c ard ia c d eath b efo re a v aila b ility o f card ia c b io m ark er a n aly sis Type 4 a: A sso cia te d w ith p erc u ta n eo us c o ro nary i n te rv en tio n ( P C I) Type 4 b: A sso cia te d w ith s te n t t h ro m bosis ( c lo t f o rm atio n w ith in a ste n t) Type 5 : A sso cia te d w ith c o ro nary a rte ry b ypass g ra ft s u rg ery (C A BG ) Dia gn osis o f U nsta b le A ngin a Unsta b le a n gin a h as t h re e p re se n ta tio ns: p ro lo nged r e st a n gin a, n ew -o nse t an gin a, a n d a ccele ra te d a n gin a ( 4 6). D if fe re n tia tio n of u nsta b le a n gin a fro m a cu te m yocard ia l i n fa rc tio n i s b ase d o n b io m ark er e le v atio n.

Man agem en t o f A cu te C oro n ary S yn dro m es 458 The f o llo w in g a re t h era p eu tic a p pro ach es t o t r e atin g p atie n ts w ith a cu te co ro nary s y ndro m es ( 4 8, 4 9):

Anti- I sc h em ic T hera p y Bed o r c h air r e st w ith c o ntin uous E C G m onito rin g Supple m en ta l o xygen w hen a rte ria l s a tu ra tio ns a re l e ss t h an 9 0% Nitr o gly cerin ; s u blin gual, o ra l, o r i n tr a v en ous a d m in is tr a tio n β-b lo ck er Angio te n sin -c o nvertin g e n zy m e i n hib ito r ( A CEi) i f l e ft v en tr ic u la r eje ctio n f ra ctio n ( L V EF) i s ≤ 40% o r w ith a n te rio r w all myocard ia l in fa rc tio n Angio te n sin r e cep to r b lo ck er f o r p atie n ts w ith e je ctio n f ra ctio ns ≤40% , o r a n te rio r w all m yocard ia l i n fa rc tio n, i f i n to le ra n t of an gio te n sin -c o nvertin g e n zy m e i n hib ito rs Ald oste ro ne a n ta g onis ts f o r p atie n ts w ith S T EM I a n d a n L V EF o f ≤40% w ho a re a lr e ad y r e ceiv in g A CEi Sta tin t o i m pro ve b lo od l ip id p ro file a n d r e d uce t h e r is k o f r e cu rre n t ev en ts In tr a -a o rtic b allo on p um p c o unte rp uls a tio n t o m ain ta in d ia sto lic pre ssu re a n d c o ro nary p erfu sio n Dual A ntip la te le t T hera p y Asp ir in Clo pid ogre l, p ra su gre l, o r t ic ag re lo r Antic o agu la n ts Unfra ctio nate d h ep arin Low m ole cu la r w eig ht h ep arin Biv alir u din ( d ir e ct t h ro m bin i n hib ito r) Pain R elie f ( D esp it e A nti- I sc h em ic T hera p y) Morp hin e Rep erfu sio n T hera p y Rep erfu sio n o f t h e in fa rct-r ela te d a rte ry m ay b e a cco m plis h ed v ia th ro m boly tic t h era p y o r v ia r e v asc u la riz atio n w ith e ith er P C I o r, m uch l e ss co m monly , C A BG ( fo r s e le cte d patie n ts w ith e ith er l e ft m ain o r s e v ere th re e-v esse l c o ro nary a rte ry d is e ase ) ( 4 5, 5 0). T hro m boly tic t h era p y h as 459 not b een dem onstr a te d t o b e b en efic ia l i n N ST EM I.

Non -S T -S eg m en t E le va tio n M yo ca rd ia l I n fa rc tio n /U nsta ble Angin a P ecto ris Tw o m an ag em en t o ptio ns a re a v aila b le f o r N ST EM I/u nsta b le a n gin a ( 4 5, 46):

1 .

Early i n vasiv e s tr a te g y: D ep en din g o n t h e r e su lts o f c o ro nary an gio gra p hy, t h e p atie n t m ay u nderg o P C I ( b y f a r t h e m ost c o m mon occu rre n ce) o r C A BG i f t h e a n ato m y i s n ot f a v ora b le f o r P C I. M ost patie n ts u nderg o t h e e arly i n vasiv e s tr a te g y i f t h ey a re hosp ita liz ed a t a c en te r c ap ab le o f P C I.

2 .

Conse rv ativ e t r e atm en t: O ptim al m ed ic al m an ag em en t w ith g ra d ed ex erc is e t e stin g p erfo rm ed e ith er b efo re d is c h arg e o r e arly afte r dis c h arg e. I f t h e p atie n t a ch ie v es 5 + M ETs w ith out s ig ns o f i s c h em ia , pro gnosis i s f a v ora b le a n d a n gio gra p hy m ay b e defe rre d .

ST -S eg m en t E le va tio n M yo ca rd ia l I n fa rc tio n The o ptim al m an ag em en t o f p atie n ts w ith S T EM I i s p ro m pt r e p erfu sio n o f th e i n fa rc t- re la te d a rte ry ( 5 0). T he e arlie r t h e r e p erfu sio n, th e b ette r t h e outc o m e f o r t h e p atie n t i n t e rm s o f l im itin g i n fa rc t s iz e, p re se rv in g l e ft ven tr ic u la r f u nctio n, a n d i m pro vin g su rv iv al.

Tw o r e p erfu sio n s tr a te g ie s a re a v aila b le : t h ro m boly sis a n d p rim ary P C I (5 0). P C I i s t h e b est o ptio n f o r t h e p atie n t i f a v aila b le .

Thro m boly sis i s perfo rm ed u sin g t is su e i n tr a v en ous p la sm in ogen a ctiv ato rs , s u ch a s te n ecte p la se o r a lte p la se , w hic h b re ak dow n c o ro nary t h ro m bose s. I t i s most e ffe ctiv e i f g iv en d urin g t h e f ir s t 3 h a fte r s y m pto m o nse t. T hese a re th e b en efits o f th ro m boly sis :

1 .

It i s r e ad ily a v aila b le i n r u ra l a n d c o m munity h osp ita ls .

2 .

It d oesn ’t r e q uir e a c ard io lo gis t o r a c ard ia c c ath ete riz atio n la b ora to ry .

3 .

It c an u su ally b e a d m in is te re d w ith in m in ute s o f t h e p atie n t’ s re ach in g t h e h osp ita l.

How ev er, t h ro m boly tic t h era p y h as s u bsta n tia l l im ita tio ns ( 5 0):

460 1 .

Resto ra tio n o f f u ll c o ro nary b lo od f lo w o ccu rs i n o nly 6 0% t o 7 0% o f case s t r e ate d w ith in 3 h o f s y m pto m o nse t.

2 .

Contr a in dic atio ns t o t h ro m boly tic a g en ts , s u ch a s p rio r i n tr a cra n ia l hem orrh ag e, p rio r i s c h em ic s tr o ke, o r a ctiv e b le ed in g, occu r i n 3 0% to 4 0% o f p atie n ts .

Patie n ts t r e ate d w ith t h ro m boly sis s h ould b e t r a n sfe rre d i m med ia te ly t o a PC I-c ap ab le f a cility ( fa cilita te d P C I) u nle ss i m possib le becau se o f w eath er or o th er c ir c u m sta n ces. P C I i s b en efic ia l a fte r b oth s u ccessfu l o r f a ile d th ro m boly sis . P rim ary P C I h as im pre ssiv e b en efits ( 5 0):

1 .

It i m pro ves m yocard ia l s a lv ag e ( le ss n ecro tic m yocard iu m ).

2 .

It l e ad s t o l e ss r e in fa rc tio n a n d v esse l r e o cclu sio n.

3 .

It i d en tif ie s c o ro nary a n ato m y m ore s u ita b le f o r C A BG , s u ch a s l e ft main o r s e v ere t h re e-v esse l c o ro nary d is e ase .

4 .

The i n vasiv e s tr a te g y h elp s i d en tif y c au se s o f S T -s e g m en t e le v atio n oth er t h an a th ero sc le ro sis , s u ch a s p eric ard itis , m yocard itis , ap ic al ballo onin g s y ndro m e ( T ak ots u bo c ard io m yopath y), c o cain e u se , a n d co ro nary v aso sp asm r e su ltin g f ro m e n doth elia l d ysfu nctio n (4 8).

The m ajo r l im ita tio n o f p rim ary P C I i s t h e d ela y i n o pen in g t h e i n fa rc t- re la te d a rte ry o nce s y m pto m s b eg in ( 5 0). F or e v ery 30 m in d ela y , t h ere i s an 8 % i n cre ase i n m orta lity a t 1 y r. D ela y s t o r e p erfu sio n m ay b e p atie n t or h osp ita l d ep en den t. P atie n t- d ep en den t dela y s i n volv e f a ilu re t o re co gniz e a n d a p pre cia te t h e i m porta n ce o f c ard ia c s y m pto m s a n d d ela y s in a ctiv atin g t h e e m erg en cy re sp onse s y ste m ( 9 11). T ypic al p atie n t- re la te d dela y s a re 2 t o 3 h . H osp ita l- d ep en den t d ela y s a re r e la te d t o s y ste m a n d pro cess fa ilu re s f o r t h e p ro m pt d eliv ery o f r e p erfu sio n t h era p y ( 5 1).

The o pen -a rte ry h ypoth esis i m plie s t h at e v en a fte r 1 2 t o 4 8 h h av e e la p se d fro m s y m pto m o nse t, P C I m ay s till l im it i n fa rc t siz e a n d i m pro ve s u rv iv al (5 0). A noth er t e rm u se d i n in vasiv e c a rd io lo gy i s no-r e flo w , w hic h i s an gio gra p hic ally o bse rv ed s lo w f lo w i n t h e i n fa rc t- re la te d c o ro nary a rte ry afte r p rim ary P C I a s a r e su lt o f s w olle n en doth elia l c ells a n d s u bse q uen t re d b lo od c ell p lu ggin g o f t h e m ic ro cir c u la tio n ( 5 2a).

Pra ctic a l A pplic a tio n 1 3.1 461 Com plic a tio n s o f A cu te M yoca rd ia l I n fa rctio n Arrh yth m ia Sev era l t y pes o f s u pra v en tr ic u la r a rrh yth m ia s a re c o m mon a fte r myocard ia l i n fa rc tio n.

Sin us b ra d ycard ia d ue t o e x cessiv e v ag al t o ne o r i s c h em ia o f th e s in oatr ia l n ode Sin us t a ch ycard ia r e la te d t o p ain , f e ar, h eart f a ilu re , o r ex cessiv e s y m path etic n erv ous s y ste m a ctiv atio n Pre m atu re a tr ia l c o ntr a ctio ns— pro vid e n o p ro gnostic in fo rm atio n Atr ia l f ib rilla tio n— obse rv ed i n u p t o 2 0% o f p atie n ts , u su ally tr a n sie n t, m ore f re q uen t i n o ld er p atie n ts , a sso cia te d w ith in cre ase d m orta lity Ven tr ic u la r a rrh yth m ia s a re a ls o c o m mon a fte r m yocard ia l in fa rc tio n.

Ven tr ic u la r f ib rilla tio n o ccu rs i n a p pro xim ate ly 5 % o f hosp ita liz ed p atie n ts . β -b lo ck ers a re e ffe ctiv e i n d ecre asin g th e i n cid en ce of t h is a rrh yth m ia i n t h e p eri- in fa rc t p erio d.

Ven tr ic u la r t a ch ycard ia i s o bse rv ed i n 1 0% t o 4 0% o f hosp ita liz ed p atie n ts ; i t i s u su ally t r a n sie n t a n d b en ig n i n t h e early postin fa rc t p erio d.

Accele ra te d i d io ven tr ic u la r r h yth m i s a ls o o bse rv ed i n 1 0% t o 40% o f h osp ita liz ed p atie n ts . I t i s n ot a sso cia te d w ith in cre ase d morta lity .

Pre m atu re v en tr ic u la r c o ntr a ctio ns a re v ery c o m mon d urin g th e p eri- in fa rc t p erio d; t h ere i s n o c le ar r e la tio nsh ip t o t h e r is k of v en tr ic u la r t a ch ycard ia o r v en tr ic u la r f ib rilla tio n.

Asy sto le o r e le ctr o m ech an ic al d is so cia tio n i s r a re , b ut i t porte n ds a n e x tr e m ely p oor p ro gnosis .

Con ductio n D is tu rb an ces Fir s t- d eg re e A V b lo ck o ccu rs i n 5 % t o 1 0% o f h osp ita liz ed patie n ts .

Type I s e co nd-d eg re e A V b lo ck ( W en ck eb ach ) o ccu rs i n 1 0% of h osp ita liz ed p atie n ts .

Type I I s e co nd-d eg re e A V b lo ck i s r a re a n d u su ally r e q uir e s 462 pacem ak er i m pla n ta tio n.

Thir d -d eg re e A V b lo ck r e q uir e s a t l e ast t e m pora ry p acin g; i t may r e so lv e s p onta n eo usly i n i n fe rio r w all M I.

Bundle B ra n ch B lo ck ( B BB) BBB o ccu rs i n a p pro xim ate ly 1 5% o f h osp ita liz ed p atie n ts ; r ig ht bundle b ra n ch b lo ck i s m ore c o m mon t h an l e ft b undle b ra n ch blo ck ( L B BB). L B BB i s a sso cia te d w ith a n i n cre ase d r is k o f t h ir d – deg re e h eart b lo ck a n d i n cre ase d m orta lity .

Card io gen ic S hock Card io gen ic s h ock i s t h e r e su lt o f i n ad eq uate c ard ia c o utp ut w ith sig ns o f p ers is te n t h ypote n sio n ( s y sto lic b lo od p re ssu re <80 m mHg fo r m ore t h an 3 0 m in ) a n d a c ard ia c i n dex < 2.0 L · m in −1 · m −2 (n orm al i s a p pro xim ate ly 3 .0 L · m in −1 · m −2 ) i n t h e p re se n ce o f ad eq uate i n tr a v asc u la r v olu m e. I t i s u su ally t h e r e su lt o f a l a rg e myocard ia l i n fa rc tio n. T re atm en t o ptio ns in clu de d ir e ct m onito rin g of p ulm onary c ap illa ry w ed ge p re ssu re w ith a S w an -G an z c ath ete r to d ete rm in e t h e e ffe cts o f p ositiv e in otr o pic a g en ts s u ch a s dobuta m in e, i n se rtio n o f a n i n tr a -a o rtic c o unte rp uls a tio n b allo on pum p t o m ain ta in b lo od p re ssu re , an d p ro m pt p erc u ta n eo us co ro n ary r ev asc u la riz a tio n . M orta lity i s h ig h w ith t h is c o nditio n.

In fa rct E xte n sio n a n d E xp an sio n In fa rc t e x te n sio n i s r e cu rre n t n ecro sis o ccu rrin g 2 t o 1 0 d a fte r myocard ia l i n fa rc tio n i n a n a re a r e m ote f ro m t h e o rig in al in fa rc tio n. I n fa rc t e x pan sio n i s t h in nin g a n d d ila ta tio n o f t h e in fa rc te d m yocard iu m w ith out n ew n ecro sis . I t o ccu rs m ost co m monly w ith a n te rio r w all m yocard ia l i n fa rc tio ns a n d m ay re su lt i n a n eu ry sm f o rm atio n, c o ngestiv e h eart f a ilu re , a n d s e rio us ven tr ic u la r a rrh yth m ia s.

Myoca rd ia l R uptu re Ruptu re o f t h e v en tr ic u la r f re e w all p re se n ts c ata str o phic ally w ith eith er s u dden d eath d ue t o ele ctr o m ech an ic a l d is so cia tio n (p uls e le ss e le ctr ic a l a ctiv it y ) o r ca rd ia c t a m pon ad e w ith card io gen ic s h ock . F ortu nate ly i t i s r a re a n d o ccu rs m ost co m monly w ith in 4 d o f t h e m yocard ia l i n fa rc tio n. L eft v en tr ic u la r ru ptu re i s m uch m ore c o m mon t h an r ig ht v en tr ic u la r r u ptu re .

463 Pre d is p osin g f a cto rs i n clu de a d van ced a g e a n d f e m ale s e x . T he only a v aila b le t r e atm en t i s e m erg en cy s u rg ery .

New M it r a l V alv e R eg u rg it a tio n Mitr a l v alv e r e g urg ita tio n i s m ost o fte n a r e su lt o f p ap illa ry m usc le or c h ord ae r u ptu re r e su ltin g f ro m t h e i n fa rc tio n. I t may a ls o o ccu r becau se o f l e ft v en tr ic u la r d ila ta tio n d ue t o h eart f a ilu re . I t ty pic ally o ccu rs d urin g t h e f ir s t f e w d ay s afte r i n fa rc tio n a n d pre se n ts a b ru ptly w ith h ypote n sio n a n d r ig ht v en tr ic u la r f a ilu re .

Tre atm en t i s p ro m pt s u rg ic al i n te rv en tio n, with r e p air o r re p la cem en t o f t h e m itr a l v alv e.

Peric a rd ia l E ffu sio n a n d P eric a rd it is Peric ard ia l e ffu sio n i s f lu id a ccu m ula tio n i n t h e p eric ard ia l s p ace.

In t h e s e ttin g o f a cu te m yocard ia l i n fa rc tio n, i t i s asso cia te d w ith peric ard itis a n d o ccu rs i n a p pro xim ate ly 1 0% o f h osp ita liz ed patie n ts . T he u su al t r e atm en t i s h ig h-d ose a sp ir in .

Postin fa rctio n S yn dro m e Als o k now n a s D re ssle r’s s y ndro m e, p ostin fa rc tio n s y ndro m e i s ple u ritic o r p eric ard ia l c h est p ain a sso cia te d w ith a f ric tio n ru b heard o n a u sc u lta tio n o f t h e h eart. A f o rm o f p eric ard itis , i t u su ally occu rs s e v era l w eek s a fte r m yocard ia l i n fa rc tio n an d i s t r e ate d with h ig h-d ose a sp ir in .

Left V en tr ic u la r M ura l T hro m bus Fif ty p erc en t o f p atie n ts w ith a n te rio r w all m yocard ia l i n fa rc tio n will d ev elo p a b lo od c lo t o n t h e e n docard ia l s u rfa ce o f th e l e ft ven tr ic le . A ntic o ag ula tio n w ith w arfa rin f o r a p erio d o f t im e i s t h e usu al t r e atm en t.

(5 2a, 5 2b) Rig h t V en tr ic u la r M yoca rd ia l I n fa rctio n Most c o m monly a sso cia te d w ith i n fe rio r w all m yocard ia l i n fa rc tio n, affe ctin g 3 0% o f t h ese p atie n ts , R V i n fa rc tio n i s t h e r e su lt of o cclu sio n o f th e p ro xim al r ig ht c o ro nary a rte ry ( 5 3). P atie n ts w ith R V i n fa rc tio n 464 pre se n t w ith h ypote n sio n a n d s ig ns o f rig ht h eart f a ilu re . I t i s a sso cia te d with h ig h-d eg re e A V b lo ck a n d i n cre ase d i n -h osp ita l m orb id ity a n d morta lity .

Thera p y c o nsis ts o f p ro m pt r e p erfu sio n o f t h e r ig ht c o ro nary a rte ry a n d main te n an ce o f a d eq uate R V f u nctio n. F or p atie n ts who s u rv iv e t h e p erio d of h osp ita liz atio n, t h e R V d ysfu nctio n r e so lv es a n d t h ere i s n o a d ditio nal lo ng-te rm i n cre ase i n m orta lity co m pare d w ith p atie n ts w ith i n fe rio r w all myocard ia l i n fa rc tio n w ith out R V i n volv em en t.

Facto rs A sso cia te d W it h P oor P ro gn osis The f o llo w in g c h ara cte ris tic s ( o ne o r m ore ) a re a sso cia te d w ith a poor p ro gnosis ( 5 4a, 5 4b):

1 .

Left v en tr ic u la r e je ctio n f ra ctio n ≤ 35% ( h eart f a ilu re w ith re d uced e je ctio n f ra ctio n) o r c h ro nic h eart f a ilu re d ue prim arily to d ia sto lic d ysfu nctio n ( h eart f a ilu re w ith p re se rv ed eje ctio n f ra ctio n) 2 .

