title: An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Regular Physical Exercise and Low‐Fat Diet: Effects on Progression of Coronary Artery Disease Improved Exercise Tolerance and Quality of Life With Cardiac Rehabilitation of Older Patients After Myocardial Infarction: Results of a Randomized, Controlled Trial Early programmes of high and low intensity exercise and quality of life after acute myocardial infarction. Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease Randomized controlled evaluation shows the effectiveness of a home-based cardiac rehabilitation program. Physiologic and related behavioral outcomes from the Women’s Lifestyle Heart Trial Treadmill test responses to an early exercise program after myocardial infarction: a randomized study. Attenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical exercise. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction Serum cholesterol, lifestyle, working capacity and quality of life in patients with coronary artery disease. Experiences from a hospital-based secondary prevention programme. All-cause mortality of patients with dyslipidemia up to 19 years after a multidisciplinary lifestyle modification programme: a randomized trial Long-Term Effects of a Multimodal Behavioral Intervention on Myocardial Perfusion—a Randomized Controlled Trial Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease. Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease [Physical training at ambulatory-polyclinical stage in complex rehabilitation and secondary prevention of patients with ischemic heart disease after acute incidents. 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Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial Cardiac rehabilitation and survival in older coronary patients. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. A 1 year follow-up randomized controlled study. High-intensity interval training may reduce in-stent restenosis following percutaneous coronary intervention with stent implantation A randomized controlled trial evaluating the relationship to endothelial function and inflammation. A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. 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Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide Training after myocardial infarction: lack of long-term effects on physical capacity and psychological variables. Long-term effects of a comprehensive rehabilitation programme after myocardial infarction. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. Effects of exercise training on HbA1c and VO2peak in patients with type 2 diabetes and coronary artery disease: A randomised clinical trial Exercise after myocardial infarction: a controlled trial. Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program. 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Effects of home-based rehabilitation on health-related quality of life and psychological status in Chinese patients recovering from acute myocardial infarction. REDUCTION IN SUDDEN DEATHS BY A MULTIFACTORIAL INTERVENTION PROGRAMME AFTER ACUTE MYOCARDIAL INFARCTION
abstract: Of 22 r and omized trials of rehabilitation with exercise  after myocardial infa rct ion ( MI ) , one trial had results that achieved conventional statistical significance . To determine whether or not these studies , in the aggregate , show a significant benefit of rehabilitation after myocardial infa rct ion , we performed an overview of all r and omized trials , involving 4,554 patients ; we evaluated total and cardiovascular mortality , sudden death , and fatal and nonfatal reinfa rct ion . For each endpoint , we calculated an odds ratio ( OR ) and 95 % confidence interval ( 95 % CI ) for the trials combined . After an average of 3 years of follow-up , the ORs were significantly lower in the rehabilitation than in the comparison group : specifically , total mortality ( OR = 0.80 [ 0.66 , 0.96 ] ) , cardiovascular mortality ( OR = 0.78 [ 0.63 , 0.96 ] ) , and fatal reinfa rct ion ( OR = 0.75 [ 0.59 , 0.95 ] ) . The OR for sudden death was significantly lower in the rehabilitation than in the comparison group at 1 year ( OR = 0.63 [ 0.41 , 0.97 ] ) . The data were compatible with a benefit at 2 ( OR = 0.76 [ 0.54 , 1.06 ] ) and 3 years ( OR = 0.92 [ 0.69 , 1.23 ] ) , but these findings were not statistically significant . For nonfatal reinfa rct ion , there were no significant differences between the two groups after 1 ( OR = 1.09 [ 0.76 , 1.57 ] ) , 2 ( OR = 1.10 [ 0.82 , 1.47 ] ) , or 3 years ( OR = 1.09 [ 0.88 , 1.34 ] ) of follow-up . The observed 20 % reduction in overall mortality reflects a decreased risk of cardiovascular mortality and fatal reinfa rct ion throughout at least 3 years and a reduction in sudden death during the 1st year after infa rct ion and possibly for 2 - 3 years . With respect to the independent effects of the physical exercise component of cardiac rehabilitation , the relatively small number of " exercise only " trials , combined with the possibility that they may have had a formal or informal nonexercise component precludes the possibility of reaching any definitive conclusion . To do so would require a r and omized trial of sufficient size to distinguish between no effect and the most plausible effect based on the results of this overview BACKGROUND Recent clinical trials have shown that modification of plasma lipoprotein concentrations can favorably alter progression of coronary atherosclerosis , but no data exist on the effects of a comprehensive program of risk reduction involving both changes in lifestyle and medications . This study tested the hypothesis that intensive multiple risk factor reduction over 4 years would significantly reduce the rate of progression of atherosclerosis in the coronary arteries of men and women compared with subjects r and omly assigned to the usual care of their physician .  