Extr e m ely p oor e x erc is e c ap acity , < 5 M ETs, a sse sse d w ith gra d ed e x erc is e t e stin g 3 .

Evid en ce o f e x te n siv e, s e v ere m yocard ia l i s c h em ia d urin g ex erc is e o r p harm aco lo gic s tr e ss t e stin g 4 .

Hav in g s u rv iv ed p rim ary ( n ot i n t h e s e ttin g o f a n a cu te myocard ia l i n fa rc tio n) s u dden c ard ia c d eath w ith out t r e atm en t with an i m pla n ta b le c ard io verte r-d efib rilla to r 5 .

Sev ere n onre v asc u la riz ed c o ro nary a rte ry d is e ase ( le ft m ain , se v ere p ro xim al t h re e-v esse l d is e ase ) 6 .

Com plic atio ns s u ch a s r e n al f a ilu re , s tr o ke Med ic a tio n s f o r O utp atie n ts A fte r M yoca rd ia l In fa rctio n Tab le 1 3.1 p ro vid es a s u m mary o f c o m mon m ed ic atio ns p re sc rib ed f o r patie n ts a fte r m yocard ia l i n fa rc tio n. S ev era l c la sse s o f d ru gs a re asso cia te d with i m pro ved s u rv iv al, s u ch a s a sp ir in , β -b lo ck ers , s ta tin s, a n d 465 an gio te n sin -c o nvertin g e n zy m e i n hib ito rs o r a n gio te n sin re cep to r b lo ck ers an d a ld oste ro ne a n ta g onis ts ( fo r p atie n ts w ith d ep re sse d l e ft v en tr ic u la r eje ctio n f ra ctio n o r a n te rio r wall m yocard ia l i n fa rc tio n) ( 4 9).

466 S tr ess T estin g A fte r A cu te M yoca rd ia l I n fa rctio n E xerc is e t e stin g i s h elp fu l a fte r m yocard ia l i n fa rc tio n f o r t h e f o llo w in g r e aso ns ( 5 5):

To e v alu ate s y m pto m s a n d p ote n tia l m yocard ia l i s c h em ia To d ete rm in e t h e n eed f o r c o ro nary a n gio gra p hy i n p atie n ts t r e ate d in itia lly w ith a n onin vasiv e s tr a te g y To d ete rm in e t h e e ffe ctiv en ess o f m ed ic al t h era p y To a sse ss f u tu re r is k a n d p ro gnosis To o bje ctiv ely d ete rm in e e x erc is e c ap acity ( th is i n fo rm atio n i s u se d fo r e x erc is e p re sc rip tio n, e n tr y i n to a n o utp atie n t c ard ia c re h ab ilita tio n p ro gra m , a n d r e tu rn t o w ork a n d o th er a ctiv itie s) S ee t h e C ontr a in dic atio ns s e ctio n o f c h ap te r 5 f o r a b so lu te c o ntr a in dic atio ns t o e x erc is e t e stin g ( 5 5, 5 6). E xerc is e t e st fa cto rs a sso cia te d w ith a n i n cre ase d r is k o f a r e cu rre n t c ard ia c e v en t a n d p oor p ro gnosis i n clu de t h e f o llo w in g ( 5 5, 5 6):

In ab ility t o e x erc is e Substa n tia l e x erc is e -in duced m yocard ia l i s c h em ia Exerc is e c ap acity < 5 M ETs Failu re o f s y sto lic b lo od p re ssu re t o i n cre ase a t l e ast 1 0 m mHg T ab le 1 3.2 p ro vid es a n o verv ie w o f s tr e ss t e stin g a fte r m yocard ia l i n fa rc tio n. T he t im in g o f t h e p erfo rm an ce o f a p ostm yocard ia l i n fa rc tio n g ra d ed e x erc is e t e st v arie s, d ep en din g o n t h e c lin ic al s itu atio n a n d t h e 467 pre fe re n ces o f t h e t r e atin g c ard io lo gis t. F or p atie n ts tr e ate d m ed ic ally , a pre d is c h arg e o r e arly p ostd is c h arg e e x erc is e t e st m ay b e p erfo rm ed t o dete rm in e t h e n eed f o r c o ro nary an gio gra p hy ( 5 5, 5 6). G en era lly , i f t e stin g occu rs b efo re 7 d p ostin fa rc tio n, a s u bm ax im al p ro to co l i s s e le cte d , alth ough so m e s tu die s h av e e v alu ate d s y m pto m -lim ite d p ro to co ls a s e arly as 4 d a fte r i n fa rc tio n. S ym pto m -lim ite d t e sts a re g en era lly perfo rm ed 7 o r more d ay s a fte r i n fa rc tio n. T hese t e sts m ay b e p erfo rm ed a t 1 4 t o 2 1 d o r 6 or m ore w eek s a fte r t h e e v en t, dep en din g o n t h e p ra ctic e p atte rn s o f t h e in div id ual c ard io lo gis ts . E xerc is e t e stin g a fte r m yocard ia l i n fa rc tio n i s s a fe if th e p re v io usly m en tio ned c o ntr a in dic atio ns a re n ot p re se n t. I d eally , a sy m pto m -lim ite d g ra d ed e x erc is e t e st s h ould b e p erfo rm ed befo re s ta rtin g outp atie n t c ard ia c r e h ab ilita tio n, a lth ough l o cal p ra ctic e p atte rn s m ay pre clu de t h is .

468 A sse ssm en t o f e x erc is e c ap acity a n d t h e p re se n ce a n d e x te n t o f m yocard ia l i s c h em ia m ay b e a cco m plis h ed u sin g s e v era l d if fe re n t te ch niq ues ( 5 5, 5 6):

Sta n dard e x erc is e e le ctr o card io gra m , w ith o r w ith out e x pir e d a ir an aly sis ( c ard io pulm onary e x erc is e t e stin g) Nucle ar i m ag in g m odalitie s t o m easu re m yocard ia l p erfu sio n Ech ocard io gra h ic i m ag in g o f v en tr ic u la r s y sto lic f u nctio n a n d re g io nal w all m otio n I n a ll t e stin g m odalitie s, t h e c lin ic al i n te rp re ta tio n o f t h e t e st r e su lt r e q uir e s i n te g ra tio n o f a ll t h e a v aila b le c lin ic al data . T hese t e sts a re n ot i n fa llib le i n d ete ctin g t h e p re se n ce o r a b se n ce o f m yocard ia l i s c h em ia . A n e x celle n t d is c u ssio n of t e st i n te rp re ta tio n i s p ro vid ed b y E lle sta d a n d c o lle ag ues ( 5 7).

S ta n dard e x erc is e e le ctr o card io gra p hy, w ith S T -s e g m en t d ep re ssio n ( o r l e ss c o m monly , S T -s e g m en t e le v atio n) o f > 1 m m a t 0 .0 8 s a fte r t h e J p oin t r e q uir e d f o r t h e d ia g nosis o f i s c h em ia , p ro vid es a s e n sitiv ity o f a p pro xim ate ly 6 5% t o 7 0% ( 5 5). O th er fa cto rs , s u ch a s t h e t im e o f o nse t o f S T d ep re ssio n ( e arly i n e x erc is e v ers u s n ear-m ax im al e x ertio n), t h e m ax im al a m ount o f ST -s e g m en t c h an ge, a n d t h e p re se n ce o f t y pic al a n gin a, i n cre ase t h e a ccu ra cy o f t h e a sse ssm en t o f i s c h em ia . L im ita tio ns o f t h e e x erc is e E C G a re i ts i n ab ility t o d ia g nose i s c h em ia i n t h e s e ttin g o f d ig oxin u se o r a n a b norm al r e st E C G ( p artic u la rly le ft b undle b ra n ch b lo ck ), i n ab ility t o l o caliz e t h e a re a o f t h e m yocard iu m t h at i s i s c h em ic b y S T -s e g m en t d ep re ssio n, l o w er se n sitiv ity t h an w ith i m ag in g t e ch niq ues ( s e n sitiv itie s o f 8 5% +), a n d t h e l a ck o f i n fo rm atio n p ro vid ed r e g ard in g t h e e x te n t of i s c h em ia . T he e x erc is e E C G d oes p ro vid e e v id en ce o f t h e i s c h em ic t h re sh old ( th e h eart r a te a n d s y sto lic b lo od p re ssu re th at c o rre sp onds t o t h e f ir s t e v id en ce o f i s c h em ia ), w hic h i s v alu ab le i n 469 pre sc rib in g p hysic al a ctiv ity f o r p atie n ts .

Dir e ct m easu re m en t o f o xygen u pta k e, c arb on d io xid e p ro ductio n, m in ute ven tila tio n, a n d a sso cia te d v aria b le s d urin g g ra d ed ex erc is e (c ard io pulm onary e x erc is e t e stin g) i s p artic u la rly u se fu l i n d ete rm in in g pro gnosis i n p atie n ts w ith c h ro nic h eart fa ilu re ( 5 8). T he t e ch niq ue i s a ls o help fu l i n d ete rm in in g t h e c au se o f u nex pla in ed d ysp nea w ith e x ertio n. I n ad ditio n, t h e dir e ct m easu re m en t o f m ax im al o xygen u pta k e i s m uch m ore accu ra te i n d ete rm in in g a ero bic e x erc is e c ap acity t h an i s e stim atin g ex erc is e c ap acity b ase d o n a ch ie v ed w ork lo ad .

Myocard ia l p erfu sio n i m ag in g u sin g r a d io is o to pes ( te ch netiu m s e sta m ib i or t e ch netiu m t e tr o fo sm in ) i s b ase d o n t h e p re m is e th at m yocard ia l u pta k e of t h ese s u bsta n ces i s p ro portio nal t o m yocard ia l b lo od f lo w ( 5 5, 5 6).

Im ag es a re o bta in ed a t r e st an d a fte r e x erc is e w ith a s in gle -p hoto n em is sio n c o m pute d t o m ogra p hy c am era s y ste m . R ev ers ib le d efe cts ( b ette r perfu sio n a t re st t h an w ith e x erc is e ) r e p re se n t i s c h em ia . F ix ed d efe cts (p re se n t a t r e st a n d w ith e x erc is e ) r e p re se n t i n fa rc t s c ar o r, le ss c o m monly , stu nned o r h ib ern atin g m yocard iu m . T he i m ag es p ro vid e q uan tif ic atio n o f in fa rc t s iz e. I n e x erc is e e ch ocard io gra p hy, quan tita tiv e e ch o i m ag es o f LV EF a n d e n d-s y sto lic v olu m e, a s w ell a s s u bje ctiv e e ch o i m ag es o f re g io nal w all m otio n a n d t h ic k en in g, are o bta in ed b efo re a n d i m med ia te ly afte r m ax im al e x erc is e ( 5 5, 5 6). T he n ucle ar a n d e ch ocard io gra p hic im ag in g t e ch niq ues are c ap ab le o f l o caliz in g a re as o f i s c h em ia a s w ell a s quan tif y in g t h e e x te n t a n d s e v erity o f i s c h em ia . I m ag in g t e ch niq ues do n ot pro vid e s e ria l i n fo rm atio n r e g ard in g i s c h em ia d urin g g ra d ed e x erc is e a n d th us d o n ot p ro vid e i n fo rm atio n r e g ard in g th e i s c h em ic t h re sh old .

Exerc is e f o r s ta n dard e x erc is e e le ctr o card io gra p hy ( w ith o r w ith out card io pulm onary m easu re m en ts ) a n d t h e i m ag in g t e ch niq ues is u su ally perfo rm ed o n a m oto riz ed t r e ad m ill, a lth ough c y cle e rg om etr y , a rm -o nly , or c o m bin atio n a rm a n d l e g e rg om etr y m ay be p re fe ra b le i n c erta in situ atio ns ( 5 6). E xerc is e t e stin g p ro to co ls a n d p ro ced ure s f o r p atie n ts w ith co ro nary a rte ry d is e ase are d esc rib ed i n s e v era l e x celle n t r e fe re n ces a n d will n ot b e r e v ie w ed h ere ( 5 6, 5 7).

Pharm aco lo gic s tr e ss u sin g i n tr a v en ous a d m in is tr a tio n o f a c o ro nary vaso dila to r ( a d en osin e) o r a p ositiv e c h ro notr o pic a n d in otr o pic a g en t (d obuta m in e) m ay b e u se d i n c o nju nctio n w ith i m ag in g t e ch niq ues f o r dete ctio n o f m yocard ia l i s c h em ia i n p atie n ts who c an not e x erc is e ad eq uate ly ( 5 5, 5 6). O bvio usly , p harm aco lo gic s tr e ss t e stin g p ro vid es n o 470 in fo rm atio n r e g ard in g e x erc is e cap acity a n d t h e h em odynam ic r e sp onse s to e x erc is e . A den osin e i s t h e m ost c o m mon c o ro nary v aso dila to r u se d i n co nju nctio n with n ucle ar p erfu sio n i m ag in g t e ch niq ues. A n a b norm al f lo w re se rv e ( le ss f lo w i n a p artic u la r r e g io n o f t h e m yocard iu m r e la tiv e to o th er re g io ns) i n t h e t e rrito ry s u pplie d b y a s te n otic c o ro nary a rte ry r e p re se n ts an i s c h em ic r e sp onse . D obuta m in e i s a sy nth etic s y m path om im etic t h at in cre ase s b oth m yocard ia l c o ntr a ctility a n d h eart r a te , t h us e le v atin g myocard ia l o xygen r e q uir e m en t in a m an ner a n alo gous t o e x erc is e . I t i s most c o m monly u se d i n c o nju nctio n w ith e ch ocard io gra p hic a sse ssm en t o f ven tr ic u la r fu nctio n a n d p ote n tia l i s c h em ia . I f a t t h e m ax im um d ose o f dobuta m in e t h e h eart r a te i s b elo w 8 5% o f a g e-p re d ic te d l e v el, atr o pin e may b e g iv en t o f u rth er i n cre ase t h e h eart r a te .

Exercis e T ra in in g: I n patie n t C ard ia c Reh ab ilit a tio n Len gth s o f h osp ita l s ta y a fte r a cu te m yocard ia l i n fa rc tio n h av e d eclin ed over t h e p ast t w o d ecad es. C urre n tly , p atie n ts a re hosp ita liz ed f o r n o m ore th an 2 o r 3 d u nle ss c o m plic atio ns a ris e . T he v ast m ajo rity o f p atie n ts w ith unsta b le a n gin a o r a cu te myocard ia l i n fa rc tio n a re t r e ate d i n vasiv ely w ith PC I, a s n ote d p re v io usly . T he d eta ile d , e x pan siv e i n patie n t r e h ab ilita tio n pro to co ls d esc rib ed b y t h is a u th or i n 1 987 s e em a rc h aic c o m pare d w ith to day ’s p ra ctic e p atte rn s ( 5 9). T here i s l ittle o pportu nity fo r f o rm al ex erc is e t r a in in g d urin g h osp ita liz atio n.

To m in im iz e t h e d ele te rio us e ffe cts o f b ed r e st, p atie n ts a re m obiliz ed a s so on a s t h ey a re s ta b le . E xposu re t o t h e n orm al str e ss o f g ra v ity i s em phasiz ed i n t h is s ta g e o f r e h ab ilita tio n t o p re v en t o rth osta tic i n to le ra n ce (6 0). P atie n ts s it, s ta n d, perfo rm a ctiv e r a n ge o f m otio n e x erc is e s f o r t h e majo r j o in ts , a n d w alk s h ort d is ta n ces a s s o on a s p ossib le t o p re v en t fu rth er deco nditio nin g. V ario us a llie d h ealth p ro fe ssio nals m ay b e in volv ed i n i n patie n t c ard ia c r e h ab ilita tio n, s u ch a s r e g is te re d nurs e s, physic al t h era p is ts , o ccu patio nal t h era p is ts , a n d e x erc is e p hysio lo gis ts .

Patie n ts w ith n eu ro m usc u la r d is e ase s o r oth er c o nditio ns t h at l im it t h eir ab ility t o a m bula te b en efit f ro m f o rm al p hysic al t h era p y t r e atm en ts . A fte r hosp ita l d is m is sa l, fra il e ld erly a n d o th er d eb ilita te d p atie n ts m ay b e re fe rre d t o o utp atie n t p osta cu te o r t r a n sitio nal c are f a cilitie s f o r v ario us tim e p erio ds b efo re r e tu rn in g h om e ( 6 1a).

471 A c ritic al a sp ect o f i n patie n t c ard ia c r e h ab ilita tio n i s t h e i n tr o ductio n o f th e c o ncep ts o f se co n dary c o ro n ary p rev en tio n of a th ero sc le ro sis t o patie n ts a n d f a m ily m em bers ( 6 1a). B asic i n fo rm atio n i s p ro vid ed re g ard in g t h e i m porta n ce o f c ard io pro te ctiv e med ic atio ns, a v oid an ce o f to bacco , h eart- h ealth y e atin g p atte rn s, b lo od p re ssu re a n d b lo od l ip id goals , e x erc is e ( in clu din g an y t e m pora ry r e str ic tio ns i m pose d b y t h e co ro nary e v en t) , p ote n tia l d ep re ssio n a fte r t h e c ard ia c e v en t, a n d r e tu rn t o usu al activ itie s. P atie n ts s h ould b e r e fe rre d t o a n o utp atie n t c ard ia c re h ab ilita tio n p ro gra m i f o ne i s a v aila b le i n t h eir h om e are a. A h om e ex erc is e p re sc rip tio n p ro vid in g g uid an ce a s t o r e co m men ded e x erc is e ty pes, i n te n sity , d ura tio n, f re q uen cy , a n d pro gre ssio n f o r t h e f ir s t f e w week s a fte r h osp ita l d is m is sa l s h ould b e g iv en t o t h e p atie n t. T ypic ally , t h e pre sc rip tio n r e co m men ds walk in g o r s ta tio nary c y clin g a t a c o m fo rta b le in te n sity , b eg in nin g w ith 1 0 t o 2 0 m in o nce o r t w ic e d aily , p ro gre ssin g t o 30 t o 4 5 m in d aily .

Exercis e T ra in in g: E arly O utp atie n t Card ia c R eh ab ilit a tio n Outp atie n t c ard ia c r e h ab ilita tio n i s r e co m men ded f o r p atie n ts w ith co ro nary h eart d is e ase b y t h e A m eric an H eart A sso cia tio n, th e A m eric an Colle g e o f C ard io lo gy, a n d t h e A m eric an A sso cia tio n o f C ard io pulm onary Reh ab ilita tio n a n d h as b een a w ard ed a cla ss I i n dic atio n ( th e h ig hest in dic atio n; t h e t r e atm en t i s e ffe ctiv e a n d s h ould b e p ro vid ed ) ( 6 1b). T his phase o f r e h ab ilita tio n can b eg in s o on a fte r h osp ita l d is m is sa l, o fte n w ith in 1 o r 2 w k ( 5 6, 6 1a). D urin g t h e i n te rv al b etw een h osp ita l d is m is sa l an d beg in nin g o utp atie n t r e h ab ilita tio n, p atie n ts a re e n co ura g ed t o e x erc is e in dep en den tly , u sin g t h eir h om e e x erc is e p re sc rip tio n pro vid ed i n t h e hosp ita l. A v arie ty o f h ealth c are p ro fe ssio nals a re t y pic ally i n volv ed i n early o utp atie n t c ard ia c r e h ab ilita tio n, su ch a s p hysic ia n s o r m id le v el pro vid ers , e x erc is e p hysio lo gis ts , r e g is te re d n urs e s, r e g is te re d d ie titia n s, physic al o r o ccu patio nal th era p is ts , s o cia l w ork ers , a n d p sy ch olo gis ts .

The i n itia l a sse ssm en t, p erfo rm ed b y c ard ia c r e h ab ilita tio n p ro fe ssio nals , may i n volv e t h e f o llo w in g ( 5 6, 6 1a):

1 .

Rev ie w o f t h e m ed ic al r e co rd s, w ith e m phasis o n t h e r e cen t c o ro nary ev en t 2 .

Physic al e x am in atio n, p erfo rm ed b y a q ualif ie d m ed ic al p ro fe ssio nal, 472 usu ally a n M D, m id le v el p ro vid er, o r r e g is te re d n urs e ; id eally s h ould in clu de a r e v ie w o f t h e n eu ro m usc u la r s y ste m s i n t e rm s o f p ote n tia l lim ita tio ns t o e x erc is e 3 .

Gra d ed e x erc is e t e st, w hic h i d eally s h ould b e p erfo rm ed t o a ssis t w ith ex erc is e p re sc rip tio n a n d w ith r is k a n d p ro gnosis a sse ssm en t; may n ot be a v aila b le i n a t im ely f a sh io n d ep en din g o n l o cal p ra ctic e p atte rn s, so a 6 m in w alk m ay b e p erfo rm ed a s a c h eck of s u bm ax im al e x erc is e re sp onse 4 .

Med ic atio n r e v ie w , w ith e m phasis o n c o m plia n ce, s id e e ffe cts , a n d optim al c ard io pro te ctiv e m ed ic atio n u se 5 .

Rev ie w o f s ta n dard c o ro nary r is k f a cto rs , w ith e m phasis o n a v oid an ce of t o bacco , p ro per n utr itio n h ab its , c o ntr o l o f b lo od pre ssu re a n d blo od l ip id s, b ody w eig ht o ptim iz atio n, a n d s tr e ss a n d d ep re ssio n man ag em en t 6 .

Patie n t- s e le cte d a n d p ro vid er-s e le cte d g oals t o w ork o n d urin g t h e pro gra m 7 .

Antic ip ate d r e tu rn t o w ork d ate , i f n eed ed 8 .

Expla n atio n o f t h e s h ort- te rm a n d l o ng-te rm b en efits o f e x erc is e tr a in in g, o ptim al c o ntr o l o f c o ro nary r is k f a cto rs , a n d t h e use o f card io pro te ctiv e m ed ic atio ns 9 .

Antic ip ate d r e h ab ilita tio n s c h ed ule , i n clu din g n um ber o f re h ab ilita tio n s e ssio ns p er w eek a n d n um ber o f w eek s i n t h e p ro gra m Card ia c r e h ab ilita tio n p ro gra m s a re i d eal f o r h elp in g p atie n ts a ch ie v e t h e se co ndary p re v en tio n g oals o f t a k in g a p pro pria te card io pro te ctiv e med ic atio ns; a v oid in g t o bacco ; f o llo w in g h eart- h ealth y e atin g p atte rn s; perfo rm in g r e g ula r e x erc is e a n d l if e sty le physic al a ctiv ity ; a ch ie v in g a desir a b le b ody w eig ht; o ptim ally c o ntr o llin g b lo od l ip id s, b lo od p re ssu re , an d b lo od g lu co se ; an d m ain ta in in g p sy ch oso cia l h ealth ( 6 1a). T ypic al early o utp atie n t c ard ia c r e h ab ilita tio n p ro gra m s p ro vid e u p t o 3 6 su perv is e d se ssio ns o ver 3 o r m ore m onth s. E ach p atie n t’ s c lin ic al s ta tu s i s ev alu ate d p erio dic ally ( e .g ., h eart r a te , E C G , b lo od p re ssu re , sy m pto m s, mood, m ed ic atio n c o m plia n ce a n d s id e e ffe cts ), a n d o ngoin g m ed ic al su rv eilla n ce i s p ro vid ed .

Counse lin g i s a m ajo r c o m ponen t o f p atie n t v is its t o c ard ia c r e h ab ilita tio n.

Case m an ag em en t, m ore r e cen tly r e n am ed d is e ase man ag em en t, i n volv es one o r m ore c ard ia c r e h ab ilita tio n s ta ff m em bers t a k in g r e sp onsib ility f o r overs ig ht o f a n i n div id ual patie n t’ s s e co ndary p re v en tio n p ro gra m ( 6 2, 63).

Dis e ase m an ag em en t b y c ard ia c r e h ab ilita tio n p ro fe ssio nals h as b een dem onstr a te d t o b e h ig hly e ffe ctiv e i n p ro m otin g p atie n t ad here n ce t o 473 se co ndary p re v en tio n m easu re s. M y o w n p ro gra m i n clu des d is e ase man ag em en t o ver 1 o r m ore y ears o f f o llo w -u p a fte r co m ple tio n o f t h e sta n dard 3 6 c ard ia c r e h ab ilita tio n s e ssio ns c o vere d b y i n su ra n ce ( 6 4).

A t e ch niq ue u se d b y h ealth c are p ro vid ers t o h elp p atie n ts m ak e h ealth y ch an ges i n b eh av io r i s m otiv atio nal i n te rv ie w in g ( 6 5).

The t e ch niq ue i s n ot dif fic u lt t o l e arn a n d i n volv es d ev elo pin g a p artn ers h ip w ith t h e p atie n t th at h onors t h e i n div id ual’ s pers p ectiv es a n d t a le n ts . T here a re f o ur gen era l p rin cip le s o f m otiv atio nal i n te rv ie w in g:

1 .

Expre ss e m path y.

2 .

Dev elo p d is c re p an cy : T he p atie n t n eed s t o p erc eiv e a d is c re p an cy betw een p re se n t b eh av io r a n d i m porta n t g oals .

3 .

Roll w ith r e sis ta n ce: A void a rg uin g f o r c h an ge.

4 .

Support s e lf -e ffic acy : A n i m porta n t m otiv ato r f o r c h an ge i s t h e patie n t’ s b elie f i n t h e p ossib ility o f c h an ge.

Exercis e P resc rip tio n The p re sc rip tio n o f e x erc is e a fte r a n a cu te c o ro nary s y ndro m e s h ould b e in div id ualiz ed , b ase d o n f a cto rs s u ch a s t h e f o llo w in g (5 4a, 5 6):

Exerc is e c ap acity Is c h em ic o r a n gin al t h re sh old o r b oth Cognitiv e a n d p sy ch olo gic al i m pair m en ts Vocatio nal a n d a v ocatio nal r e q uir e m en ts Musc u lo sk ele ta l l im ita tio ns Obesity Prio r p hysic al a ctiv ity h is to ry Patie n t g oals Tab le 1 3.3 g iv es a n o verv ie w o f t h e c o m ponen ts o f a n e x erc is e pre sc rip tio n f o r a c o ro nary p atie n t.

474 I n a n i d eal w orld , p atie n ts w ith a r e cen t a cu te c o ro nary s y ndro m e w ould e x erc is e w ith m ed ic al s u perv is io n i n a n o utp atie n t card ia c r e h ab ilita tio n p ro gra m f o r a t l e ast s e v era l w eek s. U nfo rtu nate ly , s o m e g eo gra p hic al a re as d o n ot h av e s u ffic ie n t p ro gra m s to e n su re e asy a ccessib ility f o r a ll p atie n ts . P atie n ts m ay p re se n t m ultip le b arrie rs f o r a tte n dan ce a t t h e s ta n dard t h re e su perv is e d e x erc is e s e ssio ns p er w eek o f a t y pic al c ard ia c r e h ab ilita tio n p ro gra m , s u ch a s r e tu rn t o f u ll- tim e e m plo ym en t with in a f e w d ay s o f h osp ita l d is m is sa l, d if fic u lty s e cu rin g r e lia b le t r a n sp orta tio n t o a n d f ro m t h e r e h ab ilita tio n c en te r, an d e x cessiv e o ut- o f-p ock et c o sts ( e .g ., c o in su ra n ce, p ark in g f e es). H ig h-ris k a n d d eb ilita te d p atie n ts a re b est s e rv ed w ith fre q uen t s u perv is e d r e h ab ilita tio n s e ssio ns. N onhig h-ris k p atie n ts m ay b en efit f ro m f le x ib ility i n p ro gra m d esig n. M ed ic are will r e im burs e f o r u p t o 3 6 r e h ab ilita tio n s e ssio ns o ver a 3 6 w k p erio d, a s w ill m ost p riv ate i n su ra n ce p ro vid ers . P atie n ts may a tte n d o ne t o t h re e s e ssio ns w eek ly , w ith a d ditio nal i n dep en den t e x erc is e a s p re sc rib ed b y c ard ia c r e h ab ilita tio n s ta ff.

Som e p atie n ts w ill n ot b e a b le t o a tte n d a f o rm al p ro gra m a n d w ill r e q uir e a n e n tir e ly i n dep en den t p ro gra m . R ecen tly p ublis h ed perfo rm an ce m easu re s f o r t h e r e fe rra l t o a n d d eliv ery o f c ard ia c r e h ab ilita tio n a n d s e co ndary p re v en tio n s e rv ic es s h ould h elp patie n ts o bta in a p pro pria te p osth osp ita l c o ro nary d is e ase p re v en tio n c are ( 7 4).

475 Afte r c o m ple tio n o f a s ta n dard c ard ia c r e h ab ilita tio n p ro gra m o f 3 6 se ssio ns, m ost p atie n ts w ill n eed t o c o ntin ue e x erc is e tr a in in g in dep en den tly ( o uts id e o f a f o rm al p ro gra m ). C om plia n ce w ith in dep en den t e x erc is e m ay b e i m pro ved w ith f o llo w -u p vis its w ith h ealth care p ro vid ers . I n m y o w n p ro gra m , p atie n ts a re e n co ura g ed t o r e tu rn f o r re g ula r f o llo w -u p w ith t h e c ard ia c re h ab ilita tio n s ta ff o n a c o ntin uin g b asis (6 4). S om e c ard ia c r e h ab ilita tio n p ro gra m s h av e s u ffic ie n t c ap acity t o offe r p atie n ts a m ain te n an ce e x erc is e p ro gra m ( u su ally p atie n t f u nded ) f o r a p erio d o f m onth s u p t o l if e -lo ng p artic ip atio n. S om e p ro gra m s in clu de sp ouse s t o a id i n r e te n tio n o f p atie n ts i n m ain te n an ce p ro gra m s.

Freq uen cy Exerc is e s e ssio ns s h ould o ccu r a t l e ast 3 d /w k a n d i d eally o n m ost d ay s o f th e w eek ( i.e ., 4 -7 d/w k). W ith t h e e x cep tio n o f ex tr e m ely h ig h-ris k patie n ts , o ne o r m ore s e ssio ns p er w eek s h ould b e p erfo rm ed in dep en den tly , o uts id e o f t h e s u perv is e d e n vir o nm en t of a c ard ia c re h ab ilita tio n p ro gra m . P atie n ts w ith v ery l im ite d e n dura n ce m ay p erfo rm multip le s h ort- d ura tio n ( 1 -1 0 m in ) s e ssio ns daily .

In te n sit y Exerc is e i n te n sity m ay b e p re sc rib ed u sin g o ne o r m ore o f t h e f o llo w in g:

Ratin g o f p erc eiv ed e x ertio n ( R PE ) o f 1 1 t o 1 6 o n a s c ale o f 6 t o 2 0 40% t o 8 0% o f e x erc is e c ap acity u sin g t h e h eart r a te r e se rv e m eth od, or t h e p erc en t p eak o xygen u pta k e r e se rv e t e ch niq ue i f max im al ex erc is e t e st d ata a re a v aila b le When e x erc is e t e st o r p harm aco lo gic s tr e ss d ata a re n ot a v aila b le , upper-lim it h eart r a te o f r e stin g h eart r a te + 2 0 b eats /m in an d R PE o f 11 t o 1 4, g ra d ually t itr a tin g t h e h eart r a te t o h ig her l e v els a cco rd in g t o RPE , s ig ns a n d s y m pto m s, a n d n orm al physio lo gic r e sp onse s Exerc is e i n te n sity s h ould b e k ep t b elo w t h e i s c h em ic t h re sh old , i f o ne h as been d em onstr a te d t o e x is t, u nle ss t h e r e sp onsib le physic ia n r e co m men ds oth erw is e i n p atie n ts w ith i s c h em ia , e v en a t v ery l o w e x erc is e i n te n sitie s.

Patie n ts s h ould t a k e t h eir m ed ic atio ns o n s c h ed ule f o r p erfo rm an ce o f ex erc is e t r a in in g s e ssio ns. C han ges i n t h e d ose s o f β-b lo ck ers o r o th er dru gs t h at a ffe ct t h e c h ro notr o pic r e sp onse t o e x erc is e m ay o ccu r. I n t h ese 476 case s, i t i s u nlik ely t h at a n ew e x erc is e t e st w ill b e p erfo rm ed s o le ly f o r t h e purp ose o f d ete rm in in g a n ew t a rg et h eart r a te . U sin g R PE a n d s ig ns a n d sy m pto m s, a s w ell a s d ete rm in in g t h e n ew t a rg et h eart r a te a t p re v io usly perfo rm ed w ork i n te n sitie s, i s r e co m men ded . I t i s co m mon f o r c ard ia c re h ab ilita tio n p ro fe ssio nals t o d ia g nose h ypote n sio n, e ith er o rth osta tic , a t re st, d urin g e x erc is e , o r afte r e x erc is e , d ue t o e x cessiv e m ed ic atio n d osa g e.

Dura tio n Patie n ts s h ould p erfo rm w arm -u p a n d c o ol- d ow n a ctiv itie s, i n clu din g sta tic s tr e tc h in g t o i m pro ve r a n ge o f m otio n a n d l o w -in te n sity aero bic ex erc is e , f o r 5 t o 1 0 m in b efo re a n d a fte r t h e c o nditio nin g p hase o f ex erc is e . T he g oal d ura tio n f o r c o nditio nin g aero bic e x erc is e i s 2 0 t o 6 0 min p er s e ssio n. P atie n ts m ay b eg in w ith a n e asily t o le ra b le d ura tio n o f 5 to 1 0+ m in , w ith a gra d ual i n cre ase o f 1 t o 5 m in p er s e ssio n o r 1 0% t o 20% p er w eek , a s t o le ra te d . T he p ro gre ssio n i n d ura tio n s h ould b e in div id ualiz ed fo r e ach p atie n t; s o m e p atie n ts m ay b e a b le t o p ro gre ss much m ore r a p id ly t h an o th ers b ase d o n f itn ess, e x erc is e h ab its im med ia te ly prio r t o t h e c o ro nary e v en t, s y m pto m s, a n d m usc u lo sk ele ta l lim ita tio ns. F ra il a n d o th erw is e e x tr e m ely d eco nditio ned p atie n ts may re q uir e i n te rm itte n t e x erc is e , a lte rn atin g s h ort p erio ds o f e x erc is e w ith r e st bre ak s, a lth ough m ost p atie n ts c an p erfo rm co ntin uous e x erc is e .

Typ e Aero bic f o rm s o f e x erc is e s h ould i n clu de r h yth m ic l a rg e-m usc le g ro up activ itie s. I d eally , b oth u pper a n d l o w er e x tr e m ity e x erc is e s sh ould b e in co rp ora te d i n to t h e p ro gra m , s u ch a s t h ese :

Tre ad m ill o r t r a ck f o r w alk in g ( jo ggin g o r i n clin ed w alk in g f o r m ore fit p atie n ts ) Uprig ht o r r e cu m ben t c y cle Com bin atio n u pper a n d l o w er e x tr e m ity e rg om ete r Ellip tic al Sta ir s te p per Arm e rg om ete r Row er In dep en den t e x erc is e o fte n i n clu des w alk in g o utd oors , w ith o r w ith out hills , o r w alk in g i n doors a t s h oppin g m alls o r s c h ools th at a re o pen t o t h e 477 public f o r t h is p urp ose .

Resis ta n ce T ra in in g The v ast m ajo rity o f p atie n ts w ith t r e ate d a cu te c o ro nary s y ndro m es sh ould p erfo rm s tr e n gth t r a in in g a s a c o m ponen t o f t h eir ex erc is e p ro gra m .

Patie n ts w ith s e v ere i s c h em ia o r h em odynam ic i n sta b ility s h ould b e ad eq uate ly s ta b iliz ed b efo re b eg in nin g str e n gth en in g e x erc is e s. T he purp ose s o f s tr e n gth t r a in in g f o r p atie n ts i n clu de t h e f o llo w in g ( 5 6):

To i n cre ase m usc u la r s tr e n gth a n d e n dura n ce To d ecre ase c ard ia c d em an ds o f m usc u la r w ork ( re d uce ra te – pressu re p ro d uct [ R PP] w ith l if tin g a n d c arry in g a ctiv itie s o f d aily lif e ) To i m pro ve s e lf -c o nfid en ce To m ain ta in i n dep en den ce ( e n ab le p atie n t t o p erfo rm h ouse h old a n d pers o nal c are d utie s) To p re v en t d is e ase s s u ch a s o ste o poro sis , t y pe 2 d ia b ete s, a n d o besity To s lo w t h e a g e-re la te d d eclin es i n s k ele ta l m usc le m ass a n d s tr e n gth Alth ough g uid elin es f o r s tr e n gth t r a in in g i n c ard ia c p atie n ts t r a d itio nally re co m men d w aitin g 5 w k f ro m t h e d ate o f m yocard ia l in fa rc tio n b efo re beg in nin g s tr e n gth t r a in in g, i n m y o w n p ro gra m p atie n ts b eg in s u ch tr a in in g w ith in 2 w k o f t h e e v en t. S ev era l th ousa n d p atie n ts h av e f o llo w ed th is p ra ctic e, a n d t h ere h av e b een n o c o m plic atio ns a sso cia te d w ith str e n gth t r a in in g.

Equip m en t f o r s tr e n gth t r a in in g m ay i n clu de f re e w eig hts , e la stic b an ds, weig ht m ach in es w ith p ulle y d ev ic es, s ta b ility b alls , an d w eig hte d w an ds.

Patie n t b ody w eig ht m ay a ls o b e u se d a s r e sis ta n ce f o r s e le cte d e x erc is e s.

Movem en ts s h ould b e p erfo rm ed in a s lo w , c o ntr o lle d m an ner w hile main ta in in g a r e g ula r b re ath in g p atte rn a n d a v oid in g s tr a in in g a n d musc u lo sk ele ta l p ain .

RPE r a tin gs i n itia lly s h ould r a n ge f ro m 1 1 t o 1 4 o n th e 6 t o 2 0 s c ale . I n itia l r e sis ta n ces s h ould a llo w 1 2 t o 1 5 r e p etitio ns (a p pro xim ate ly 3 0% t o 6 0% o f 1 R M ). T he r e sis ta n ce m ay b e g ra d ually in cre ase d , a n d m ost p atie n ts m ay p ro gre ss t o 8 t o 1 2 r e p etitio ns with a re sis ta n ce o f 6 0% t o 8 0% o f 1 R M , w ith o ne t o f o ur s e ts o f r e p etitio ns.

Exerc is e s s h ould b e p erfo rm ed f o r t h e m ajo r musc le g ro ups, u su ally 8 t o 10 d if fe re n t e x erc is e s. F re q uen cy s h ould b e 2 o r 3 s e ssio ns p er w eek o n nonco nse cu tiv e d ay s.

478 Aero bic I n te rv a l T ra in in g Over t h e p ast 3 5 y ears , t h ere h as b een a g ra d ual e asin g o f r e str ic tio ns re g ard in g e x erc is e t r a in in g f o r p atie n ts w ith c ard io vasc u la r dis e ase s. F or ex am ple , o utp atie n t e x erc is e t r a in in g a fte r m yocard ia l i n fa rc tio n n ow beg in s w ith in a f e w d ay s o f h osp ita l d is m is sa l (ra th er t h an s e v era l w eek s), with m ore a g gre ssiv e a ero bic e x erc is e a n d s tr e n gth t r a in in g ( fo rb id den i n th e p ast) . P atie n ts with c h ro nic h eart f a ilu re a re n ow e n co ura g ed t o ex erc is e r a th er t h an t o r e st. T he l a te st e x erc is e t a b oo t o b e l if te d i s h ig h- in te n sity in te rv al t r a in in g f o r c ard ia c p atie n ts . I n vestig ato rs h av e docu m en te d s u perio r i m pro vem en ts i n O 2 peak , m easu re s o f e n doth elia l fu nctio n, a n d l e ft v en tr ic u la r s y sto lic a n d d ia sto lic f u nctio n i n c o ro nary patie n ts w ith h ig h-in te n sity in te rv al t r a in in g ( u p t o 9 5% o f m ax im al h eart ra te f o r s h ort p erio ds o f t im e i n te rs p ers e d w ith l o w er-in te n sity e x erc is e ) co m pare d with c o nven tio nal c o ntin uous a ero bic t r a in in g ( 6 6, 6 7).