METHODS AND RESULTS Three hundred men ( n = 259 ) and women ( n = 41 ) ( mean age , 56 + /- 7.4 years ) with angiographically defined coronary atherosclerosis were r and omly assigned to usual care ( n = 155 ) or multifactor risk reduction ( n = 145 ) . Patients assigned to risk reduction were provided individualized programs involving a low-fat and -cholesterol diet , exercise , weight loss , smoking cessation , and medications to favorably alter lipoprotein profiles . Computer-assisted quantitative coronary arteriography was performed at baseline and after 4 years . The main angiographic outcome was the rate of change in the minimal diameter of diseased segments . All subjects underwent medical and risk factor evaluations at baseline and yearly for 4 years , and reasons for all hospitalizations and deaths were documented . Of the 300 subjects r and omized , 274 ( 91.3 % ) completed a follow-up arteriogram , and 246 ( 82 % ) had comparative measurements of segments with visible disease at baseline and follow-up . Intensive risk reduction result ed in highly significant improvements in various risk factors , including low-density lipoprotein cholesterol and apolipoprotein B ( both , 22 % ) , high-density lipoprotein cholesterol ( + 12 % ) , plasma triglycerides ( -20 % ) , body weight ( -4 % ) , exercise capacity ( + 20 % ) , and intake of dietary fat ( -24 % ) and cholesterol ( -40 % ) compared with relatively small changes in the usual-care group . No change was observed in lipoprotein(a ) in either group . The risk-reduction group showed a rate of narrowing of diseased coronary artery segments that was 47 % less than that for subjects in the usual-care group ( change in minimal diameter , -0.024 + /- 0.066 mm/y versus -0.045 + /- 0.073 mm/y ; P < .02 , two-tailed ) . Three deaths occurred in each group . There were 25 hospitalizations in the risk-reduction group initiated by clinical cardiac events compared with 44 in the usual-care group ( rate ratio , 0.61 ; P = .05 ; 95 % confidence interval , 0.4 to 0.9 ) . CONCLUSIONS Intensive multifactor risk reduction conducted over 4 years favorably altered the rate of luminal narrowing in coronary arteries of men and women with coronary artery disease and decreased hospitalizations for clinical cardiac events Background Significant regression of coronary and femoral atherosclerotic lesions has been documented by angiographic studies using aggressive lipid-lowering treatment . This study tested the applicability and effects of intensive physical exercise and low-fat diet on coronary morphology and myocardial perfusion in nonselected patients with stable angina pectoris . Methods and Results Patients were recruited after routine coronary angiography for stable angina pectoris ; they were r and omized to an  intervention group ( n = 56 ) and a  control group on “ usual care ” ( n = 57 ) . Treatment comprised intensive physical exercise in group training sessions ( minimum , 2 hr/wk ) , daily home exercise periods ( 20 min/d ) , and low-fat , low-cholesterol diet ( American Heart Association recommendation , phase 3 ) . No lipid-lowering agents were prescribed . After 12 months of participation , repeat coronary angiography was performed ; relative and minimal diameter reductions of coronary lesions were measured by digital image processing . Change in myocardial perfusion was assessed by 201TI scintigraphy . In patients participating in the intervention group , body weight decreased by 5 % ( p<0.001 ) , total cholesterol by 10 % ( p<0.001 ) , and triglycerides by 24 % ( p<0.001 ) ; high density lipoproteins increased by 3 % ( p = NS ) . Physical work capacity improved by 23 % ( p<0.0001 ) , and myocardial oxygen consumption , as estimated from maximal rate-pressure product , by 10 % , ( p<0.05 ) . Stress-induced myocardial ischemia decreased concurrently , indicating improvement of myocardial perfusion . Based on minimal lesion diameter , progression of coronary lesions was noted in nine patients ( 23 % ) , no change in 18 patients ( 45 % ) , and regression in 13 patients ( 32 % ) . In the control group , metabolic and hemodynamic variables remained essentially unchanged , whereas progression of coronary lesions was noted in 25 patients ( 48 % ) , no change in 18 patients ( 35 % ) , and regression in nine patients ( 17 % ) . These changes were significantly different from the intervention group ( p<0.05 ) . Conclusions In patients participating in regular physical exercise and low-fat diet , coronary artery disease progresses at a slower pace compared with a control group on usual care Background —Whether cardiac rehabilitation ( CR ) is effective in patients older than 75 years , who have been excluded from most trials , remains unclear . We enrolled patients 46 to 86 years old in a r and omized trial and assessed the effects of 2 months of post-myocardial infa rct ion ( MI ) CR  on total work capacity ( TWC , in kilograms per meter ) and health-related quality of life ( HRQL ) . Methods and Results —Of 773 screened patients , 270 without cardiac failure , dementia , disability , or contraindications to exercise were r and omized to outpatient , hospital-based CR ( Hosp-CR ) , home-based CR ( Home-CR ) , or no CR within 3 predefined age groups ( middle-aged , 45 to 65 years ; old , 66 to 75 years ; and very old , > 75 years ) of 90 patients each .  TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline , after CR , and 6 and 12 months later . Within each age group , TWC improved with Hosp-CR and Home-CR and was unchanged with no CR . The improvement was similar in middle-aged and old persons but smaller , although still significant , in very old patients . TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR .  HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients . Complications were similar across treatment and age groups . Costs were lower for Home-CR than for Hosp-CR . Conclusions —Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group . However , with lower costs and more prolonged positive effects , Home-CR may be the treatment of choice in low-risk older patients OBJECTIVE --To determine whether a group programme of light exercise could improve quality of life in patients after acute myocardial infa rct ion to the same extent as a high intensity exercise training programme . SETTING --Australian teaching hospital . PATIENTS --224 men from a consecutive series of 339 men under 70 admitted to a coronary care unit with transmural acute myocardial infa rct ion . INTERVENTION-- Patients were r and omly allocated in hospital to a group programme lasting eight weeks of either high intensity exercise training or light exercise . MAIN OUTCOME MEASURES --Physical working capacity based on metabolic equivalents achieved from treadmill exercise tests at entry , after 11 weeks , and after one year . Quality of life based on self report scores of anxiety , depression , denial , and wellbeing and interview assessment s of activities and psychosocial adjustment at entry , after four months , and after one year . RESULTS --The two groups were well matched at entry . At 11 weeks the mean results of treadmill testing were 10.7 ( 95 % confidence interval 10.20 to 11.20 ) metabolic equivalents for exercise training and 9.7 ( 9.26 to 10.14 ) for light