In m y o w n p ro gra m , w e h av e u se d i n te rv al t r a in in g i n s e v era l t h ousa n d card ia c p atie n ts f o r t h e p ast 9 y r a n d h av e n ot e n co unte re d sa fe ty i s su es o r patie n t r e lu cta n ce t o t r y i t. W e s ta rt w ith a p pro xim ate ly 2 w k o f s ta n dard co ntin uous a ero bic t r a in in g, i n cre asin g th e d ura tio n t o a t l e ast 2 0 m in befo re b eg in nin g i n te rv al t r a in in g. W e s ta rt w ith 3 0 s i n te rv als , t h re e t o fiv e t im es d urin g th e e x erc is e s e ssio n, i n te rs p ers e d w ith l o w er-in te n sity ex erc is e f o r 2 t o 3 m in . O ver a p erio d o f d ay s t o w eek s, t h e l e n gth of t h e hig h-in te n sity i n te rv als i s i n cre ase d t o 6 0 t o 1 20 s o r l o nger, a s t o le ra te d .

In te rv al t r a in in g o ccu rs 2 o r 3 d /w k.

Bala n ce E xerc is e s Man y p artic ip an ts i n c ard ia c r e h ab ilita tio n p ro gra m s a re o ld er t h an 6 5 y r.

With i n cre asin g a g e, t h e n eu ro m usc u la r r e fle x es in volv ed w ith pro prio cep tio n a n d b ala n ce b eco m e l e ss e ffe ctiv e. F alls a re a c o m mon cau se o f m orb id ity a n d m orta lity i n o ld er in div id uals . A b ala n ce ab norm ality w as f o und i n o ver h alf o f a c o nse cu tiv e s a m ple o f 2 84 partic ip an ts i n m y p ro gra m ( 6 8).

Wom en a n d p atie n ts o ver 6 5 y r o f a g e were m ore l ik ely t o e x hib it p oor b ala n ce. A s p art o f t h e b ase lin e asse ssm en t o f p atie n ts beg in nin g o utp atie n t c ard ia c r e h ab ilita tio n, a bala n ce a sse ssm en t u sin g s im ple t e ch niq ues s u ch a s t h e s in gle -le g s ta n d an d th e t a n dem g ait ( w alk in g h eel t o t o e i n a s tr a ig ht l in e) s h ould b e perfo rm ed . F or p atie n ts w ith p oor b ala n ce, s p ecif ic e x erc is e s may b e 479 pre sc rib ed ( 5 6).

Lif e sty le P hysic a l A ctiv ity In a d ditio n t o f o rm al e x erc is e s e ssio ns, p atie n ts s h ould b e e n co ura g ed t o gra d ually r e tu rn t o g en era l a ctiv itie s o f l if e , su ch a s w alk in g f o r tr a n sp orta tio n, h ouse h old t a sk s, s h oppin g, g ard en in g, n onse d en ta ry hobbie s, a n d s p ort a ctiv itie s ( 5 6).

Measu rin g l if e sty le a ctiv ity i s r e la tiv ely easy u sin g a p ed om ete r ( s te p s/d ay ), w ris t- w orn a ctiv ity s e n so r, o r v ario us sm artp hone ap plic atio ns. T he m ore t im e s p en t s ittin g, s u ch a s w atc h in g te le v is io n o r o n t h e c o m pute r, t h e g re ate r t h e r is k o f c ard io vasc u la r an d all- c au se m orta lity a s w ell a s n onfa ta l c ard io vasc u la r e v en ts ( 6 9, 7 0).

Gre ate r e n erg y e x pen ditu re r e su ltin g f ro m i n cre ase d lif e sty le p hysic al activ ity f a cilita te s w eig ht l o ss.

Exercis e P ro gra m min g f o r O verw eig h t C oro n ary Patie n ts The v ast m ajo rity o f c o ro nary p atie n ts w ho e n te r o utp atie n t c ard ia c re h ab ilita tio n a re e ith er o verw eig ht o r o bese . S ta n dard ex erc is e pro to co ls u se d i n m ost p ro gra m s— 30 t o 4 5 m in o f m odera te – in te n sity a ero bic e x erc is e t h re e t im es p er w eek ( a p pro xim ate ly 800 kcal/w k) f o r 3 m o— are g en era lly n ot a d eq uate t o r e su lt i n su bsta n tia l b ody f a t l o ss. I n vestig ato rs u se d a h ig h-c alo rie ex erc is e pro to co l ( a p pro xim ate ly 3 ,0 00 k cal/w k), w hic h r e q uir e d 4 5 t o 6 0 min o f w alk in g m ore t h an 4 d /w k ( 7 1). C om pare d w ith sta n dard card ia c r e h ab ilita tio n, t h e h ig h-c alo rie e x erc is e p ro to co l r e su lte d i n tw ic e t h e w eig ht l o ss ( 8 .2 k g v s. 3 .7 k g).

In m y o w n p ro gra m , w e e n co ura g e p atie n ts w ho d esir e t o l o se co nsid era b le w eig ht t o c o nsu lt w ith o ur r e g is te re d d ie titia n , gra d ually i n cre ase e x erc is e d ura tio n t o 6 0 m in f iv e o r s ix d /w k, in co rp ora te h ig h-in te n sity i n te rv al t r a in in g 2 o r 3 d /w k, an d perfo rm m odera te s tr e n gth t r a in in g u sin g f re e w eig hts a n d w eig ht mach in es 2 o r 3 d /w k. T his h ig h-v olu m e e x erc is e p ro to co l re q uir e s very m otiv ate d p atie n ts .

480 Safe ty o f E xercis e T ra in in g f o r C oro n ary P atie n ts Superv is e d e x erc is e t r a in in g h as b een d em onstr a te d t o b e s a fe f o r p atie n ts with c ard io vasc u la r d is e ase s. F ra n klin a n d c o lle ag ues re p orte d t h e a v era g e in cid en ce o f c ard ia c a rre st, n onfa ta l m yocard ia l i n fa rc tio n, a n d d eath a s one f o r e v ery 1 17,0 00, 2 20,0 00, an d 7 50,0 00 p atie n t- h ours o f partic ip atio n, r e sp ectiv ely ( 7 2). A l a rg e t r ia l o f o ver 1 ,0 00 h ig her-ris k patie n ts w ith c h ro nic heart f a ilu re ( m ore t h an h alf w ith c o ro nary d is e ase ) stu die d t h e s a fe ty o f s u perv is e d a n d i n dep en den t m odera te -in te n sity aero bic ex erc is e t r a in in g. O ver a p pro xim ate ly 3 0 m o, t h ere w ere 3 7 e v en ts asso cia te d w ith e x erc is e t h at r e su lte d i n h osp ita liz atio n.

In o ver s e v era l millio n p atie n t- h ours o f e x erc is e , o nly f iv e d eath s o ccu rre d ( 7 3). T he ben efits o f e x erc is e t r a in in g f a r o utw eig h th e r is k s f o r c o ro nary p atie n ts with out a b so lu te c o ntr a in dic atio ns t o e x erc is e .

Ben efit s o f C ard ia c R eh ab ilit a tio n a n d S eco n dary Prev en tio n P ro gra m s The f o llo w in g l is t s u m mariz es t h e i m porta n t b en efits a v aila b le t o p atie n ts with c o ro nary d is e ase w ho p artic ip ate i n c ard ia c re h ab ilita tio n ( 7 5, 7 6, 7 7, 78). A s a r e su lt o f t r a in in g, O 2 peak m ay i m pro ve 1 0% t o 2 0% o r m ore (7 5). I n g en era l, t h e m ag nitu de o f t h e r e la tiv e i m pro vem en t i s i n vers e ly pro portio nal to t h e b ase lin e e x erc is e c ap acity . T he r a te o f i m pro vem en t i s gre ate st d urin g t h e f ir s t 3 m o o f t r a in in g, b ut i n cre ase s i n aero bic c ap acity may c o ntin ue f o r 6 m o o r m ore . H ig h-in te n sity i n te rv al t r a in in g r e su lts i n gre ate r i m pro vem en ts i n O 2 peak t h an t r a d itio nal c o ntin uous i n te n sity tr a in in g ( 6 6).

Sum mary o f B en efit s o f C ard ia c R eh ab ilit a tio n P ro gra m s Im pro ved a ero bic c ap acity In cre ase i n s u bm ax im al e x erc is e e n dura n ce In cre ase i n m usc u la r s tr e n gth Red uctio n i n s y m pto m s: a n gin a p ecto ris , d ysp nea o n e x ertio n, fa tig ue, c la u dic atio n Vasc u la r r e g en era tio n v ia b one m arro w –deriv ed e n doth elia l pro gen ito r c ells Decre ase i n m yocard ia l i s c h em ia a n d p ote n tia l i n cre ase i n m yocard ia l 481 perfu sio n Im pro ved e n doth elia l f u nctio n Im pro ved l e ft v en tr ic u la r s y sto lic a n d d ia sto lic f u nctio n i n c h ro nic heart f a ilu re Pote n tia l r e ta rd atio n o f c o ro nary d is e ase p ro gre ssio n a n d a ctu al re g re ssio n o f p la q ue In co rp ora tio n o f h eart- h ealth y d ie ta ry p ra ctic es Im pro ved b lo od l ip id p ro file Im pro vem en t i n i n dic es o f o besity Decre ase i n b lo od p re ssu re Decre ase i n t o bacco u se Im pro ved g lu co se i n to le ra n ce a n d i n su lin r e sis ta n ce Decre ase i n i n fla m mato ry m ark ers ( e .g ., h ig h-s e n sitiv e C r e activ e pro te in , h sC RP) Im pro ved a u to nom ic t o ne: l e ss s y m path etic a ctiv ity , m ore para sy m path etic a ctiv ity Red uctio n i n v en tr ic u la r a rrh yth m ia s Im pro ved b lo od p la te le t f u nctio n a n d b lo od r h eo lo gy Im pro ved p sy ch oso cia l f u nctio n ( le ss d ep re ssio n, a n xie ty , so m atiz atio n, h ostility ) Rep eate d s u rv eilla n ce o f b lo od p re ssu re , s y m pto m s, a rrh yth m ia s, a n d so o n, l e ad in g t o e arlie r t r e atm en t Im pro ved p atie n t c o m plia n ce w ith t a k in g c ard io pro te ctiv e med ic atio ns Red uced r e h osp ita liz atio ns Red uced h ealth c are c o sts Red uced m orta lity Str e n gth t r a in in g r e su lts i n s ig nif ic an t g ain s i n s k ele ta l m usc le s tr e n gth .

Sym pto m s r e la te d t o c o ro nary d is e ase u su ally i m pro ve with c ard ia c re h ab ilita tio n. L eft v en tr ic u la r f u nctio n m ay i m pro ve. I m pro vem en t i n co ro nary r is k f a cto rs i s o bse rv ed . A th ero gen esis is s lo w ed , e n doth elia l fu nctio n i s i m pro ved , a n d m yocard ia l i s c h em ia m ay b e l e sse n ed .

Psy ch oso cia l f u nctio n m ay i m pro ve ( 7 5, 76, 7 7, 7 8). A m eta -a n aly sis o f se v era l r a n dom iz ed t r ia ls d em onstr a te d a 3 1% r e d uctio n i n m orta lity f o r patie n ts w ho p artic ip ate d in c ard ia c r e h ab ilita tio n ( 7 9).

For m y o w n pro gra m , l o cate d a t a n a cad em ic m ed ic al c en te r, w e h av e d em onstr a te d a 56% , 4 5% , a n d 4 6% r e d uctio n i n a ll- c au se morta lity f o r p artic ip an ts w ith eith er a cu te m yocard ia l i n fa rc tio n, P C I, o r C A BG , r e sp ectiv ely , c o m pare d with n onpartic ip an ts (8 0, 8 1a, 8 1b).

In a d ditio n, i n a l a rg e s a m ple o f Med ic are b en efic ia rie s, a d ose – re sp onse r e la tio nsh ip b etw een t h e n um ber 482 of c ard ia c r e h ab ilita tio n se ssio ns a tte n ded a n d v ario us c ard io vasc u la r outc o m es w as d ete rm in ed ( i.e ., t h e m ore s e ssio ns a tte n ded , t h e b ette r t h e outc o m es) (8 2).

Underu tiliz a tio n o f C ard ia c R eh ab ilit a tio n S erv ic es In s p ite o f t h e i m pre ssiv e b en efits o f e x erc is e -b ase d c ard ia c r e h ab ilita tio n, most p atie n ts d o n ot a tte n d a fte r a n a cu te c o ro nary sy ndro m e. A m ong Med ic are b en efic ia rie s, o nly 1 9% o f e lig ib le p atie n ts p artic ip ate i n outp atie n t c ard ia c r e h ab ilita tio n ( 8 3).

Old er a d ults , n onw hite s, p atie n ts with c o m orb id itie s, p atie n ts w ith l o w s o cio eco nom ic s ta tu s, t h e unem plo yed , s in gle p are n ts , an d w om en a re l e ss l ik ely t o p artic ip ate ( 8 4, 85, 8 6). S uggeste d s te p s t o i m pro ve t h e e n ro llm en t r a te i n c ard ia c re h ab ilita tio n pro gra m s i n clu de a u to m atin g t h e r e fe rra l p ro cess, desig natin g r e fe rra l a n d e n ro llm en t i n c ard ia c r e h ab ilita tio n a s a q uality in dic ato r i n c ard io vasc u la r c are , d esig nin g p ro gra m s t h at u tiliz e t h e te le p hone o r I n te rn et f o r p atie n ts w ho l iv e i n a re as with out p ro gra m s, dete rm in in g h ow b est t o i n clu de u nders e rv ed p opula tio ns, a n d d ev elo pin g a m ultim ed ia e d ucatio n p ro gra m o n th e b en efits o f c ard ia c r e h ab ilita tio n dir e cte d a t b oth p atie n ts a n d h ealth c are p ro vid ers ( 8 7).

Con clu sio n Acu te c o ro nary s y ndro m es a re t h e r e su lt o f a th ero sc le ro tic p la q ue dev elo pm en t, w ith s u bse q uen t p la q ue d is ru ptio n a n d t h ro m bus fo rm atio n le ad in g t o m yocard ia l i s c h em ia a n d p ote n tia l n ecro sis . U nsta b le a n gin a pecto ris i s t h e r e su lt o f t r a n sie n t c o ro nary arte ry o cclu sio n w ith sp onta n eo us c lo t d is so lu tio n a n d n o d em onstr a b le m yocard ia l n ecro sis .

Vesse l o cclu sio n p ers is tin g f o r more t h an 1 h r e su lts i n m yocard ia l necro sis , w hic h i s t h e h allm ark o f a cu te m yocard ia l i n fa rc tio n. M yocard ia l in fa rc tio ns are c ate g oriz ed , b ase d o n e le ctr o card io gra p hic f in din gs, a s eith er S T -s e g m en t e le v atio n o r n on-S T -s e g m en t e le v atio n. P re fe rre d tr e atm en t i s p ro m pt r e p erfu sio n o f t h e o cclu ded v esse l, a n d t h is r e su lts i n le ss m yocard ia l d am ag e. S ev era l c la sse s o f c ard io pro te ctiv e med ic atio ns are g iv en t o s u rv iv ors o f a cu te c o ro nary s y ndro m es. I n a d ditio n t o t h ese med ic atio ns, c o m pre h en siv e c ard ia c r e h ab ilita tio n, in clu din g e x erc is e tr a in in g, f o rm s t h e b asis f o r s e co ndary p re v en tio n o f f u tu re c ard ia c e v en ts fo r t h ese p atie n ts . C ard ia c re h ab ilita tio n r e su lts i n i m pre ssiv e b en efits f o r patie n ts , i n clu din g r e d uced m orta lity .

483 Go o nlin e t o r e v ie w t h e w eb r e so urc e c ase s tu dy a n d d is c u ssio n q uestio ns fo r t h is c h ap te r.

484 Chap te r 1 4 Rev asc u la riz a tio n o f t h e H ea rt Neil A . S m art, P hD A ckn ow le d gm en t:

M uch o f t h e w ritin g i n t h is c h ap te r w as a d ap te d f ro m t h e t h ir d e d itio n o f Clin ic a l Exerc is e P hysio lo gy . T hus, w e w is h t o g ra te fu lly a ck now le d ge t h e p re v io us e ffo rts o f a n d t h an k Mark P atte rs o n, P hD .

H eart d is e ase r e m ain s t h e l e ad in g c au se o f d eath a cco rd in g t o t h e C en te rs f o r D is e ase C ontr o l a n d P re v en tio n. C onsid erin g th is r e ality i s o f u pm ost i m porta n ce i n u nders ta n din g t h e p ro ced ure s u se d t o p ote n tia lly a lle v ia te s y m pto m s, r e d uce r is k o f sig nif ic an t h eart i n ju ry , o r e v en s a v e t h e l iv es o f t h ose a fflic te d w ith h eart d is e ase . I t i s a ls o i m porta n t t o k now h ow t o u tiliz e e x erc is e a s a t h era p y, a fte r r e v asc u la riz atio n, t o m ain ta in o r i m pro ve p hysic al f u nctio nin g o f t h e h eart a n d b ody to m ain ta in l o w er r is k o f f u rth er a d vers e c ard ia c e v en ts a n d i m pro ve a p ers o n’s q uality o f l if e .

Defin it io n T he t e rm re va sc u la riz a tio n r e fe rs t o a s u rg ic al p ro ced ure t o h elp p ro vid e n ew o r a d ditio nal b lo od s u pply t o a b ody p art o r o rg an . S ev era l o rg an s, s u ch as t h e h eart, l u ngs, k id ney s, l iv er, a n d m usc le s ( in s itu atio ns s u ch a s g an gre n e), c an b en efit f ro m t h is p ro ced ure . T ypic ally , dia g nostic t e sts m ay i n volv e u sin g m ag netic r e so nan ce i m ag in g ( M RI), C T s c an s, o r X r a y f lu oro sc o py t o i d en tif y t h e n eed f o r re v asc u la riz atio n o r h elp i n g uid an ce o f t h e p ro ced ure .

A lth ough t h ere a re m ultip le p arts o f t h e b ody a n d o rg an s f o r w hic h r e v asc u la riz atio n m ay b e i n dic ate d , t h e f o cu s o f t h is c h ap te r is o n p ro ced ure s c o ncern in g t h e h eart.

Y ou w ill s e e t e rm s s u ch a s perc u ta neo us t r a nslu m in al c o ro nary a ngio pla sty ( P T C A ) a n d perc u ta neo us c o ro nary i n te rv en tio n ( P C I), w ith o r w ith out s te n tin g, a n d co ro nary a rte ry b yp ass s u rg ery ( C A BS), a ll t e ch niq ues f o r e sta b lis h in g p ro per b lo od f lo w b ack t o t h e h eart.

485 Sco p e When a p ers o n h as c o ro nary a rte ry d is e ase , c lin ic al p ro ced ure s m ay b e ele cte d t o r e sto re m yocard ia l b lo od f lo w , w ith t h e s p ecif ic in te n t o f sy m pto m r e lie f a n d i m pro ved m orb id ity a n d m orta lity . T he t w o m ost co m monly u se d t e ch niq ues a re c o ro nary a rte ry b ypass su rg ery ( C A BS) an d p erc u ta n eo us t r a n slu m in al c o ro nary a n gio pla sty ( P T C A ) o r perc u ta n eo us c o ro nary i n te rv en tio n ( P C I), w ith or w ith out s te n tin g. T he Natio nal C en te r f o r B io te ch nolo gy I n fo rm atio n e stim ate d r a te s o f C A BS an d P C I i n t h e a d ult U .S . p opula tio n in 2 008. M ore t h an 2 40,0 00 C A BS an d 8 17,0 00 P C I w ere p erfo rm ed .