exercise ( t = 2.85 , df = 181 , p = 0.005 ) . Apart from this small temporary benefit in mean physical working capacity , there were no significant differences between groups . Improvement in occupational adjustment score from baseline to four months was greater after exercise training than after light exercise , but at one year repeated measures analysis of variance showed no significant effects of treatment or interaction between treatment and time point . CONCLUSION --The effects on quality of life of a low cost programme of light exercise are similar to those obtained from a high intensity exercise training programme Background : The CardioFit internet-based expert system was design ed to promote physical activity in patients with coronary heart disease ( CHD ) who were not participating in cardiac rehabilitation . Design : This r and omized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes . Methods : A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and r and omly assigned to either  CardioFit  ( n = 115 ) or  usual care ( n = 108 ) . The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking . They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist . Usual care consisted of physical activity guidance from an attending cardiologist .  Physical activity was measured by pedometer and self-reported over a 7-day period , 6 and 12 months after r and omization . Results : The CardioFit internet-based physical activity expert system significantly increased objective ly measured ( p = 0.023 ) and self-reported physical activity ( p = 0.047 ) compared to usual care . Emotional ( p = 0.038 ) and physical ( p = 0.031 ) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care . Conclusions : Patients with CHD using an internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care . Use of the CardioFit program could extend the reach of rehabilitation and secondary -prevention services OBJECTIVE To evaluate the effectiveness of a home-based cardiac rehabilitation ( CR ) program on post-coronary arteries bypass graft patients . METHODS This is a r and omized study conducted in King Fahd Armed Forces Hospital , Jeddah , Kingdom of Saudi Arabia between June 2008 and January 2010 . Forty-nine participants were r and omized to either a control group ( st and ard hospital treatment , n=21 ) or an intervention group ( home-based CR , n=28 ) . Data were collected before hospital discharge ( baseline test ) and repeated 6 months after hospital discharge ( follow-up test ) . RESULTS There were no significant differences between the groups in the body mass index , hemodynamics , serum fasting lipid profile , and Quality of Life question naire ( QoL ) ( p>0.05 ) , with differences in physical function and Hospital Anxiety and Depression Scales ( HADS ) ( p<0.05 ) at the baseline test . At the follow-up test , the intervention group showed greater improvement in health-related QoL and risk factors compared to the control group , with significant differences in fasting blood glucose , triglycerides , high density lipoprotein cholesterol , physical function , and both QoL and HADS question naires ( p<0.05 ) . The intervention group also demonstrated significant improvements in QoL , HADS , body mass index , heart rate , high density lipoprotein cholesterol and physical function ( p<0.05 ) , while significant differences were observed in the control group in heart rate , QoL and physical function ( p<0.05 ) . CONCLUSION The home-based CR program improves health-related QoL and risk factor profiles for patients following coronary arteries bypass graft to greater extent than the st and ard hospital care The Women ’s Lifestyle Heart Trial was a small ( N=28 ) r and omized controlled trial to evaluate the effects of a comprehensive lifestyle self-management program ( very low-fat vegetarian diet , stress-management training , exercise , group support , and smoking cessation ) on reduction of cardiovascular risk factors in postmenopausal women with coronary heart disease ( CHD ) . Women assigned to the treatment condition ( Prime Time ) participated in a week-long retreat followed by twice-weekly 4-hour meetings . Endpoints were program adherence ; changes in lipid profiles , body mass , blood pressure , hypolipidemic and antihypertensive medications ; and quality of life . Risk factor and psychosocial evaluations were conducted at baseline and at 4 , 12 , and 24 months . Repeated measures analyses of covariance revealed that the dietary , stress management , and physical activity changes made by intervention women were dramatic and lasting . There were significantly greater improvements in the Prime Time condition compared to the usual care control group on body mass , angina symptoms , and quality of life , and a tendency for a greater reduction in blood pressure-lowering medications . Similar patterns were seen in lipids , blood pressure , and lipid-lowering medications , but did not reach significance . These results demonstrate that postmenopausal CHD women can make lasting lifestyle changes , and that these changes may reduce the need for cardiac medications and improve CHD risk factors and quality of life The effects of an exercise program started early after myocardial infraction and the added effects of an outpatient teaching-counseling program were studied . At r and om , 84 patients were allocated to a control group ( A ) , 88 patients to an exercise group ( B1 ) and 86 patients to an exercise and teaching-counseling group ( B2 ) . The same exercise program was prescribed for patients in groups B1 and B2 and was started about 4.5 days after myocardial infa rct ion and continued for 3 months . The outpatient teaching-counseling program consisted of eight group sessions pertaining to risk factor reduction and psychosocial adjustment to myocardial infraction . A low-level treadmill test and an exercise test were performed at 3 months and the exercise test was repeated at 6 months . The clinical , hemodynamic and electrocardiographic responses to these tests were not different among the three groups . However , by the end of 3 months , patients in group B1 and B2 reported walking greater distances than patients in group A. The incidence of morbidity and mortality was not different between the groups . No deleterious or beneficial physiologic effects of an exercise program either by itself or combined with a teaching-counseling program were demonstrated . Routine medical care and our interventions were equally effective in permitting the spontaneous hemodynamics improvements after myocardial infraction . More than 3 months after myocardial infa rct ion , the group as a whole manifested spontaneous recovery in the form of a significant decrease in resting heart rate ( p less than 0.001 ) and a significant increase in systolic and diastolic blood pressure at rest and with submaximal exercise ( p less than 0.001 ) . No further improvements were observed between 3 and 6 months BACKGROUND It was the aim of this study to assess the long-term effects of physical exercise and low-fat diet on the progression of coronary artery disease . At the beginning of the study , 113 male patients with coronary artery disease were r and omized to an intervention group ( n=56 ) or a control group ( n=57 ) ; 90 patients ( 80 % ) could be reevaluated after 6 years . METHODS AND RESULTS Patients in the intervention group ( n=40 ) showed a reduction in total serum cholesterol ( 6.03+/-1.03 versus 5.67+/-1.01 mmol/L ; P<.03 ) and triglyceride levels ( 1.94+/-0.8 versus 1.6+/-0.89 mmol/L ; P<.005 ) and maintained their initial body mass index ( 26+/-2 versus 27+/-2 kg/m2 ; P = NS ) , but results were not statistically different from the control group ( n=50 ) ( total serum cholesterol , 6.05+/-1.02 versus 5.79+/-0.88 mmol/L ; triglycerides , 2.25+/-1.28 versus 1.85+/-0.96 mmol/L [ both P = NS ] ; body mass index , 26+/-2 versus 28+/-3 kg/m2 [ P<.0001 ] ) . In the intervention group , there was a significant 28 % increase in physical work capacity ( 166+/-59 versus 212+/-89 W ; P<.001 ) , whereas values remained essentially unchanged in the control group ( 165+/-51 versus 170+/-60 W ; P = NS ; between groups , P<.05 ) . In the intervention group , coronary stenoses progressed at a significantly slower rate than in the control group ( P<.0001 ) . Energy expenditure during exercise was assessed in a subgroup ; patients with regression of coronary stenoses spent an average of 1784+/-384 kcal/wk ( approximately 4 hours of moderate aerobic exercise per week ) . Multivariate regression analysis identified only physical work capacity as independently contributing to angiographic changes . CONCLUSIONS After 6 years of multifactorial risk intervention , there is significant and persistent improvement in lipoprotein levels and physical work capacity , which results in a significant retardation of disease progression . These beneficial effects appear to be largely due to chronic physical exercise Background It is widely believed that cardiac rehabilitation following acute myocardial infa rct ion ( MI ) reduces mortality by approximately 20 % . This belief is based on systematic review s and meta-analyses of mostly small trials undertaken many years ago . Clinical management has been transformed in the past 30–40 years and the findings of historical trials may have little relevance now . Objectives The principal objective was to determine the effect of cardiac rehabilitation , as currently provided , on mortality , morbidity and health-related quality of life in patients following MI . The secondary objectives included seeking programmes that may be more effective and characteristics of patients who may benefit more . Design , setting , patients , outcome measures A multi-centre r and omised controlled trial in representative hospitals in Engl and and Wales compared 1813 patients referred to comprehensive cardiac rehabilitation programmes or discharged to ‘ usual care ’ ( without referral to rehabilitation ) .  The primary outcome measure was all-cause mortality at 2 years . The secondary measures were morbidity , health service use , health-related quality of life , psychological general well-being and lifestyle cardiovascular risk factors at 1 year . Patient entry ran from 1997 to 2000 , follow-up of secondary outcomes to 2001 and of vital status to 2006 . A parallel study compared 331 patients in matched ‘ elective ’ rehabilitation and ‘ elective ’ usual care ( without rehabilitation ) hospitals . Results There were no significant differences between patients referred to rehabilitation and controls in mortality at 2 years ( RR 0.98 , 95 % CI 0.74 to 1.30 ) or after 7–9 years ( 0.99 , 95 % CI 0.85 to 1.15 ) , cardiac events , seven of eight domains of the health-related quality of life scale ( ‘ Short Form 36 ’ , SF36 ) or the psychological general well-being scale . Rehabilitation patients reported slightly less physical activity . No differences between groups were reported in perceived overall quality of cardiac aftercare . Data from the ‘ elective ’ hospitals comparison concurred with these findings . Conclusion In this trial , comprehensive rehabilitation following MI had no important effect on mortality , cardiac or psychological morbidity , risk factors , health-related quality of life or activity . This finding is consistent with systematic review s of all trials reported since 1983 . The value of cardiac rehabilitation as practised in the UK is open to question Coronary artery diseases ( CAD ) are main causes of morbidity and hospitalisation in western countries and CAD patients are at considerable risk of suffering further cardiac events . The development and evaluation of secondary prevention programmes therefore an important task . This thesis includes investigations on CAD patients admitted to a secondary prevention programme at Malmö University Hospital , Malmö , Sweden . Four weeks after discharge from the hospital , consecutive male and female patients aged 50 - 70 years with acute myocardial infa rct ion ( AMI ) or treated with coronary artery bypass grafting ( CABG ) surgery  were r and omised to a hospital organised preventive intervention or to usual follow-up at their general practitioners . In the three studies using this r and omised design , 87 ( study II ) , 90 ( study IV ) , and 106 ( study V ) intervention patients were available for evaluation . In addition , without r and omisation , lipid levels at four weeks after the event was compared with levels estimated within 24 hours after onset of symptoms in 141 AMI patients ( study I ) , and quality of life ( QL ) were estimated by question naire at one month and at one year after the event in 266 AMI , 94 CABG , and 16 percutaneous transluminal coronary angioplasty ( PTCA ) patients ( study III ) . The prevention programme was effective in improving food habits but showed no impact on smoking habits or physical exercise in AMI patients ( study II ) . The intervention also did not show any significant improvement in working capacity in AMI and CABG patients . However , working capacity improved in both intervention and reference CABG patients , most probably due to improved