Recen t w ork f ro m t h e U nite d K in gdom s h ow s p atte rn s o f r e fe rra l t o card ia c r e h ab ilita tio n h as i n cre ase d t o a lm ost 5 0% o f e lig ib le patie n ts ( 6 0).

Today , b ecau se o f a d van ces i n c o ro nary i n vasiv e t e ch nolo gy, c ard ia c re h ab ilita tio n p ro gra m s a re s e ein g a g ro w in g num ber o f p eo ple w ho h av e ex perie n ced p erc u ta n eo us i n te rv en tio ns, i n clu din g p erc u ta n eo us tr a n slu m in al c o ro nary an gio p la sty a lo ne a n d, m ore f re q uen tly , i n co m bin atio n w ith ste n t t h era p y, w hic h i n volv es t h e p la cem en t o f a m esh tu be a lo ng t h e a rte ry w all t o p re v en t r e o cclu sio n ( 2 , 5 3). E ven t h ough min or co nvale sc en t d if fe re n ces e x is t a m ong t h e d if fe re n t p erc u ta n eo us in te rv en tio nal p ro ced ure s, t h e s ta n dard s o f p ra ctic e a n d e x pecte d outc o m es fo r c ard ia c r e h ab ilita tio n a re s im ila r ( 3 2, 8 3); t h us, t h is c h ap te r f o cu se s o n patie n ts w ho h av e u nderg one C A BS o r PT C A w ith o r w ith out s te n t th era p y.

An i m porta n t n ote c o ncern s t h e e m erg in g i n fo rm atio n r e g ard in g mech an ic al r e v asc u la riz atio n v ers u s a g gre ssiv e m ed ic al m an ag em en t.

In a 2008 p ap er, D r. B arry F ra n klin , P hD , o utlin ed s e v era l a rtic le s t h at in dic ate d q uestio nab le m orta lity b en efit f o r t h ose who u nderw en t C A BS o r PC I v ers u s m ed ic al m an ag em en t. I t w as s till a d van ta g eo us f o r t h ose w ith ev olv in g m yocard ia l i n fa rc tio n or u nsta b le a n gin a t o u nderg o re v asc u la riz atio n, b ut f o r t h ose w ith s ta b le a n gin a, t h e b en efit i s n ot a s cle ar ( 3 1). S om e ev id en ce d oes e x is t s u ggestin g t h at r e g ula r e x erc is e tr a in in g m ay r e su lt i n s u perio r e v en t- fre e s u rv iv al a n d e x erc is e c ap acity , co m pare d w ith P C I, i n p eo ple w ith c o ro nary a rte ry d is e ase ( 4 3).

Reg ard le ss o f w heth er p atie n ts w ith c o ro nary a rte ry d is e ase are re v asc u la riz ed o r n ot, m ultip le s tu die s h av e d em onstr a te d t h at f o r e ach 1 MET ( m eta b olic e q uiv ale n t) i m pro vem en t i n e x erc is e cap acity , t h ere ap pears t o b e b etw een a n 8 % a n d 1 7% r e d uctio n i n m orta lity ( 1 0).

486 Path op hysio lo gy Coro nary a rte ry d is e ase ( C A D) i n volv es a b uild up o f l ip id s, m acro phag es, pla te le ts , c alc iu m , a n d f ib ro us c o nnectiv e t is su e with in t h e c o ro nary arte rie s. T his r e su lts i n t h e f o rm atio n o f a p la q ue t h at p ro gre ssiv ely narro w s t h e l u m en . T his m ay e v en tu ally cau se a l im ita tio n o r o bstr u ctio n of n orm al b lo od f lo w . W hile s y m pto m s o r c h an ges o n a n ele ctr o card io gra m ( E C G ) d urin g a s tr e ss te st m ay n ot o ccu r u ntil a co ro nary a rte ry h as a 7 5% o r g re ate r s te n osis , l e sio ns t h at c o m pro m is e 50% o r m ore o f t h e l u m en in a m ajo r c o ro nary a rte ry m ig ht b e c o nsid ere d clin ic ally s ig nif ic an t. M ultip le f a cto rs s u ch a s l o catio n o f t h e l e sio n, sta b ility of t h e p la q ue, s y m pto m s, s h ort- a n d l o ng-te rm p ro gnosis , a n d quality o f l if e m ay a ll i n flu en ce t h e d ecis io n o n w heth er a p artic u la r patie n t i s a c an did ate f o r r e v asc u la riz atio n p ro ced ure s.

Coro n ary A rte ry B yp ass S urg ery Coro nary a rte ry b ypass s u rg ery i n volv es r e v asc u la riz atio n u sin g a v en ous gra ft f ro m a n a rm o r l e g o r a n a rte ria l g ra ft— both en ds f re e o r f ro m a re g io nal i n ta ct n ativ e v esse l ( e .g ., i n te rn al m am mary ; gastr o ep ip lo ic arte ry )— to p ro vid e b lo od f lo w t o t h e m yocard iu m b ey ond t h e s ite o f t h e occlu ded o r n early o cclu ded a re a i n a c o ro nary a rte ry . A lth ough CA BS h as tr a d itio nally i n volv ed a ste rn oto m y an d t h e u se o f a hea rt a n d l u ng byp ass , t e ch nic al a d van ces n ow p erm it a g ro w in g n um ber o f p ro ced ure s t o be p erfo rm ed . R ecen t a d van ces i n C A BS i n clu de:

1 .

Pre fe re n tia l u se o f t h e l e ft i n te rn al m am mary a rte ry f o r l e ft a n te rio r desc en din g ( L A D) a rte ry g ra ftin g, a s o ppose d t o t h e sa p hen ous v ein .

The f o rm er h as s h ow n t o h av e s u perio r 1 0 y r p ate n cy f o r L A D g ra fts (4 1).

2 .

A r e cen t m eta -a n aly sis h as s h ow n t h at a v oid an ce o f o n-p um p b ypass su rg ery w ith a n o ff-p um p t e ch niq ue r e d uces t h e i n cid en ce of posto pera tiv e a tr ia l f ib rilla tio n b y 1 3% t o o dds r a tio 0 .8 7, a s w ell a s decre ase s v en tila tio n t im e m ean d if fe re n ce, I C U sta y , a n d h osp ita l sta y .

3 .

A m in is u rg ery p ro ced ure p erfo rm ed t h ro ugh s m all p ort i n cis io ns usin g m ic ro sc o pic t e ch niq ues.

4 .

Pro ced ure s p erfo rm ed w ith r o botic t e ch nolo gy 5 .

Surg ery p erfo rm ed o n t h e b eatin g h eart w ith out t h e u se o f 487 card io pulm onary b ypass Subse q uen t t o t h ese t e ch nic al a d van ces, p osto pera tiv e m orb id ity h as sig nif ic an tly d ecre ase d . T he p osts u rg ic al h osp ita l s ta y fo r C A BS p atie n ts with out c o m plic atio ns i s n ow l e ss t h an 5 d . A s a r e su lt o f t h e e v olu tio n o f re v asc u la riz atio n p ro ced ure s (p artic u la rly p erc u ta n eo us i n te rv en tio n), t h e ro le f o r C A BS h as c h an ged ; i t i s n ow r e se rv ed f o r t h e f o llo w in g p atie n ts :

1 .

Patie n ts w ho a re p ost- P T C A o r s te n tin g ( o r b oth ) w ith r e ste n osis 2 .

Patie n ts w ho a re n o l o nger c an did ate s f o r a n gio pla sty b ut s till h av e ta rg et v esse ls o ffe rin g p re se rv atio n o f l e ft v en tr ic u la r sy sto lic fu nctio n 3 .

Those w ith m ultiv esse l d is e ase n ot a m en ab le t o a n gio pla sty o r ste n tin g 4 .

Those w ith t e ch nic ally d if fic u lt v esse l l e sio ns ( e .g ., a l e sio n o n t h e cu rv e o f a v esse l o r i n a d is ta l l o catio n n ot r e ad ily am en ab le t o an gio pla sty o r s te n tin g) The n um ber o f s u rg ic al r e v asc u la riz atio n p ro ced ure s h as d eclin ed , b ut th ese p ro ced ure s s till p la y a n e sse n tia l r o le i n h ig her-ris k occlu siv e dis e ase . S uccessfu l C A BS r e su lts i n m yria d i m pro ved e x erc is e r e sp onse s; an d w hen c o m bin ed w ith m ed ic al t h era p y, CA BS m ay m ore e ffe ctiv ely re lie v e s ig nif ic an t r e sid ual e x erc is e -in duced s y m pto m atic o r s ile n t myocard ia l i s c h em ia . T here i s als o s o m e e v id en ce t h at i n p ers o ns w ith dia b ete s, t h e n eed f o r f u tu re r e v asc u la riz atio n p ro ced ure s i s l e ss w ith CA BS t h an with P T C A o r s te n tin g ( 1 4, 4 2). T hus, t h e s y m pto m r e lie f, im pro ved f u nctio nal c ap acity , a n d i m pro ved q uality o f l if e m ay b e th e most p ra ctic al a n d i m porta n t p atie n t b en efits o f C A BS.

Percu ta n eo u s I n te rv en tio n s Coro nary a n gio pla sty , w hic h i s a ls o c alle d p erc u ta n eo us t r a n slu m in al co ro nary a n gio pla sty ( P T C A ), i s l e ss i n vasiv e t h an C A BS.

Sev era l te ch niq ues h av e b een d ev elo ped f o r u se i n r e sto rin g a d eq uate b lo od f lo w in d is e ase d c o ro nary a rte rie s. O fte n t h e p ro ced ure is c o m bin ed w ith s te n t th era p y t o r e d uce t h e l ik elih ood t h at t h e a rte ry w ill r e o cclu de.

Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty 488 PT C A i s a w ell- e sta b lis h ed , s a fe , a n d e ffe ctiv e r e v asc u la riz atio n p ro ced ure fo r p atie n ts w ith s y m pto m s a ttr ib uta b le t o C A D.

The p ro ced ure m ay u se one o r m ore t e ch niq ues a lo ne o r i n c o m bin atio n t o o pen t h e v esse l:

1 .

Ballo on d ila tio n i s m ost c o m monly u se d i n c o nju nctio n w ith s te n t pla cem en t ( fig ure 1 4.1 ).

2 .

Rota tio nal a th ere cto m y, a r o ta tio nal d ev ic e u se d f o r r e m ovin g p la q ue, may b e a p plie d t o c en tr a l b ulk y l e sio ns i n a m in ority of c ase s.

3 .

Dir e ctio nal a th ere cto m y a n d l a se r m ay b e u se d t o d eb ulk l a rg e le sio ns, b ut t h e r is k o f v esse l w all p erfo ra tio n o r d is se ctio n may b e gre ate r. T he u se o f t h ese d ev ic es i s l im ite d t o a f e w c en te rs i n co nte m pora ry p ra ctic e.

The c o m plic atio ns o f a n gio pla sty a re a cu te v esse l c lo su re ( re b ound vaso co nstr ic tio n) o r c h ro nic r e ste n osis , t h ro m botic d is ta l em bolis m , myocard ia l i n fa rc tio n ( M I), a rrh yth m ia s, d is se ctio n o f t h e c o ro nary a rte ry , an d b le ed in g.

489 Fig u re 1 4.1 Perc u ta n eo us t r a n slu m in al c o ro nary a n gio pla sty b allo on c ath ete r a n d t w o t y pes o f s te n ts : l a ttic ed s te el ( le ft) a n d c o ile d ste n t ( rig ht) .

S te n t T hera py T o r e d uce t h e r is k o f a cu te c lo su re a n d r e ste n osis o f c o ro nary a rte rie s a fte r P T C A ( 3 7), s e v era l m odels o f i n tr a co ro nary s te n ts hav e b een a d vocate d .

S te n t t h era p y i s f re q uen tly u se d i n c o nju nctio n w ith o ne o f t h e p re v io usly d esc rib ed t e ch niq ues t o p re se rv e th e p ate n cy o f t h e v esse l. S te n ts a re s ta in le ss s te el m esh t u be b rid ges t h at a re a d van ced o n t h e e n d o f a b allo on c ath ete r, passe d a cro ss t h e c u lp rit l e sio n, a n d e x pan ded . T he s te n t, s e rv in g a s a p erm an en t i n tr a v asc u la r p ro sth esis , c o m pre sse s t h e le sio n, r e su ltin g i n a n o pen v esse l. T his i s t h e f in al t r e atm en t f o llo w in g b allo on a n gio pla sty o r d eb ulk in g i n o ver 9 5% o f case s. A fte r r e m oval o f t h e b allo on c ath ete r, t h e s te n t r e m ain s p erm an en tly i n t h e c o ro nary a rte ry a n d i s e v en tu ally c o vere d w ith e n doth eliu m , b eco m in g p art o f t h e l u m in al w all s tr u ctu re .

I n t h e l a st d ecad e, d ru g-e lu tin g s te n ts h av e b eco m e a v aila b le . T he m eta l s c affo ld in g p re v en ts a cu te c lo su re a n d a ls o p ro vid es a v eh ic le f o r l o cal d ru g d eliv ery . T his i n novatio n p lu s t h e u se o f a sp ir in a n d t h ie n opyrid in es ( c lo pid ogre l a n d p ra su gre l) has r e d uced t h e p ro ble m o f i n -s te n t r e ste n osis t o a g re at e x te n t ( 1 , 6 6, 8 0, 8 8).

M an y s te n t p ro ced ure s r e q uir e a o ne-n ig ht h osp ita l s ta y o r a re a s a m e-d ay p ro ced ure . T he l o ss i n f u nctio nal c ap acity f o llo w in g PC I i s l e ss t h an t h at f o llo w in g a b ypass p ro ced ure . S ubse q uen tly , P C I p atie n ts b eg in c ard ia c 490 re h ab ilita tio n a t h ig her f u nctio nal cap acity , q uality o f l if e , a n d se lf – effic a cy ( 3 6, 5 7).

The H is to ry a n d F utu re o f P T C A S urg ery The f ir s t P T C A s u rg erie s u se d o nly a b allo on a n d n o s te n t; t h is re su lte d i n p oor r e ste n osis r a te s c o m pare d w ith t o day . B are meta l ste n ts w ere f ir s t u se d i n t h e e arly 1 980s, a n d d ual a n tip la te le t med ic atio ns w ere r e q uir e d i n a n a tte m pt t o p re v en t re ste n osis . T he in tr o ductio n o f n ew a n tip la te le t d ru gs, s u ch a s p ra su gre l, r e d uced en doth elia l h yperp la sia ( s c arrin g a ro und th e s te n t, l e ad in g t o partia l o r c o m ple te r e ste n osis ). A dm in is tr a tio n o f a n tic an cer d ru gs to r e d uce m ito sis a ro und t h e s te n t so lv ed t h e p ro ble m o f r e ste n osis but i n tr o duced a n ew p ro ble m : S te n ts w ere d esig ned t o b eco m e part o f t h e e n doth eliu m , a n d an tim ito tic m ed ic atio n s to pped t h e en doth elia liz atio n o f t h e s te n ts , c au sin g l a te s te n t t h ro m bosis . A re cen t m eta -a n aly sis has s h ow n t h at a sk in g p atie n ts t o c o ntin ue an tip la te le t m ed ic atio n b ey ond 3 m o, p re fe ra b ly f o r 1 2 m o, r e d uces th is c o m plic atio n (7 8). T he n ex t g en era tio n o f s te n ts a re l ik ely t o be b io deg ra d ab le p oly m er r e sin s, w hic h w ill r e d uce t h e t h re at o f en doth elia l hyperp la sia a n d a ls o l a te s te n t t h ro m bosis ( 9 0).

A 2 013 m eta -a n aly sis s u ggests t h at P C I w ith d ru g-e lu tin g s te n ts i s a s a fe a n d d ura b le a lte rn ativ e t o C A BS f o r t h e r e v asc u la riz atio n of unpro te cte d l e ft m ain c o ro nary a rte ry s te n osis i n s e le ct p atie n ts a t lo ng-te rm f o llo w -u p ( 1 5).

Clin ic a l C on sid era tio n s The s u ccess r a te o f a r e v asc u la riz atio n p ro ced ure m ay b e p re d ic te d , i n part, b y t h e p atie n t’ s a g e, e x is tin g c o m orb id itie s, an d s e v erity a n d l o catio n of t h e l e sio n.

Coro n ary A rte ry B yp ass S urg ery 491 Ele ctiv e C A BS i m pro ves t h e l ik elih ood o f l o ng-te rm s u rv iv al i n p atie n ts who h av e t h e f o llo w in g:

Sig nif ic an t l e ft m ain C A D Thre e-v esse l d is e ase Tw o-v esse l d is e ase w ith a p ro xim al l e ft a n te rio r d esc en din g s te n osis Tw o-v esse l d is e ase a n d i m pair e d l e ft v en tr ic u la r f u nctio n ( 2 ) In p atie n ts e x perie n cin g f a ile d a n gio pla sty w ith p ers is te n t p ain o r hem odynam ic i n sta b ility , a cu te M I w ith p ers is te n t o r r e cu rre n t is c h em ia re fra cto ry t o m ed ic al t h era p y, ca rd io gen ic s h ock , o r f a ile d P T C A w ith a n are a o f m yocard iu m s till a t r is k , r e v asc u la riz atio n b y C A BS o ffe rs effe ctiv e r e lie f o f a n gin a p ecto ris an d i m pro ves t h e q uality o f l if e ( 2 ). T he occlu sio n r a te o f g ra fts i s a p pro xim ate ly 1 0% , 2 0% , a n d 4 0% a fte r 1 , 5 , an d 1 1 y r, re sp ectiv ely ( 1 0). T he C A BS p atie n t’ s p osto pera tiv e e d ucatio n sh ould i n clu de w ound c are , a p pro pria te m an ag em en t o f r e cu rrin g sy m pto m s, a n d r is k f a cto r m odif ic atio n.

Percu ta n eo u s T ra n slu m in al C oro n ary A ngio p la sty In s e le ct c ase s o f u nsta b le a n gin a, P T C A h as a n a cu te s u ccess r a te o f o ver 84% . F ollo w in g s u ccessfu l P T C A , r e ste n osis o ccu rs in a p pro xim ate ly 2 5% of p atie n ts , a lm ost a lw ay s w ith in t h e f ir s t 6 m o ( 2 , 4 ). F ollo w in g t h e dev elo pm en t o f d ru g-e lu tin g s te n ts , re ste n osis r a te s h av e d ro pped dra m atic ally i n m an y c ase s, t o b elo w 5 % a fte r 2 y r ( 3 3).

Tab le 1 4.1 l is ts se v era l p re d ic to rs o f r e ste n osis ( 6 7).

492 O th er v ery i m porta n t p ote n tia l p re d ic to rs i n clu de c o m orb id itie s s u ch a s d ia b ete s m ellitu s a n d w heth er p atie n ts a re o n o ptim al med ic al t h era p y t h at i n clu des u se o f a sp ir in a n d t h ie n opyrid in es s u ch a s P la v ix a n d E ffie n t ( 1 , 3 3).

P atie n ts w ho h av e h ad P T C A i n t h e s e ttin g o f u nsta b le a n gin a s h ould h av e c lo se s u rv eilla n ce f o llo w in g h osp ita l d is c h arg e a n d sh ould b e a d vis e d t o s e ek p ro m pt m ed ic al a tte n tio n i n t h e e v en t o f a r e cu rre n ce o f t h e s y m pto m s t h at w ere o ccu rrin g b efo re th eir P T C A ( 1 9).

S te n t T hera p y I m pro ved t e ch nolo gy c u rre n tly c o nfe rs p ro ced ura l s u ccess r a te s i n e x cess o f 9 5% i n m ost c en te rs . A cu te c lo su re a n d r e ste n osis re m ain a s l im ita tio ns t o s h ort- a n d l o ng-te rm s u ccess, r e sp ectiv ely , a lth ough t h e i n cid en ce o f b oth t h ese c o m plic atio ns h as decre ase d d ra m atic ally i n r e cen t y ears . T he i n cid en ce o f t h ro m bosis a n d a cu te c lo su re i s i n t h e r a n ge o f 1 % t o 2 % w ith 493 use of t h ie n opyrid in es ( c lo pid ogre l o r t ic lo pid in e); t h ere fo re , c h ro nic an tic o agu la tio n t h era p y i s n o l o nger r e q uir e d . R este n osis r a te r a n ges fro m 2 5% t o 4 0% w ith b are m eta l s te n ts a n d l e ss t h an 1 0% w ith d ru g- elu tin g ste n ts ( 4 , 5 8). T hese r e su lts v ary d ep en din g o n c o m orb id itie s a n d effic acy o f a g gre ssiv e m ed ic al m an ag em en t a s w ell a s o n su rg ic al t im e, ty pe o f s u rg ery , a n d o n- o r o ff-p um p s u rg ic al m eth ods.