coronary circulation from the surgery ( study IV ) . Cholesterol levels decreased significantly in AMI and CABG intervention patients as compared to the corresponding reference patients . This difference most likely was due to a higher frequency of lipid lowering drugs used in the intervention patients ( study V ) . The prevention programme also decreased body mass index significantly in AMI but not in CABG patients ( study V ) . In AMI patients receiving thrombolysis , cholesterol levels estimated within 24 hours after onset of symptoms and at four weeks after the event were virtually equal . In AMI patients not receiving thrombolysis , the lipid estimates from four weeks after the event were slightly , but significantly , above the within 24 hours from onset of symptoms estimates ( study I ) . One month after the event , both somatic and psychological aspects of QL were negatively affected in AMI and CABG patients compared to population controls . One year after the event , patients differed from controls mainly in somatic symptoms ( study III ) . Thus , the intervention programme was most successful in affecting lipid levels and food habits in AMI patients .  QL was considerably affected in patients following an cardiac event , especially during the initial recovery phase . In addition , in patients receiving thrombolysis , cholesterol levels estimated four weeks after an AMI are reasonably valid estimates of baseline values and may be used to decide about lipid lowering interventions Background : Many studies have shown that individual lifestyle factors are associated with cardiovascular mortality and all-cause mortality . Observational studies of comprehensive programmes have reported risk reductions . The objectives were to assess the long-term all-cause mortality by diagnosis in patients referred to a lifestyle modification programme  , aim ed at combating coronary heart disease and stroke . Methods : A r and omized trial with 325 patients referred to the centre between 1988 and 1989 for dyslipidemia , hypertension , type 2 diabetes and coronary heart disease ; 239 patients were r and omized to the programme , 86 r and omized to usual care . Cases were admitted to the centre in groups of 30 for a 4-week residential comprehensive activity , in total 114 full-time hours , focusing on food preferences and selection s , and physical exercise . The activities were repeated during a 4-day revisit to the centre 1 year and 5 years after the 4-week intervention . Controls were referred back to their doctors , mainly in primary care , for usual care . Main outcome measure was all-cause mortality during 11–12 and 18–19 years after intervention . Results : At follow-up 11–12 years after referral , the relative risk reduction ( RRR ) was 76 % with the intention-to-treat analysis among cases admitted for dyslipidemia ( hazards ratio 0.24 , confidence interval 0.06–0.89 , P = 0.033 ) . After 18–19 years , the RRR was 66 % ( hazards ratio 0.34 , confidence interval 0.13–0.88 , P = 0.026 ) . No RRR was found for the other three diagnoses . Conclusion : Patients admitted for dyslipidemia reached a real long-term RRR of all-cause mortality . They had by definition a need for this programme Background Recent advances in drug therapy question as to the additional impact behavioral interventions may have on the prognosis of patients with clinical ly stable coronary heart disease ( CHD ) . Purpose The aim of the study was to evaluate the effects of a multimodal , behavioral intervention on myocardial perfusion ( MP ) and cardiac events , compared to st and ardized cardiologic care , in patients with stable CHD . Methods Seventy-seven CHD patients ( age 54.2 ± 6.9 years , male 87 % ) were r and omly assigned to a behavioral intervention plus st and ardized cardiologic care ( INT , n = 39 ) or st and ardized cardiologic care alone ( CO , n = 38 ) . MP was assessed by 201Thallium MP-scintigrams ( SPECT ) at baseline , after 2 , 3 , and 7 years , respectively . Subsequent cardiac events ( MI , PCI , CABG ) were assessed using the cardiologists ’ charts . Results Sixty-five patients ( 84 % ) completed the study . In all patients , the course of MP was significantly better in INT analysis of variance ( ANOVA group × time p = 0.001 ) ; this was also true for patients without subsequent PCI/CABG ( ANOVA group × time p = 0.002 ) . Incidence of cardiac events was significantly associated with INT ( 6 vs. 14 ; log rank test p = .047 ) . Conclusion The study suggests additional long-term benefits of a behavioral intervention  on myocardial perfusion and cardiac events in patients with stable CHD compared to st and ardized cardiologic care only BACKGROUND This study examined whether a supervised exercise program improved 19-year survival in 30- to 64-year-old male myocardial infa rct ion patients . METHODS AND RESULTS The men ( n=651 ) were participants in the National Exercise and Heart Disease Project , a 3-year multicenter r and omized clinical trial conducted in the United States ( 1976 - 1979 ) . The treatment group ( n=315 ) exercised for 8 weeks in a laboratory . Thereafter , they jogged , cycled , or swam in a gymnasium/pool setting guided by an individualized target heart rate . Participants in the control group ( n=319 ) were to maintain normal routines but not participate in any regular exercise program . Participants were followed up until their death or December 31 , 1995 . Cox proportional hazards analysis revealed the all-cause mortality risk estimates ( 95 % CIs ) in the exercise group compared with controls to be 0.69 ( 0.39 to 1.25 ) after an average follow-up of 3 years , 0.84 ( 0.55 to 1.28 ) after 5 years , 0.95 ( 0.71 to 1.29 ) after 10 years , 1.02 ( 0.79 to 1.32 ) after 15 years , and 1.09 ( 0.87 to 1 . 