Hyb rid C oro n ary A rte ry R ev asc u la riz a tio n Hybrid c o ro nary a rte ry r e v asc u la riz atio n ( H CR) r e fe rs t o c o m ple te o r near-c o m ple te r e v asc u la riz atio n u sin g t h e c o m bin atio n of s in gle -v esse l co ro nary a rte ry b ypass g ra ft ( C A BG ), w ith t h e l e ft i n te rn al m am mary arte ry ( L IM A) p la ced t o t h e l e ft a n te rio r desc en din g c o ro nary a rte ry (L A D), a n d p erc u ta n eo us c o ro nary i n te rv en tio n ( P C I) o f s ig nif ic an t co ro nary l e sio ns i n o th er v esse ls .

The l a rg est o bse rv atio nal s tu dy co m pare d 2 00 p atie n ts w ho u nderw en t H CR w ith 9 8 p atie n ts w ho underw en t m ultiv esse l P C I ( 3 9a).

At 1 2 m o, t h ere w as n o d if fe re n ce i n t h e ra te o f m ajo r a d vers e c ard ia c a n d c ere b ro vasc u la r e v en ts . H CR i s a re aso nab le a p pro ach to m ultiv esse l c o ro nary a rte ry r e v asc u la riz atio n i n se le cte d p atie n ts a t f a cilitie s w ith s ig nif ic an t e x pertis e .

Tab le 1 4.2 p ro vid es a s u m mary o f m ed ic atio ns c o m monly p re sc rib ed .

494 E xercis e T estin g T he g ra d ed e x erc is e t e st ( G XT) i s c o m monly u se d f o r c o ntin ued d ia g nosis o f p ossib le i s c h em ic m yocard iu m , p ro gnostic atio n, an d t h e e sta b lis h m en t o f f u nctio nal s ta tu s f o r e x erc is e p re sc rip tio n p urp ose s. A lth ough a n i n te g ra l c o m ponen t f o r e x erc is e pre sc rip tio n, t h e t im in g o f t h e G XT i s s o m ew hat c o ntr o vers ia l. S ta n dard a d m in is tr a tio n p ro ced ure s a n d c o ntr a in dic atio ns t o te stin g, d is c u sse d i n c h ap te r 5 , s h ould b e f o llo w ed .

P ra ctic al a p plic atio n 1 4.1 o utlin es e x erc is e t e stin g f o r r e v asc u la riz ed p atie n ts .

Pra ctic a l A pplic a tio n 1 4.1 495 Exercis e T estin g R ev ie w f o r S urg ery P atie n ts Testin g p ro ced ure s o utlin ed i n AC SM ’s G uid elin es f o r E xerc is e Testin g a nd P re sc rip tio n, T en th E ditio n , i n dic ate t h at f o r s e v ere re g urg ita n t ( le ak in g) o r s te n otic ( n arro w in g) v alv e d is e ase , v alv e re p la cem en t m ay b e e sse n tia l fo r s y m pto m r e lie f a n d i m pro ved ex erc is e t o le ra n ce. R eg ard in g t h e o pen -h eart s u rg ic al p ro cess, pre cau tio ns s im ila r t o t h ose fo r t h e b ypass s u rg ery p atie n t s h ould be f o llo w ed , w ith a tte n tio n t o a f e w s p ecia l c o nsid era tio ns. T he in tr o ductio n o f t r a n sc ath ete r ao rtic v alv e i m pla n ta tio n ( T A VI) h as re d uced t h e i n cid en ce o f o pen -h eart v alv e s u rg ery . T A VIs a re in tr o duced v ia a f e m ora l arte ry i n cis io n o r b y m in im ally i n vasiv e su rg ery . A n i n itia l p ro ble m w ith i n se rtio n w as d if fic u lty p la cin g th e T A VI d ue t o movem en t a sso cia te d w ith t h e b eatin g h eart. A pacin g w ir e i s u se d t o c re ate v en tr ic u la r t a ch ycard ia ; p erh ap s co unte rin tu itiv ely , in cre asin g h eart r a te r e d uces c ard ia m ovem en t an d a llo w s p re cis e i n se rtio n o f t h e T A VI. O nce t h e T A VI i s co rre ctly p la ced it i s d ep lo yed . M in im ally i n vasiv e s u rg ery r e d uces tim e s p en t i n t h e i n te n siv e c are u nit ( 2 3).

496 Specia l c o nsid era tio ns: S ym pto m r e so lu tio n m ay n ot o ccu r im med ia te ly f o llo w in g s u rg ery . S ym pto m s m ay g ra d ually r e so lv e becau se of h eart r e m odelin g a fte r v alv e r e p la cem en t ( e .g ., f o r ao rtic s te n osis ). A void s tr e n gth t r a in in g f o r s e v ere s te n otic o r re g urg ita n t valv ula r d is e ase . S ev era l m eta -a n aly se s h av e s h ow n is o m etr ic e x erc is e m ay o ffe r a n o pportu nity t o m an ag e hyperte n sio n i n p atie n ts who c an not p erfo rm , o r w is h t o u se a n ad ju nct t o , a ero bic e x erc is e ( 4 5). C om mon e x erc is e -in duced sy m pto m s i n clu de s h ortn ess of b re ath , f a tig ue, a n d d iz zin ess o r lig ht- h ead ed ness.

Exerc is e p re sc rip tio n: F ollo w p ro ced ure s s im ila r t o t h ose f o r re v asc u la riz atio n s u rg ery .

C oro n ary A rte ry B yp ass S urg ery R eq uir in g a ll p atie n ts t o h av e a n e x erc is e t e st a fte r s u ccessfu l b ypass s u rg ery f o r t h e p urp ose o f b eg in nin g a s u perv is e d an d m onito re d e x erc is e 497 pro gra m i s o f q uestio nab le c lin ic al b en efit a n d a n u nnecessa ry f in an cia l burd en ( 6 1). T he p atie n t’ s co ro nary a n ato m y i s k now n, a n d u nle ss s u rg ic al co m plic atio ns o r p osts u rg ic al s y m pto m s a re p re se n t, t h e c h an ce o f dete ctin g unknow n i s c h em ia i s e x tr e m ely l o w . I n a d ditio n, b ecau se o f t h e acu te c o nvale sc en t p erio d, t h e p atie n t m ay n ot b e a b le t o g iv e a physio lo gic al m ax im al e ffo rt, s a crif ic in g t e st s e n sitiv ity .

A m ore o pportu ne t im e f o r t e stin g t h e p atie n t i s a fte r i n cis io nal p ain h as re so lv ed , b lo od v olu m es a n d h em oglo bin c o ncen tr a tio ns hav e n orm aliz ed , an d s k ele ta l m usc u la r s tr e n gth a n d e n dura n ce h av e i m pro ved f ro m partic ip atin g i n l o w -le v el e x erc is e a n d a ctiv ity .

At l e ast 4 w k p osts u rg ery , th e p atie n t w ill b e a b le t o g iv e a n ear-m ax im al p hysio lo gic al e ffo rt, pro vid in g t e st r e su lts w ith gre ate r d ia g nostic a ccu ra cy f o r a sse ssin g fu nctio nal c ap acity , d ete rm in in g r e tu rn -to -w ork s ta tu s, o r r e co m men din g th e r e su m ptio n of p hysic ally v ig oro us r e cre atio nal a ctiv itie s. F or p atie n ts whose s u rg ic al r e v asc u la riz atio n w as n ot s u ccessfu l o r w ho a re ex perie n cin g s y m pto m s s u ggestiv e o f i s c h em ia , a c lin ic al e x erc is e t e st befo re s ta rtin g a n e x erc is e p ro gra m i s r e co m men ded .

All t e stin g pro ced ure s s h ould f o llo w p ro fe ssio nal g uid elin es ( 8 , 9 , 1 1) a s n ote d i n ch ap te r 5 .

Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty Deb ate e x is ts r e g ard in g t h e p ro per t im in g o f s tr e ss t e stin g i n P T C A patie n ts . S ev era l r e p orts o f a cu te t h ro m botic o cclu sio n asso cia te d w ith ex erc is e t e stin g s h ortly a fte r s u ccessfu l P T C A h av e b een r e p orte d , alth ough t h ese h av e n ot b een b orn e o ut as r e le v an t i n c lin ic al p ra ctic e.

Alth ough n o c h est p ain i s r e p orte d d urin g t h e t e st, i s c h em ia w ith in 1 h afte r t e stin g h as been r e p orte d ( 2 0, 7 1). T he m ech an is m s f o r t h e a p pare n tly ab norm al t e st r e sp onse s a re u ncle ar b ut a re p ossib ly r e la te d t o th e fo llo w in g:

1 .

Hig her l e v els o f pla te le t a ggreg atio n durin g e x erc is e t e stin g 2 .

An i n cre ase i n t h ro m boxan e A 2 3 .

Pla te le t a ctiv atio n a n d h yperre activ ity i n cre ase d urin g e x erc is e 4 .

In cre ase d a rte ria l w all s tr e ss a sso cia te d w ith i n cre ase d c o ro nary b lo od flo w 5 .

The h ig her b lo od p re ssu re t h at o ccu rs d urin g e x erc is e , w hic h m ay tr a u m atiz e a n a lr e ad y d is ru pte d in tim a ( 2 0, 5 1) 498 On t h e o th er h an d, e x erc is e t e stin g o f p atie n ts w ith P T C A h as b een accep te d s ta n dard p ra ctic e, p artic u la rly f o r t h ose w ith in co m ple te re v asc u la riz atio n. A l a rg e b ody o f e v id en ce s u pports t h e u se o f e arly postp ro ced ure e x erc is e t e stin g ( 1 o r 2 d ) to e v alu ate t h e f u nctio nal s ta tu s o f th e P T C A p atie n t ( 5 , 6 , 1 7, 1 9, 7 5).

Ste n t T hera py Contr o vers y w ith r e g ard t o s a fe ty o f e arly t e stin g a fte r s te n t p la cem en t h as esse n tia lly b een l a id t o r e st. M ost a u th oritie s now a ccep t t h at p erfo rm in g a str e ss t e st a fte r c o ro nary s te n tin g i s s a fe . R ecen tly , t h ere h as b een in cre asin g s u pport f o r ex erc is e t e stin g b efo re t h e s ta rt o f a n e x erc is e pro gra m ( 1 3, 1 9, 2 4, 4 8, 4 9). T he a ccu ra cy o f t h ese t e sts , h ow ev er, c an still be d eb ate d . I n p artic u la r, t h ere h av e b een r e p orts o f f a ls e -p ositiv e str e ss t e st r e su lts e arly o n a fte r c o ro nary s te n tin g.

As w ith C A BS a n d PT C A , t h e n eed t o t e st a ll p atie n ts a fte r s te n t t h era p y b efo re s ta rtin g card ia c r e h ab ilita tio n i s d eb ata b le .

One s c en ario f o r w hic h i t m ig ht b e use fu l i s f o r p atie n ts w ho e ith er c an not p artic ip ate i n a s u perv is e d p ro gra m or c h oose to e x erc is e i n dep en den tly a n d n eed s o m e r e assu ra n ce a n d i n itia l guid an ce. I n g en era l, f o r t h e s u ccessfu lly r e v asc u la riz ed patie n t, a n ex erc is e t e st m ay b e r e d undan t a n d m ay n ot p ro vid e a n y f u rth er u se fu l clin ic al i n fo rm atio n b efo re t h e p atie n t sta rts a s u perv is e d e x erc is e pro gra m . T he p rim ary c o ncern s w ith P T C A a n d s te n t a re reo cclu sio n a n d reste n osis . S ubse q uen t r e ste n osis m ay n ot b e d ete cte d i m med ia te ly fo llo w in g t h e p ro ced ure . T he p atie n t c an e x erc is e i n a s u perv is e d ex erc is e pro gra m a n d b e t e ste d a t a l a te r d ate i f s y m pto m s r e cu r o r f o r a sse ssm en t of f u nctio nal c ap acity b efo re r e tu rn t o work . A dditio nally , a p oor r e sp onse to e x erc is e t r a in in g, d em onstr a tin g n o i m pro vem en t i n f u nctio nal c ap acity , may b e i n dic ativ e of r e ste n osis ( 5 , 6 , 5 6).

Pra ctic al a p plic atio n 1 4.2 p ro vid es a d vic e o n h elp in g r e v asc u la riz ed patie n ts a d here t o a l o ng-te rm e x erc is e p ro gra m .

Pra ctic a l A pplic a tio n 1 4.2 Clie n t– C lin ic ia n I n te ra ctio n 499 Med ic al a d van ces h av e c o m e a l o ng w ay t o a ssis t t h e c lin ic al ex erc is e p ro fe ssio nal i n h elp in g i n div id uals r e tu rn t o e x erc is e an d more a ctiv e l if e sty le s s o oner. D esp ite a ll t h ese a d van ces, m ost re v asc u la riz ed p atie n ts e v en tu ally r e tu rn t o a m ore s e d en ta ry lif e sty le . T he f ie ld o f b eh av io r c h an ge h as s ta rte d t o b eco m e a n in cre asin gly i m porta n t p art o f h elp in g t h ese i n div id uals main ta in th eir e x erc is e p ro gra m s a n d m ore a ctiv e l if e sty le s.

One o f t h e m ost i m porta n t t o ols y ou c an u se t o i n cre ase e x erc is e ad here n ce i s y our e ars . T ak e t h e t im e t o l is te n t o y our p atie n ts .

Unders ta n d w hat i t i s t h ey h av e g one t h ro ugh. L is te n t o t h eir f e ars an d c o ncern s w hen y ou a re t e stin g o r d esig nin g e x erc is e pro gra m s.

Unders ta n d t h eir p hysic al, e m otio nal, a n d e n vir o nm en ta l b arrie rs .

If y ou t a k e t h e t im e t o c o nsid er t h eir s o urc es of s u pport a n d t h eir re so urc es f o r a ctiv ity a n d e x erc is e , a n d t h en r e m em ber t o r e asse ss th eir g oals , t o b e f le x ib le , a n d t o fo llo w u p i n a t im ely f a sh io n, t h ey will b e m ore l ik ely t o s u cceed .

Isc h em ic P re co n ditio n in g Recen tly a n um ber o f m eta -a n aly se s h av e n ote d t h e b en efits o f i s c h em ic pre co nditio nin g b efo re p la n ned c ard ia c s u rg ery . I s c h em ic pre co nditio nin g is e x posu re t o f o ur c y cle s o f 5 m in o f c u ff i n fla tio n a t s u pra sy sto lic pre ssu re ( o fte n 2 00 m mHg), w ith 3 t o 5 m in o f r e co very b etw een in fla tio ns. R ed uced i n cid en ce a n d s iz e o f p eri- a n d p osto pera tiv e myocard ia l i n fa rc ts h av e b een re p orte d , a m ong o th er a cq uir e d b en efits .

Rep eate d e x posu re t o i s c h em ic p re co nditio nin g h as a ls o b een i n vestig ate d fo r m an ag in g hyperte n sio n a n d w ound h ealin g ( 2 6).

Exercis e P resc rip tio n a n d T ra in in g Over t h e p ast d ecad e, t h e a v era g e l e n gth o f h osp ita l s ta y f o r c ard io vasc u la r patie n ts h as d ecre ase d d ra m atic ally . C urre n tly , th e h osp ita l s ta y f o r unco m plic ate d c ase s o f C A BS i s u su ally 2 t o 5 d . F or P T C A s te n ts , t h e sta y i s 1 o r 2 d ; t h is p ro ced ure is a ls o d one o n a n o utp atie n t b asis , w ith t h e patie n t m an ag ed i n a n a cu te r e co very s u ite a n d d is c h arg ed o n t h e s a m e day . A lth ough card ia c r e h ab ilita tio n b eg in s a s s o on a s p ossib le d urin g hosp ita l a d m is sio n, t h e s h orte r l e n gth o f h osp ita l s ta y h as c h an ged th e 500 in patie n t p ro gra m t o b asic r a n ge o f m otio n e x erc is e s a n d a m bula tio n; a n d th e e d ucatio nal f o cu s i s o n d is c h arg e p la n nin g— te ach in g ab out med ic atio ns, h om e a ctiv itie s, a n d f o llo w -u p a p poin tm en ts . E ducatio nal to pic s p re v io usly c o vere d i n t h e i n patie n t s e ttin g are n ow t h e r e sp onsib ility of t h e o utp atie n t p ro gra m . M ore o ver, c ard ia c r e h ab ilita tio n p ro fe ssio nals must m ak e e v ery e ffo rt to e n ro ll p atie n ts i n a n o utp atie n t p ro gra m . I n te rv al tr a in in g m ay o ffe r a n a lte rn ativ e t o c o ntin uous e x erc is e i n s e v ere ly deco nditio ned p atie n ts . L ate r, i n p hase I I a n d b ey ond, h ig h-in te n sity in te rv al e x erc is e ( H IIT ) m ay o ffe r s u perio r b en efits to m odera te -in te n sity co ntin uous e x erc is e ( 4 6). A h ybrid a p pro ach t o c ard ia c r e h ab ilita tio n m ay offe r a c o m pro m is e i n t h ose cau tio us a b out u sin g H IIT ( 5 2).

Tab le 1 4.3 re v ie w s t h e e x erc is e p re sc rip tio n f o r t h e r e v asc u la riz ed p atie n t.

501 502 W ith in t h e f ir s t f e w d ay s o f b ed r e st, m an y b ody c o m positio n c h an ges ( lo ss o f l e an b ody m ass) o ccu r ( 7 9), s u pportin g t h e n eed fo r e arly e x erc is e i n te rv en tio n d urin g h osp ita l a d m is sio n. P atie n ts w ho p erfo rm t y pic al w ard a ctiv itie s a n d m odera te , s u perv is e d am bula tio n d o n ot s u ffe r t h e m ag nitu de o f l o ss i n l e an b ody t is su e s e en i n t h ose w ho r e m ain i n activ e. E arly s ta n din g a n d l o w -le v el activ itie s, i n clu din g r a n ge o f m otio n a n d s lo w a m bula tio n, m ay b e a ll t h at i s r e q uir e d t o d ete r p osts u rg ic al l e an b ody m ass lo ss w hile t h e p atie n t i s i n t h e h osp ita l ( 7 9).

A fte r h osp ita l d is c h arg e, m an y p ositiv e p hysio lo gic al a d ap ta tio ns o ccu r i n r e v asc u la riz ed p atie n ts w ho p artic ip ate i n a s u perv is e d ex erc is e p ro gra m ( 8 3):

Im pro ved c ard ia c p erfo rm an ce a t r e st a n d d urin g e x erc is e Im pro ved e x erc is e c ap acity ( a ero bic a n d s tr e n gth ) Gre ate r t o ta l w ork p erfo rm ed Im pro ved a n gin a-fre e e x erc is e t o le ra n ce, m uch o f w hic h i s attr ib uta b le t o p erip hera l m usc u la r a d ap ta tio ns ( 4 0) Im pro ved n eu ro hum ora l t o ne ( 5 4) P atie n ts i n s u ch a p ro gra m g ain i n s e v era l w ay s:

They m ore o fte n a ch ie v e f u ll w ork in g s ta tu s.

They h av e f e w er h osp ita l r e ad m is sio ns.

They a re l e ss l ik ely t o s m oke a t 6 m o f o llo w in g c o m ple tio n o f 503 ex erc is e t h era p y ( 9 ).