36 ) after 19 years . Cardiovascular disease ( CVD ) mortality risk estimates ( 95 % CI ) for the same follow-up periods were 0.73 ( 0.37 to 1.43 ) , 0.98 ( 0.60 to 1.61 ) , 1.21 ( 0.79 to 1.60 ) , 1.14 ( 0.84 to 1.54 ) , and 1.16 ( 0.88 to 1.52 ) . However , each 1-MET increase in work capacity from baseline to the end of the original trial result ed in consistent reductions in all-cause and CVD mortality risk at each follow-up period , regardless of initial work-capacity level . CONCLUSIONS These findings indicate exercise-program participation result ed in nonsignificantly reduced mortality risks early in the follow-up period . Benefits diminished as time since participation increased , which suggests that the protective mechanisms associated with the program may be short term . Contamination between groups over time could also explain the diminished effects , because increased work capacity provided survival benefits up to 19 years OBJECTIVE To examine and evaluate improvements in cardiorespiratory fitness , psychological wellbeing , quality of life , and vocational status in postmyocardial infa rct ion patients during and after a comprehensive 12 month exercise rehabilitation programme . SUBJECTS The sample population comprised 124 patients with a clinical diagnosis of myocardial infa rct ion ( 122 men and two women ) . INTERVENTIONS 62 patients were r and omly allocated to a regular weekly aerobic training programme , three times a week for 12 months , and compared with 62 matched controls who did not receive any formal exercise training . A five year follow up question naire/interview was subsequently conducted on this population to determine selected vocational/lifestyle changes . RESULTS Significant improvements in cardiorespiratory fitness ( p < 0.01 - 0.001 ) , psychological profiles ( p < 0.05 - 0.001 ) , and quality of life scores ( p < 0.001 ) were recorded in the treatment population when compared with their matched controls . Although there were no significant differences in mortality , a larger percentage of the regular exercisers resumed full time employment and they returned to work earlier than the controls . Controls took lighter jobs , lost more time from work , and suffered more non-fatal reinfa rct ions ( p < 0.05 - 0.01 ) . CONCLUSIONS Regularly supervised and prolonged aerobic exercise training improves cardiorespiratory fitness , psychological status , and quality of life . The trained population also had a reduction in morbidity following myocardial infa rct ion , and significant improvement in vocational status over a five year follow up period A prospect i ve , r and omized , controlled clinical trial in patients with coronary artery disease ( CAD ) and a concurrent physical disability evaluated the effects of a home exercise training program on cardiovascular function and blood lipids .  Eighty-eight men between the ages of 42 and 72 years ( mean 62 ) with documented CAD and a physical disability with functional use of > or = 2 extremities including 1 arm were r and omized to either a 6-month home exercise training program using wheelchair ergometry or to a control group that received usual and customary care .  Both groups received dietary instructions and were requested to follow a fat-controlled diet .  Exercise test variables with echocardiography and blood lipids were measured at baseline and at 6 months . The home exercise training group significantly improved both peak exercise left ventricular ejection fraction ( p = 0.007 ) and fractional shortening ( p = 0.01 ) between baseline to 6 months , whereas the control group showed no significant changes . Exercise training effects of decreased resting heart rate ( p = 0.03 ) and decreased peak rate pressure product ( p = 0.03 ) were also found in the treatment group . No exercise-related cardiac complications occurred . Both groups significantly ( p < or = 0.01 ) increased high-density lipoprotein cholesterol levels . These results indicate that physically disabled men with CAD can safely participate in a home exercise training program which may result in intrinsic cardiac benefits . The metabolic cost of activities of daily living imposed on this disabled population may also have a positive effect on high-density lipoprotein cholesterol levels Background Exercise improves the clinical outcome of patients with coronary artery disease ( CAD ) ; however , the ideal exercise duration for each patient remains unclear . Objective To investigate the effects of exercise duration on arterial elastic properties and antioxidant/pro-oxidant mechanisms in patients with CAD . Design , setting , patients , interventions Sixty male patients with CAD were r and omised into two groups , and underwent exercise for 30 min or 60 min in a crossover design with 2 weeks ' wash-out period . In all participants aortic and radial blood pressures ( BP ) and arterial elastic properties ( augmentation index (AIx)/pulse wave velocity ( PWV ) ) were determined at baseline and 24 h after exercise .  Plasma malonyldialdehyde ( MDA ) and superoxide dismutase (SOD)1 and SOD2 levels were also measured . Results Exercise had no effect on aortic and radial BP ( p = NS for all ) . Walking for 30min improved AIx ( from 33.79±0.91 % to 31.73±0.86 % , p<0.001 ) and PWV ( from 9.26±0.95 m/s to 9.06± 0.21 m/s , p<0.001 ) , while exercise for 60min had adverse effects on vascular stiffness ( for AIx : from 33.37± 0.93 % to 33.73± 1.05 % , p = NS and for PWV : from 9.25±0.19 m/s to 9.37±0.21 m/s , p<0.05 mainly in older patients ) . Exercise for 60min was associated with a significant 20 % increase in MDA levels ( p<0.05 ) . Exercise had no effects on SOD1 levels , however it significantly increased SOD2 levels after 30min ( from 2.26±0.22ng/mL to 2.36±0.18ng/mL , p<0.05 ) but not after 60min ( p = NS ) . Conclusion Shorter exercise duration was associated with favourable antioxidant and vascular effects , while longer exercise blunted these beneficial effects and was accompanied by adverse effects on vascular function , mainly in older coronary patients . Further studies are required to explore the hypothesis that a more individualised approach to the selection of the appropriate exercise programme should be considered for patients with CAD AIM To investigate efficacy of early and long term physical training ( PT ) of moderate intensity in conditions of practical health care in Russia in patients with ischemic heart disease ( IHD ) of able to work age - survivors of acute coronary events . MATERIAL AND METHODS Three hundred ninety two patients were enrolled in this study . They were r and omized into intervention group " O " ( n=197 ) and control group " C " ( n=195 ) . Inclusion period was 3- 8 weeks from onset of myocardial infa rct ion ( MI ) , unstable angina ( UA ) , or intervention on coronary arteries . Patients were followed up for 1 year and efficacy of intervention was assessed by results of laboratory ( levels of lipids ) , instrumental ( ECG , exercise test on veloergometer , echocardiography ) , and clinical examination . In the group " O " regimen of PT with work loads of moderate intensity ( 50 - 60 % of power achieved during exercise test ) was used . Duration of FT was 45 - 60 min , frequency - 3 times a week . All patients received st and ard therapy for IHD and a lipid lowering drug when indicated . RESULTS Proofs of efficacy of PT in the given contingent of patients were obtained . This was manifested by significant increase of physical working capacity : prolongation of exercise time ( + 31.7 % , p<0.001 ) , increases of volume of work performed ( + 74.3 % , p<0.001 ) and efficiency of cardiac work according to results of exercise tests . All parameters were significantly different from those in the group " C " . Structural functional parameters of the heart also improved in the group " O " : left ventricular ( LV ) stroke volume increased 4.5 % ( p<0.005 ) , ejection fraction increased 7.2 % ( p<0.001 ) , diastolic LV volume decreased 2.5 % ( p<0.05 ) , systolic LV volume decreased 8.1 % ( p<0.001 ) . In the group " C " stroke volume and LV ejection fraction rose to a lesser degree - by 5.5 % ( p<0.01 ) and 2.9 % ( p<0.05 ) , respectively . Differences between groups in dynamics of these parameters turned out to be significant ( p<0.05 ) . Moreover in group " C " LV diastolic volume increased 2.3 % ( p<0.05 ) and systolic volume did not change , while left atrium increased 3.4 % ( p<0.002 ) . At intergroup comparison differences in dynamics of these parameters were significant ( p<0.005 ) . Analysis of lipid profile after 1 year showed no changes in patients of group " C " , while in group " O " it revealed significant ( 3.6 % ) lowering of total ( T ) cholesterol ( CH ) ( p<0.05 compared with baseline and change in group " C " ) and elevation of high density lipoprotein ( HDL ) CH ( + 12.3 % , p<0.001 ; compared with group " C " p<0.005 ) . Atherogeneity index TCH/HDLCH decreased 8.5 % in the group " O " ( p<0.01 ) , and increased 12 % ( p<0.02 ) in the group " C " , difference between groups was statistically significant ( p<0.001 ) . In the group " O " body mass index decreased 2.8 % ( p<0.001 ) , and frequency of attacks of angina decreased 50.8 % ( p<0.001 ; compared with group " C " p<0.001 ) . Statistically significant differences were registered between the following parameters of composite end point and surrogate points : total number of cardiovascular events - 26 ( 14.8 % ) vs 47 ( 27 % ) , p<0.01 ; number of cardiovascular catastrophes - 5 ( 3 % ) vs 15 ( 8.7 % ) , p<0.05 ; number of days out of work because of exacerbation of IHD per 1 person/year - 2.4 vs 4.2 , p<0.05 in groups " O " and " C " , respectively . Thus in the group " O " positive effect of PT on the course and outcomes of the disease was registered compared with the group " C " . CONCLUSION The data obtained are indicative of sufficient efficacy of the used program of PT and feasibility of its application in practice of ambulatory rehabilitation of patients with IHD - survivors of acute coronary events . It also can be looked upon as a method of secondary prevention as results of the study showed its positive impact on risk factors and outcomes of the disease Background In cardiac rehabilitation , 40 - 60-min exercise training sessions are advised . However , because of the increasing coronary artery disease ( CAD ) prevalence and higher workload for cardiac rehabilitation centres , it remains unclear whether 40-min exercise training sessions are equally effective as 60-min exercise training sessions . Design Prospect i ve r and omized clinical trial . Methods One hundred and thirty-four CAD patients were included in a 7-week rehabilitation programme . All patients exercised 3 days per week , at a heart rate corresponding to 65 % of baseline peak oxygen uptake ( VO2peak ) . Patients were r and omized in two groups : 40 versus 60-min exercise training sessions .  Changes of body anthropometrics , resting haemodynamics , exercise capacity and ventilatory threshold , blood plasma lipid profile and C-reactive protein level were assessed . Results As a result of rehabilitation , exercise capacity , ventilatory threshold , and blood plasma lipid profile improved significantly in the total population ( P < 0.05 ) , without differences between subgroups ( P > 0.05 ) . Body weight and waist circumference decreased significantly in total population ( P < 0.01 ) , but with a greater magnitude in the 40 versus 60-min exercise session group ( P < 0.05 ) . Conclusions In the early rehabilitation of CAD patients , 40-min exercise training sessions seem to be at least as effective for improving body anthropometrics , blood plasma lipid profile and exercise capacity , as compared with 60-min exercise training sessions . Eur J Cardiovasc Prev Rehabil 15:453 - 459 © 2008 The European Society of Cardiology INTRODUCTION AND OBJECTIVES Very little information is available on the effect of cardiac rehabilitation programs on long-term survival . The primary aim of this study was to assess the effect of a structured cardiac rehabilitation program on mortality in patients who had suffered acute myocardial infa rct ion . The secondary endpoint was the effect on morbidity . PATIENTS AND METHOD The study included 180 low-risk male patients aged under 65 years . Patients were r and omly assigned to one of 2 groups : 90 entered into a comprehensive cardiac rehabilitation program , and 90 served as a control group . The mean follow-up period was 10 years . RESULTS All-cause mortality was significantly lower in the intervention group : the 10-year survival rate was 91.8 % in the intervention group compared with 81.7 % in the control group ( P=.04 ) . There was also a decrease in cardiovascular mortality , though it was not statistically significant : the 10-year survival rate was 91.8 % in the intervention group compared with 83.8 % in the control group ( P=.10 ) . The incidence of non-fatal complications was lower in the intervention group ( 35.2 % vs 63.2 % , P=.03 ) , as was the incidence of unstable angina ( 15.7 % vs 33.9 % , P = .02 ) and cardiac heart failure ( 3.0 % vs 14.4 % , P=.02 ) , and the need for coronary intervention ( 8.4 % vs 22.9 % , P=.02 ) . CONCLUSIONS The application of a comprehensive cardiac rehabilitation program significantly decreased long-term mortality and morbidity in low-risk patients after acute myocardial infa rct ion AIMS In a multifactorial lifestyle behaviour programme , of 2 years duration , to study the maintenance of achieved behaviour and risk factor-related changes . METHODS AND RESULTS Out of a consecutive population of 151 patients treated with percutaneous transluminal angioplasty under 65 years of age , 87 were r and omly allocated to an intervention group ( n=46 ) or to a control group ( n=41 ) . The programme started with a 4 week residential stay , which was focused on health education and the achievement of  behaviour change .  