When w e c o m pare t h e p hysio lo gic al a n d p sy ch oso cia l o utc o m es b etw een CA BS, P T C A –ste n t, a n d M I p atie n ts a t t h e b eg in nin g a n d en d o f 1 2 w k o f card ia c r e h ab ilita tio n, s o m e g ro up t r e n ds a re a p pare n t. C A BS p atie n ts m ay beg in w ith l o w er f u nctio nal c ap acitie s an d l o w er r a tin gs o f q uality o f l if e an d s e lf -e ffic acy a ttr ib uta b le t o t h e s u rg ic al r e cu pera tiv e p ro cess ( 8 4), b ut th ey s h ow gre ate r i m pro vem en t d urin g t h e p ro gra m a n d o bta in s im ila r o r gre ate r v alu es c o m pare d w ith o th er c ard ia c p atie n ts a t p ro gra m co m ple tio n, r e g ard le ss o f a g e ( 2 5, 3 6, 5 7). T his r e su lt m ay r e fle ct l o w er ra te s o f is c h em ia t h an i n M I p atie n ts , g re ate r c o nfid en ce i n t h eir o w n ab ility , a n d t h e p ote n tia l p sy ch olo gic al f e elin g t h at s o m eth in g w as done ab out t h eir h eart d is e ase a n d t h at t h ey a re “ cu re d .” R eg ard le ss o f a g e, t h e CA BS p atie n ts d em onstr a te f u nctio nal i m pro vem en t but m ay r e q uir e a lo nger t r a in in g p erio d t o o bta in t h e s a m e m ag nitu de o f e ffe ct ( 7 0). T he PT C A –ste n t g ro ups h av e n ot s u ffe re d th e l o ss i n f u nctio nal c ap acity becau se o f t h e m ore p ro lo nged r e cu pera tiv e p ro cess f o llo w in g a n M I o r bypass s u rg ery a n d h av e gre ate r f u nctio nal c ap acity w hen s ta rtin g c ard ia c re h ab ilita tio n ( 3 6, 5 7).

Exerc is e p re sc rip tio n g uid elin es f o r rev asc u la riz a tio n p atie n ts h av e b een publis h ed b y t h e A m eric an C olle g e o f S ports M ed ic in e ( 1 1), A m eric an Asso cia tio n o f C ard io vasc u la r a n d Pulm onary R eh ab ilita tio n ( 9 ), a n d Am eric an H eart A sso cia tio n ( 8 ).

Specia l E xercis e C on sid era tio n s Alth ough r e v asc u la riz ed p atie n ts a re j u st a s k now le d geab le a b out r is k fa cto rs a s p ost- M I p atie n ts , t h ey a re l e ss c o m pelle d to m ak e c h an ges ( 3 7).

Post- M I p atie n ts i n itia te c o nsid era b ly g re ate r l if e sty le c h an ges t h an re v asc u la riz ed p atie n ts d o ( 6 5).

Patie n ts u nderg oin g r e v asc u la riz atio n m ay be l e ss m otiv ate d t o a d here t o r is k f a cto r b eh av io r c h an ge b ecau se o f a perc ep tio n of t h at t h ey a re l e ss s ic k o r h av e b een c u re d , w hic h h as a neg ativ e e ffe ct o n c o m plia n ce w ith r is k f a cto r m odif ic atio n ( 3 8, 47, 6 4).

Rev asc u la riz ed p atie n ts m ay e n co unte r, o r a n tic ip ate , r e str ic tio ns dif fe re n tly t h an o th er c ard ia c p atie n ts d o. M ost P T C A –ste n t patie n ts a re cap ab le o f r e su m in g n orm al a ctiv itie s o f d aily l iv in g f o llo w in g h osp ita l dis c h arg e, b ut p atie n ts f re q uen tly p erc eiv e co nsid era b le r e str ic tio ns a fte r th e p ro ced ure w ith r e sp ect t o a ll a ctiv itie s o f d aily l iv in g— le is u re activ itie s, s e x ual a ctiv ity , an d e arly r e tu rn t o w ork ( 2 8, 6 8, 7 3).

504 Dep re ssio n r e m ain s p re v ale n t i n p atie n ts w ith c o ro nary h eart d is e ase a fte r majo r c ard ia c e v en ts ( C A BS a n d P T C A i n clu ded ).

Card ia c r e h ab ilita tio n does r e d uce t h e p re v ale n ce a n d s e v erity o f d ep re ssio n. T here fo re , c ard ia c patie n ts s h ould b e r o utin ely sc re en ed a n d o ffe re d t h e b en efits o f co m pre h en siv e c ard ia c r e h ab ilita tio n, i n clu din g p sy ch oso cia l s u pport a n d pasto ra l c are (6 2). T here h as a ls o b een s o m e r e se arc h o n p re p ro ced ure ex erc is e a n d c o unse lin g ( p re h ab ilita tio n) a n d e x te n ded t e le p hone co unse lin g afte r t h e p ro ced ure a n d r e h ab ilita tio n s e ssio ns h av e e n ded ; th ese s tu die s h av e s h ow n p ro m is e i n r e d uctio n i n d ep re ssio n s u rro undin g re v asc u la riz atio n p ro ced ure s ( 3 5, 7 4).

Spouse s m ay b e m ore l ik ely t o s e ek i n fo rm atio n a b out t h e p atie n t’ s psy ch olo gic al r e actio ns a n d r e co very , w here as p atie n ts are m ore l ik ely t o se ek i n fo rm atio n a b out t h eir p hysic al c o nditio n a n d r e co very ( 6 4). P atie n ts te n d t o b e m ore p ositiv e t h an sp ouse s, w ho t e n d t o b e m ore f e arfu l o f t h e fu tu re ( 3 9b). A ls o , p atie n ts a n d s p ouse s d if fe r i n t h eir v ie w s o n t h e c au se s of CA D a n d a b out t h e r e sp onsib ility f o r l if e sty le c h an ges a n d t h e man ag em en t o f h ealth a n d s tr e ss ( 6 9). T here fo re , a sse ssin g both t h e patie n t’ s a n d t h e s p ouse ’s e d ucatio nal n eed s i s i m porta n t. H ealth C are Check lis t f o r P C I/S te n t P atie n ts l is ts i m porta n t co ncern s i n t h e re h ab ilita tio n o f t h e p ost- P T C A p atie n t, t a k in g i n to a cco unt t h at e x erc is e may b e c o ntr a in dic ate d f o r p atie n ts who c o ntin ue t o b e s y m pto m atic poste v en t o r p ostp ro ced ure , p artic u la rly a t l o w w ork lo ad s ( < 5.0 M ETs).

Anoth er c o nsid era tio n i s t h e p ote n tia l u nco verin g o f c la u dic atio n i n perip hera l a rte ry d is e ase ( P A D) w ith a m bula tio n a fte r re v asc u la riz atio n. I t is w ell e sta b lis h ed t h at p ers o ns w ith C A D a re a t h ig her r is k t h an o th ers f o r PA D ( a n d v ic e v ers a ). T his may b e m ore o f a n i s su e w ith p atie n ts w ho hav e b een v ery s e d en ta ry a n d t h en s ta rt a n ew e x erc is e r e g im en a fte r t h e pro ced ure an d d ev elo p s y m pto m s o f c la u dic atio n.

Hea lt h C are C heck lis t f o r P C I/S te n t P atie n ts Contr o l o f h yperte n sio n, o besity , a n d s m okin g Pro gre ssiv e e x erc is e a n d w eig ht r e d uctio n Aware n ess o f o th er c ard ia c r is k f a cto rs Id en tif ic atio n o f s tr e ssfu l f a cto rs Counse lin g s e rv ic es f o r w eig ht r e d uctio n, s tr e ss m an ag em en t, 505 an d s m okin g c essa tio n Main ta in in g c lo se c o nta ct b etw een h ealth p ro fe ssio nals Org an iz in g a n d m ain ta in in g l o ng-te rm f o llo w -u p r e co rd s Rein fo rc in g t h e n oncu ra tiv e n atu re o f P C I/s te n t a s c ard ia c tr e atm en t m odality Enco ura g in g r e v asc u la riz atio n p atie n ts a n d P C I/s te n t p atie n ts to t a k e a p ro activ e a p pro ach t o i m pro ve h ealth o utc o m es Coro n ary A rte ry B yp ass S urg ery Prim ary c o ncern s f o r t h e C A BS p atie n t w hen e n te rin g o utp atie n t c ard ia c re h ab ilita tio n a re t h e s ta te o f i n cis io nal h ealin g an d s te rn al s ta b ility , hypovole m ia , a n d l o w h em oglo bin c o ncen tr a tio ns. D urin g t h e i n itia l patie n t i n te rv ie w , t h e r e h ab ilita tio n pro fe ssio nal n eed s t o e n su re t h at t h e su rg ic al w ound h as n o s ig ns o f i n fe ctio n, s ig nif ic an t d ra in in g, o r in sta b ility . Q uestio ns sh ould f o cu s o n t h e f o llo w in g:

Excessiv e o r u nusu al s o re n ess a n d s tif fn ess Cra ck in g, g rin din g, o r m otio n i n t h e s te rn al r e g io n Wheth er t h e p atie n t i s s le ep in g a t n ig ht How t h e p atie n t’ s c h est a n d l e g i n cis io ns a re r e sp ondin g t o c u rre n t activ itie s o f d aily l iv in g s in ce d is c h arg e Als o , k now in g h ow p atie n ts p erfo rm ed d urin g t h e i n patie n t p ro gra m m ay help d ete rm in e h ow s o on t h ey c an b eg in t h e o utp atie n t pro gra m a n d a t what l e v el t h ey c an b eg in e x erc is in g. F or e x am ple , w as t h e p atie n t o ut o f bed , u prig ht, a n d w alk in g s o on a fte r su rg ery w ith out p ro ble m s? I f n ot, w as th e p atie n t’ s l a ck o f a ctiv ity a ttr ib uta b le t o e x tr e m e p hysic al d is c o m fo rt, clin ic al or o rth oped ic d if fic u ltie s, o r l a ck o f m otiv atio n? R ecen t r e se arc h has s h ow n t h at c h est s o re n ess c an r e d uce w alk in g d is ta n ce, whic h c an hav e a n i m pact o n f u nctio nal f itn ess ( 1 6).

His to ric ally , s u rg ic al p atie n ts d id n ot b eg in c ard ia c r e h ab ilita tio n f o r 4 t o 6 wk p osts u rg ery o r l o nger a n d a v oid ed u pper ex tr e m ity e x erc is e f o r e v en lo nger p erio ds. T oday , s ta n dard p ra ctic e i s f o r p atie n ts t o b eg in t h e outp atie n t p ro gra m p rio r to , o r s o on a fte r, d is c h arg e, o fte n w ith in a w eek of s u rg ery . F or t h e u nco m plic ate d r e v asc u la riz ed p atie n t, l ig ht u pper ex tr e m ity ex erc is e s a re n ow p re sc rib ed , i n clu din g r a n ge o f m otio n ex erc is e s, l ig ht h an d w eig hts p ro gre ssin g t o l ig ht r e sis tiv e m ach in ery , an d 506 gra d ually p ro gre ssiv e u pper e x tr e m ity e rg om etr y b eg in nin g a t z ero re sis ta n ce. R ecen t r e se arc h i n dic ate s t h at w om en t e n d not t o r e sp ond t o in patie n t c ard ia c r e h ab ilita tio ns a s m uch a s m en ( 2 9).

Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty The p rim ary c o ncern f o r t h e P T C A o r s te n t p atie n t i s r e ste n osis . A t t h e patie n t’ s i n itia l o rie n ta tio n s e ssio n, q uestio nin g sh ould a d dre ss t h e pre se n ce o f s ig ns o r s y m pto m s i n dic ativ e o f a n gin a o r t h e p ers o n’s partic u la r a n gin al e q uiv ale n t. E ducatio n sh ould i n clu de i n fo rm atio n a b out sy m pto m s, i n clu din g a n gin al e q uiv ale n ts ; m an ag em en t o f a n gin a ( e .g ., how t o u se n itr o gly cerin , goin g t o t h e e m erg en cy d ep artm en t) ; pre cip ita tin g f a cto rs ( e x ertio n o r a n xie ty r e la te d ); a n d c are o f t h e c ath ete r in se rtio n site . P atie n ts w ith P T C A s a n d s te n ts m ay b eg in t h e o utp atie n t pro gra m a s s o on a s t h ey a re d is c h arg ed f ro m t h e h osp ita l o r im med ia te ly fo llo w in g t h e p ro ced ure i f i t h as b een p erfo rm ed o n a n o utp atie n t b asis (8 2).

Exerc is e t r a in in g m ay a lle v ia te t h e p ro gre ssio n o f c o ro nary a rte ry s te n osis afte r P T C A b y i n hib itin g s m ooth m usc le c ell p ro lif e ra tio n, lo w erin g s e ru m lip id s, i m pro vin g i n su lin r e sis ta n ce a n d g lu co se i n to le ra n ce, a n d c au sin g hem osta tic c h an ges ( 5 5, 8 5). T ra d itio nal aero bic t r a in in g f o r 3 0 t o 4 0 m in , fo ur t o s ix t im es p er w eek f o r 1 2 w k, i m pro ves t r e ad m ill t im e a n d myocard ia l p erfu sio n an d r e d uces t h e r e ste n osis r a te a t 3 m o f o llo w in g PT C A ( 5 5, 5 7). R ecen tly t h e u se o f r e p eate d , s h orte r i n te rv als o f v ig oro us or h ig h-in te n sity e x erc is e h as b een t r ia le d w ith p ro m is in g r e su lts ( 6 3).

As a r e su lt o f a n gio pla sty w ith i m pro ved t e ch niq ues o f r e v asc u la riz atio n, more p atie n ts w ith l o w -ris k p ro file s a re b ein g r e fe rre d to c ard ia c re h ab ilita tio n ( i.e ., p atie n ts w ith a g re ate r e x erc is e c ap acity , n o e v id en ce o f is c h em ia , n orm al l e ft v en tr ic u la r fu nctio n, a n d n o a rrh yth m ia s). S pecif ic ex am ple s i n clu de p atie n ts w ho a re y ounger, h av e s in gle -v esse l d is e ase , an d d id n ot ex perie n ce a n M I b efo re t h eir P T C A . R eg ard in g e x erc is e pre sc rip tio n, t h ese i n div id uals m ay b e t r e ate d s im ila rly t o a p pare n tly health y i n div id uals w ith t h e a d ditio n o f e d ucatio n c o ncern in g t h e re co gnitio n o f a n gin al e q uiv ale n ts , s e lf -m onito rin g, s e lf -c are , an d r is k fa cto r m odif ic atio n. O ptim iz ed m ed ic al t h era p y a lo ng w ith a p pro pria te ly pre sc rib ed e x erc is e t r a in in g c an b e a n a lte rn ativ e ap pro ach t o in te rv en tio nal s tr a te g ie s i n s e le cte d p atie n ts w ho a re a sy m pto m atic ( 4 3).

When P C I i s t h e t h era p y o f c h oic e, i t sh ould b e c o m bin ed w ith d aily 507 physic al e x erc is e a n d i n cre ase d p hysic al a ctiv ity t o o ptim iz e s u ccess ( 4 3).

Card ia c r e h ab ilita tio n re su lts i n e arly a n d s u sta in ed i m pro vem en t i n quality o f l if e a n d i s h ig hly c o st- e ffe ctiv e ( 9 1). I n a d ditio n, a n gio pla sty patie n ts c o m monly e x perie n ce r e ste n osis . S uperv is e d e x erc is e t r a in in g a n d ed ucatio n i m pro ve r e co gnitio n o f s ig ns a n d s y m pto m s asso cia te d w ith clo su re . M ost i m porta n t, a n gio pla sty p atie n ts n eed i n str u ctio n c o ncern in g ap pro pria te e x erc is e t r a in in g, d ie ta ry modif ic atio ns, m ed ic atio ns, a n d gen era l r is k f a cto r r e d uctio n t o s lo w o r r e v ers e t h e c o ro nary d is e ase pro cess.

Becau se t h e P T C A p atie n t r e m ain s o n c o m ple te b ed r e st w hile t h e s h eath is i n s itu f o r a p pro xim ate ly 1 8 t o 2 4 h , t h e i m mobiliz atio n ofte n c au se s back p ain . A ppro pria te f le x ib ility e x erc is e s t h at e n han ce r a n ge o f m otio n ofte n h elp t o r e so lv e l o w b ack p ain .

Ste n t T hera py Pla cem en t o f s te n ts u se s t h e s a m e c ath ete r p ro ced ure a s i n t h e P T C A , s o th e s a m e c o nsid era tio ns e x is t. B ut t h e r is k f o r t h ro m bosis is g re ate r fo llo w in g s te n t t h era p y. C onse q uen tly , p atie n ts a re o fte n p la ced o n an tic o ag ula n t t h era p y f o r p re v en tiv e p urp ose s.

Alth ough n o s p ecif ic co ntr a in dic atio ns p re clu de e x erc is e f o llo w in g r e cen t s te n t p la cem en t, pro ceed in g w ith s im ila r c au tio n is p ru den t.

Card io vasc u la r E xercis e The m ultip le i m pro vem en ts i n p atie n ts ’ t o le ra n ce t o a cu te b outs o f ex erc is e a fte r r e v asc u la riz atio n i n clu de t h e f o llo w in g (3 6, 5 7):

Im pro ved m yocard ia l b lo od f lo w In cre ase d f u nctio nal c ap acity Im pro ved c y cle e rg om ete r o r t r e ad m ill p erfo rm an ce Varia b le i m pro vem en ts i n l e ft v en tr ic u la r f u nctio n In cre ase d m ax im al h eart r a te In cre ase d r a te – pre ssu re p ro duct Red uctio n i n S T -s e g m en t d ep re ssio n Relie f o r i m pro vem en t i n a n gin al s y m pto m s w ith e x erc is e Im pro ved h eart r a te r e co very Red uctio n i n e x ertio nal h ypote n sio n 508 The i n itia l e x erc is e p re sc rip tio n i s b ase d o n i n fo rm atio n g ain ed f ro m t h e patie n t’ s o rie n ta tio n i n te rv ie w f o r t h e o utp atie n t card ia c r e h ab ilita tio n pro gra m . P atie n ts a re q uestio ned c o ncern in g t h e p re se n ce o f s ig ns o r sy m pto m s, t h eir a ctiv ity w hile in t h e h osp ita l, a n d t h eir a ctiv ity l e v el s in ce th eir r e tu rn h om e f ro m t h e h osp ita l. O f e q ual i m porta n ce a re t h eir l e v el an d co nsis te n cy o f c o nditio nin g b efo re t h eir c ard ia c e v en t. D ep en din g o n how l o ng t h ey w ere i n t h e h osp ita l a n d t h e a m ount o f deco nditio nin g, bette r-c o nditio ned , h ig her-fu nctio nin g p atie n ts m ay b e a b le t o r e tu rn t o hig her l e v els o f e x erc is e v olu m e an d i n te n sity m ore q uic k ly t h an m ost patie n ts . I n itia lly , p atie n ts a re c lo se ly o bse rv ed a n d m onito re d t o e sta b lis h ap pro pria te ex erc is e i n te n sitie s a n d d ura tio ns t h at a re w ith in t h eir to le ra n ce.

A s ta rtin g p ro gra m m ay i n clu de t r e ad m ill w alk in g ( 5 -1 0 m in ), c y cle erg om etr y ( 5 -1 0 m in ), c o m bin ed a rm a n d l e g e rg om etr y ( 5 -1 0 min ), a n d upper b ody e rg om etr y ( 5 m in ). I n itia l i n te n sitie s m ay a p pro xim ate 2 t o 3 METs ( m ultip le o f r e stin g o xygen u pta k e of 3 .5 m L · k g −1 · m in −1 ), b ut sta rtin g M ET l e v els m ay b e a b it h ig her d ep en din g o n e x erc is e h is to ry a n d prio r c o nditio nin g. A s m an y c ard ia c p atie n ts hav e l o w f u nctio nal c ap acity , esp ecia lly a fte r c ard ia c s u rg ery , t h eir d aily g en era l l iv in g a ctiv itie s pro bab ly e x ceed t h eir max im um c ard io re sp ir a to ry f itn ess ( p eak O 2 ). F or th is r e aso n, H IIT m ay b e i n dic ate d t o q uic k ly i m pro ve f itn ess; o ver t im e, fre q uen t e x posu re t o v ig oro us h ig h-in te n sity activ ity h as b een s h ow n t o re d uce M I r is k ( 8 6). A c o m mon e x erc is e p re sc rip tio n i s f o ur w ork in te rv als o f 4 m in w ith 3 m in re st o r r e co very b etw een e ach w ork i n te rv al.

An i n te n sity o f 8 5% t o 9 5% p eak O 2 i s c o m monly u tiliz ed ( 8 9), w ith a 5 to 1 0 m in w arm -u p, 5 m in c o ol- d ow n, a n d r e co very b outs a ll c o m ple te d a t ab out 5 5% t o 65% p eak O 2 .

The p atie n t’ s h eart r a te , b lo od p re ssu re , r a tin g o f p erc eiv ed e x ertio n, a n d sig ns a n d s y m pto m s a re m onito re d a n d r e co rd ed .

Pro gra m s a re g ra d ually titr a te d d urin g t h e i n itia l s e ssio ns t o a r a tin g o f p erc eiv ed e x ertio n o f 1 1 t o 14 i n t h e a b se n ce o f an y a b norm al s ig ns o r s y m pto m s.

In g en era l, e x erc is e i n te n sity i s p ro gre sse d b y 0 .5 t o 1 .0 M ET i n cre m en ts (i.e ., 0 .5 m ph [ 0 .8 k ph] o r 2 .0 % g ra d e o n t h e t r e ad m ill or 1 2.5 -2 5.0 W atts on t h e c y cle ). T he r a te o f p ro gre ssio n i s b ase d o n t h e p atie n t’ s s y m pto m s, sig ns o f o vere x ertio n, r a tin g of p erc eiv ed e x ertio n, i n dic atio ns o f a n y ex erc is e -in duced a b norm alitie s, a n d p ru den t c lin ic al j u dgm en t o n t h e p art of t h e card ia c r e h ab ilita tio n s ta ff. P atie n ts w ith g re ate r e x erc is e c ap acitie s (P T C A –ste n t p atie n ts w ith n o M I) a re s ta rte d a cco rd in g to t h eir e x erc is e 509 cap acitie s a n d p ro gre sse d m ore r a p id ly . T he s e le ctio n o f e x erc is e m odality dep en ds o n t h e p ers o n’s p ro gra m obje ctiv es. F or e x am ple , t h ose w ho a re em plo yed i n a l a b or-ty pe o ccu patio n o r p erfo rm m an y u pper e x tr e m ity activ itie s a t h om e sp en d a g re ate r p ortio n o f t h eir e x erc is e t im e d oin g upper e x tr e m ity e x erc is e s. I f s p ecif ic l im ita tio ns p re clu de c erta in e x erc is e modalitie s, p ro gra m m odif ic atio ns a re m ad e t h at a llo w m ore t im e o n to le ra b le e q uip m en t t o o bta in t h e g re ate st c ard io vasc u la r an d m usc u la r ad van ta g e. F or p atie n ts w ho h av e a n e x erc is e t e st, s ta n dard r e co m men ded pro ced ure s f o r e x erc is e p re sc rip tio n are f o llo w ed ( 8 , 9 , 1 1).

Resis ta n ce T ra in in g Musc u la r s tr e n gth a n d e n dura n ce e x erc is e t r a in in g s h ould b e i n co rp ora te d eq ually w ith c ard io vasc u la r e n dura n ce a n d f le x ib ility ex erc is e t r a in in g durin g t h e e arly o utp atie n t r e co very p erio d. F ollo w in g r e v asc u la riz atio n, lo w -ris k p atie n ts c an p erfo rm musc u la r s tr e n gth a n d e n dura n ce e x erc is e tr a in in g s a fe ly a n d e ffe ctiv ely ( 5 0). D ep en din g o n t h e p atie n t’ s c lin ic al a n d physic al sta tu s, s u ccessfu l a p pro ach es f o r u pper a n d l o w er e x tr e m ity str e n gth e n han cem en t i n clu de 1 0 t o 1 2 r e p etitio ns w ith a v arie ty of t y pes of e q uip m en t t h at m ay i n clu de e la stic b an ds, V elc ro -s tr a p ped w ris t a n d an kle w eig hts , h an d w eig hts , a n d v ario us m ultis ta tio n mach in es. U su al guid elin es i n clu de m ain te n an ce o f r e g ula r b re ath in g p atte rn s ( a v oid in g t h e Vals a lv a m an eu ver ), s e le ctio n o f w eig hts s o t h at t h e l a st r e p etitio n o f a se t i s m odera te ly o r s o m ew hat h ard , a n d p ro gre ssio n w hen t h e p erc ep tio n of d if fic u lty d ecre ase s. C A BS p atie n ts m ay s ta rt r a n ge o f m otio n e x erc is e s with l ig ht w eig hts o f 1 t o 3 l b ( 0 .5 -1 .5 k g) w ith in 4 w k o f s u rg ery a s l o ng as s te rn al s ta b ility i s e n su re d a n d e x cessiv e i n cis io nal d is c o m fo rt i s n ot pre se n t. P T C A –ste n t p atie n ts may s ta rt r e sis ta n ce t r a in in g i m med ia te ly .

Exerc is e s s h ould b e s e le cte d t h at w ill s tr e n gth en m usc le g ro ups u se d durin g n orm al activ itie s o f d aily l iv in g f o r l if tin g a n d c arry in g a n d occu patio nal o r r e cre atio nal t a sk s ( 2 ).

Weig hts a re s e le cte d t h at a llo w t h e c o m ple tio n o f 1 2 t o 1 5 r e p etitio ns in itia lly ; t h e p atie n t t h en p ro gre sse s t o h ig her w eig hts an d 1 0 t o 1 2 re p etitio ns, w ith t h e l a st t h re e r e p etitio ns f e elin g m odera te ly h ard . T hose who c an not s e cu re ly h old h an d w eig hts sh ould u se w ris t w eig hts w ith Velc ro s tr a p s. T ypic ally , e x erc is e s a re s e le cte d t h at u se u pper a n d l o w er ex tr e m ity m usc le g ro ups in volv ed i n r o utin e l if tin g a n d c arry in g a n d o th er activ itie s o f d aily l iv in g. P atie n ts a re p ro gre sse d f ro m s tr e tc h b an ds an d lig ht h an d w eig hts t o r e sis ta n ce m ach in es, a g ain u sin g r e sis ta n ces t h at 510 re su lt i n a p erc ep tio n o f d if fic u lty o f m odera te ly hard f o r t w o o r t h re e s e ts of 1 0 t o 1 2 r e p etitio ns.

Fig ure s 1 4.2 t h ro ugh 14.4 o utlin e p ossib le ex erc is e s f o r a r e h ab ilita tiv e e x erc is e p ro gre ssio n f o r r e v asc u la riz ed patie n ts .

Pro gre ssio n o f e x erc is e i s b ase d o n p atie n ts w ith o pen -h eart p ro ced ure s; patie n ts u nderg oin g P T C A a n d s te n tin g c an p erfo rm all e x erc is e s l is te d f o r th e b eg in nin g o f t h e p ro gra m w ith p ro per p ro gre ssio n b ase d o n p rio r ex erc is e h is to ry a n d c lin ic al ju dgm en t o f t h e c ard ia c r e h ab ilita tio n t e am .

The l is t t h at f o llo w s i s b ase d p artly o n i n fo rm atio n f ro m A dam s a n d co lle ag ues (7 ).

Early -P hase R eh ab ilit a tiv e E xercis e s ( 2 -4 w k P ostd is c h arg e) Tra d itio nally p atie n ts a t t h is p hase h av e b een t o ld t o a v oid s tr e n gth tr a in in g a n d d o o nly r a n ge o f m otio n o r v ery l ig ht, if a n y, s tr e n gth t r a in in g.

You m ay c o nsid er h av in g p atie n ts s ta rt t h ese e x erc is e s e arlie r i n t h eir re co very i f s te rn al h ealin g is g oin g w ell a n d t h ey a re a m bula to ry :

Seate d l e g e x te n sio n Seate d o r s ta n din g l e g c u rl ( s u pin e l a te p hase o nly ) Sta n din g c alf r a is e ( w ith out s ig nif ic an t w eig ht o n s h ould ers ) Dum bbell c u rl Tric ep s p ush -d ow n 511 F ig u re 1 4.2 Early -p hase r e h ab ilita tiv e e x erc is e s: ( a ) s e ate d l e g e x te n sio n, ( b ) s ta n din g l e g c u rl, ( c ) s ta n din g c alf r a is e , ( d ) d um bbell c u rl, a n d ( e ) tr ic ep s p ush -d ow n.

512 513 Photo s c o urte sy o f M ark A . P atte rs o n.

Mid phase R eh ab ilit a tiv e E xercis e s ( 4 -6 w k P ostd is c h arg e) Dum bbell b en t- o ver r o w Seate d r o w Late ra l d um bbell r a is e Should er p re ss Tric ep s k ic k back 514 Fig u re 1 4.3 Mid phase r e h ab ilita tiv e e x erc is e s: ( a ) d um bbell b en t- o ver ro w , ( b ) s e ate d r o w , ( c ) l a te ra l d um bbell r a is e , ( d ) s h ould er p re ss, a n d ( e ) tr ic ep s k ic k back .

515 Photo s c o urte sy o f M ark A . P atte rs o n.

Late -P hase R eh ab ilit a tiv e E xercis e s ( 6 w k o r M ore P ostd is c h arg e) Lat p ull- d ow n Dum bbell b en ch p re ss Dum bbell f ly Fro nt r a is e 516 Fig u re 1 4.4 Late -p hase r e h ab ilita tiv e e x erc is e s: ( a ) l a t p ull- d ow n, ( b ) dum bbell b en ch p re ss, ( c ) d um bbell f ly , a n d ( d ) f ro nt r a is e .

517 Photo s c o urte sy o f M ark A . P atte rs o n.

The p ote n tia l b en efits o f r e sis ta n ce t r a in in g i n t h e r e v asc u la riz ed popula tio n i n clu de i m pro vin g m usc u la r s tr e n gth a n d e n dura n ce an d possib ly a tte n uatin g t h e h eart r a te a n d b lo od p re ssu re r e sp onse t o a n y giv en w ork lo ad ( lo w er w ork lo ad o n t h e h eart) . G en era l re sis ta n ce t r a in in g guid elin es f o r c ard ia c r e h ab ilita tio n a re p re se n te d i n P atie n t’ s G uid e f o r Resis ta n ce T ra in in g. R is k s tr a tif y in g patie n ts t o d ete rm in e e lig ib ility i s im porta n t.

Patie n t’s G uid e f o r R esis ta n ce T ra in in g Choose a n i n itia l w eig ht y ou c an c o m fo rta b ly l if t f o r 1 2 t o 1 5 re p etitio ns; a s y ou p ro gre ss o ver t im e, i n cre ase t h e w eig ht acco rd in gly s o t h at y our m usc le s w ill g et s ig nif ic an tly t ir e d by 1 0 t o 1 2 r e p etitio ns b ut y ou a re n ot s tr u gglin g t o c o m ple te th em .

Avoid t ig ht g rip pin g d urin g p ush in g, p ullin g, a n d l if tin g ex erc is e s.

Do n ot h old y our b re ath d urin g t h e a ctiv ity . E xhale d urin g t h e ex ertio n p hase , a n d a v oid s tr a in in g.

Perfo rm t w o o r t h re e s e ts o f e ach e x erc is e , a n d t r a in t h re e tim es p er w eek .

Rest 3 0 t o 4 5 s b etw een s e ts .

In cre ase w eig ht m odestly ( 1 -2 l b , o r 0 .5 -1 .0 k g) a fte r y ou c an easily p erfo rm 1 2 t o 1 5 r e p etitio ns o f a g iv en w eig ht.

518 Ran ge o f M otio n Each e x erc is e s e ssio n b eg in s w ith a s e rie s o f r a n ge o f m otio n a n d fle x ib ility e x erc is e s d esig ned t o m ain ta in o r i m pro ve t h e ra n ge o f m otio n aro und j o in ts a n d m ain ta in o r i m pro ve f le x ib ility o f m ajo r m usc le g ro ups ( fig ure 1 4.5 ). T he e x erc is e s b eg in i n t h e s ta n din g p ositio n ( o r s e ate d i n a ch air , i f t h e p ers o n h as d if fic u lty s ta n din g) w ith t h e n eck , pro gre ssin g dow nw ard t o t h e s h ould ers a n d t r u nk a n d e v en tu ally t o t h e l o w er ex tr e m itie s. T he f in al s tr e tc h es f o r t h e i m pro vem en t of p oste rio r l e g musc le s a n d l o w er b ack f le x ib ility m ay b e p erfo rm ed o n t h e f lo or, o r i n a ch air f o r t h ose w ith d if fic u lty gettin g t o t h e f lo or.

519 F ig u re 1 4.5 Str e tc h in g e x erc is e s: ( a ) h ead t o s h ould er, ( b ) a rm c ir c le s, ( c ) l a te ra l a rm o ver h ead , ( d ) s h ould er s h ru g, ( e ) s e ate d h am str in g s tr e tc h , a n d ( f ) c alf s tr e tc h in g.

520 521 Photo s c o urte sy o f M ark A . P atte rs o n.

The f o llo w in g a re e x am ple s o f s tr e tc h es f o r t h e r e v asc u la riz ed p atie n t.

Patie n ts w ho u nderw en t a n o pen -h eart p ro ced ure s h ould perfo rm s tr e tc h es with c au tio n i n t h e e arly s ta g es a fte r h osp ita l d is c h arg e. P atie n ts s h ould d o th e s tr e tc h es d aily , a n d i d eally multip le t im es a d ay , b ut s h ould t a k e e ach str e tc h o nly t o t h e p oin t w here t h ey m ay f e el s o m e m ild t u ggin g o n t h e ste rn oto m y site ; t h e s tr e tc h s h ould n ot b e p ain fu l.

Head t o s h ould er Arm c ir c le s Late ra l a rm o ver h ead Should er s h ru g Seate d h am str in g s tr e tc h Calf s tr e tc h in g Tab le 1 4.4 o utlin es e x erc is e p re sc rip tio n f o r r e v asc u la riz ed p atie n ts .

522 Pra ctic a l A pplic a tio n 1 4.3 Rese a rch F ocu s: E arlie r P ro gressio n a n d F ew er Restr ic tio n s C on cern in g S tr en gth T ra in in g Guid elin es f o r s ta rtin g a n d p ro gre ssin g s tr e n gth t r a in in g a fte r re v asc u la riz atio n m ay o ccasio nally b e c o nsid ere d o verly re str ic tiv e, as m an y t a sk s o f d aily l iv in g d em an d l if tin g o r p ullin g obje cts t h at e x ceed t h e s u ggeste d s tr e n gth t r a in in g w eig ht l im its .

Clin ic ia n s m ay u se c lin ic al j u dgm en t t o s ta rt s tr e n gth t r a in in g a t earlie r s ta g es w hile t a k in g i n to c o nsid era tio n t h e p atie n t’ s prio r co nditio nin g a n d e x perie n ce w ith s tr e n gth t r a in in g e x erc is e s, a s well a s t h e k now le d ge t h at n o a b so lu te c o ntr a in dic atio ns to str e n gth t r a in in g a re p re se n t. A r e cen t p ositio n s ta n d s u ggests e arly pro gre ssiv e u se o f s tr e n gth t r a in in g e v en f o r c ard ia c patie n ts w hen ex erc is e s a re s e le cte d i n div id ually , w ith s a fe ty a n d e ffic acy o f re sis ta n ce e x erc is e i n m in d ( 7 7). T his m eth od puts v ario us s tr e n gth tr a in in g e x erc is e s i n to c ate g orie s b y t h eir p ote n tia l t o c au se h arm to t h e p atie n t ( s u ch a s d am ag e t o th e s te rn um o f t h e C A BS patie n t) .

Rev asc u la riz a tio n E xercis e K ey P atie n t A dvic e CA BS p atie n ts a re v ery p ro te ctiv e o f t h eir s te rn oto m y s ite s an d a re s o m etim es r e lu cta n t t o d o r a n ge o f m otio n a n d 523 str e tc h in g ex erc is e s. B e v ery p ers is te n t i n e n su rin g t h ey a re perfo rm in g e x erc is e s t o r e sto re n orm al f u nctio n t o u pper b ody movem en ts as s o on a s p ossib le t o l im it f u tu re i s su es w ith upper b ody s tr e n gth a n d f le x ib ility .

Red uced a rm s w in g w ill r e d uce s tr id e l e n gth a n d h en ce walk in g s p eed ; i f n ot c o rre cte d r e la tiv ely q uic k ly , t h is c o uld hav e an a d vers e e ffe ct o n w eek ly e x erc is e .

Access t o e q uip m en t t h at c an b e t itr a te d a t m in ute i n cre m en ts in w ork lo ad i s v ery i m porta n t a s c ard ia c p atie n ts h av e l o w le v els of f itn ess, e sp ecia lly i n t h e i m med ia te p osto pera tiv e perio d, s o e q uip m en t s u ch a s s ta tio nary c y cle s m ay n eed t o b e ad ju ste d in t in y 2 W att i n cre m en ts i n w ork lo ad t o acco m modate s e v ere ly d eco nditio ned p atie n ts .

Rev asc u la riz ed p atie n ts s o m etim es f e el c u re d o f t h eir d is e ase ; th e r e h ab ilita tio n t e am n eed s t o r e in fo rc e p ro per l if e sty le an d med ic al m an ag em en t t o e n su re c o ntin ued l o w er r is k o f f u tu re card ia c e v en ts a n d h osp ita liz atio ns.

Man y r e v asc u la riz ed p atie n ts a re o n β -b lo ck er m ed ic atio ns, whic h m ak es e x erc is e p re sc rip tio n b y h eart r a te d if fic u lt i f n ot im possib le . I t i s b ette r t o u se r a tin g o f p erc eiv ed e x ertio n; sp en d t im e h elp in g t h em “ fe el” h ow h ard t o b e e x erc is in g when th ey a re o n t h eir o w n, a n d h elp t h em g et s o m e p ra ctic al ex perie n ce i n u nders ta n din g t h e s e n sa tio n o f p ro per e x erc is e in te n sity .

While m an y r e v asc u la riz ed p atie n ts s tr u ggle w ith d ep re ssio n, so m e a re o n t h e o th er e n d o f t h e s p ectr u m a n d f e el b ette r t h an th ey h av e i n y ears ; t h ese p atie n ts m ay b e t o o a g gre ssiv e i n pro gre ssin g e x erc is e .

Con clu sio n Advan ces i n c o ro nary r e v asc u la riz atio n p ro ced ure s a n d a n a g in g popula tio n h av e l e d t o a g re ate r n um ber o f p atie n ts p re se n tin g fo r re h ab ilita tio n f o llo w in g C A BS, P C TA , a n d s te n tin g. P re h ab ilita tio n a n d oth er i n te rv en tio ns m ay b ette r p re p are p atie n ts fo r s u rg ery a n d r e su lt i n bette r a d here n ce t o p osts u rg ery e x erc is e r e h ab ilita tio n ( 7 6). I n a d ditio n t o ex erc is e p ro gra m min g, ris k f a cto r m odif ic atio n i s e sse n tia l f o r p re v en tio n of r e cu rre n t e v en ts ( 2 1, 5 9). F urth erm ore , b arrin g n o n ew s y m pto m s, t h e GXT, a lth ough a g ood p ro gnostic t o ol, m ay b ette r s e rv e i ts p urp ose o f 524 asse ssin g f u nctio nal s ta tu s i f i t i s p ostp oned u ntil la te r i n t h e r e h ab ilita tio n pro gra m . P ro vid ed t h at n o u nto w ard e v en ts o ccu r o ver t h e c o urs e o f re h ab ilita tio n, C A BS a n d P T C A patie n ts u su ally o utp erfo rm t h eir M I co unte rp arts , a ch ie v in g g re ate r f itn ess i m pro vem en ts a t a f a ste r r a te .

Go o nlin e t o r e v ie w t h e w eb r e so urc e c ase s tu dy a n d d is c u ssio n q uestio ns fo r t h is c h ap te r.

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