During the first year of follow-up , a maintenance programme included regular contacts with a nurse , while no further rehabilitative efforts were offered during the second year . One patient died ( control ) . During the second year the proportion of hospitalized patients was lower in the intervention group ( 4 % vs 20%;P<0.05 ) . Patients in the intervention group improved several lifestyle dependent behaviours : diet ( index at 0 , 12 and 24 months ) : 10.5+/-3 . 4 , 12.9+/-2.5 and 12.4+/-2.6 in the intervention group ( I ) vs 10 . 1+/-3.2 , 10.7+/-3.0 and 11.8+/-3.2 in the control group (C);P<0.05 , exercise sessions per week : 2.5+/-2.3 , 4.5+/-1.9 and 4.4+/-2.1 ( I ) vs 3.1+/-2.2 , 3.5+/-2.3 and 3.7+/-2.7 (C);P<0.05 , and smoking ; 18 % , 6 % and 9 % ( I ) vs 12 % , 21 % and 18 % (C);P<0.05 . This corresponded to improvement in exercise capacity ( 0 , 12 and 24 months ) : 156+/-42 , 174+/-49 and 165+/-47 W ( I ) vs 164+/-40 , 163+/-49 and 156+/-48 watts (C);P<0.05 . There were no significant differences between the two groups with regard to serum cholesterol levels at 0 and 24 months : 5 . 4+/-0.8 and 5.2+/-0.9 mmol . l(-1)(I ) vs 5.4+/-1.0 and 4.9+/-0.9 mmol . l(-1)(C ) ; ns , low density lipoprotein cholesterol level : 3.6+/-0.8 and 3.4+/-0.8 mmol . l(-1)(I ) vs 3.7+/-0.9 and 3.3+/-0.7 mmol . l(-1)(C ) ; ns , triglyceride level : 2.2+/-1.6 and 1.8+/-1.3 mmol . l(-1)(I ) vs 2.2+/-1.4 and 1.6+/-0.6 mmol . l(-1)(C ) ; ns , body mass index ( 0 , 12 and 24 months ) : 27.5+/-4.5 , 27.0+/-4.3 and 27.4+/- 4.5 kg . m(-2)(I ) vs 26.8+/-2.8 , 26.9+/-2.7 and 26.9+/- 3.2 kg . m(-2)(C ) ; ns , waist/hip ratio or blood pressure . The two groups did not differ in quality of life , or psychological factors . Return to work after 12 and 24 months was 74 % and 78 % ( I ) vs 68 % and 61 % ( C ) ; ns . CONCLUSION This rehabilitation programme influenced important lifestyle behaviour and reduced some , but not all , important risk Introduction Systematic review er authors intending to include all r and omized participants in their meta-analyses need to make assumptions about the outcomes of participants with missing data . Objective The objective of this paper is to provide systematic review er authors with a relatively simple guidance for addressing dichotomous data for participants excluded from analyses of r and omized trials . Methods This guide is based on a review of the Cochrane h and book and published method ological research . The guide deals with participants excluded from the analysis who were considered ‘ non-adherent to the protocol ’ but for whom data are available , and participants with missing data . Results Systematic review er authors should include data from ‘ non-adherent ’ participants excluded from the primary study authors ' analysis but for whom data are available . For missing , unavailable participant data , authors may conduct a complete case analysis ( excluding those with missing data ) as the primary analysis . Alternatively , they may conduct a primary analysis that makes plausible assumptions about the outcomes of participants with missing data . When the primary analysis suggests important benefit , sensitivity meta-analyses using relatively extreme assumptions that may vary in plausibility can inform the extent to which risk of bias impacts the confidence in the results of the primary analysis . The more plausible assumptions draw on the outcome event rates within the trial or in all trials included in the meta- analysis . The proposed guide does not take into account the uncertainty associated with assumed events . Conclusions This guide proposes methods for h and ling participants excluded from analyses of r and omized trials . These methods can help in establishing the extent to which risk of bias impacts meta- analysis results OBJECTIVE To estimate the incremental effects on cost and quality of life of  cardiac rehabilitation after an acute coronary syndrome . DESIGN Open r and omised controlled trial with 1 year 's follow-up . Analysis was on an intention-to-treat basis . SETTING Two tertiary hospitals in Sydney . INTERVENTION 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor . PARTICIPANTS 113 patients aged 41 - 75 years who were self-caring and literate in English . Patients with uncompensated heart failure , uncontrolled arrhythmias , severe and symptomatic aortic stenosis or physical impairment were excluded . MAIN OUTCOME MEASURES Costs ( hospitalisations , medication use , outpatient visits , investigations , and personal expenses ) ; and measures of quality of life . Incremental cost per quality -adjusted life year ( QALY ) saved at 1 year ( this estimate combines within- study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality ) . Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival , 3 years of treatment effect on survival and variations in utility . RESULTS The estimated incremental cost per QALY saved for  rehabilitation  relative to st and ard care was 42,535 US dollars when modelling included the reported treatment effect on survival . This increased to 70,580 US dollars per QALY saved if treatment effect on survival was not included . The results were sensitive to variations in utility and ranged from 19,685 US dollars per QALY saved to rehabilitation not being cost-effective . CONCLUSIONS The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome . The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee To evaluate the efficacy of exercise training for increasing functional capacity in the 6 months after clinical ly uncomplicated myocardial infa rct ion , 198 men 52 + /- 9 years of age participated in a training study . They were r and omly assigned to one of four exercise protocol s : 8 to 26 weeks of training at home ( group 1 , n = 66 ) or in a group program ( group 2 , n = 61 ) following treadmill testing performed 3 weeks after infa rct ion , treadmill testing at 3 weeks without subsequent training ( group 3 , n = 34 ) , and treadmill testing for the first time at 26 weeks ( control , n = 37 ) . At 26 weeks functional capacity was significantly higher in patients training at home or in a group program than that in patients without training or in control patients : 8.1 + /- 1.5 , 8.5 + /- 1.3 , 7.5 + /- 1.8 , and 7.0 + /- 1.7 METs , respectively ( p less than .05 and p less than .001 ) . No significant differences in functional capacity were noted between patients training at home and those in a group program . No training-related complications occurred . Home and group training are equally effective in increasing functional capacity of low-risk patients after myocardial infa rct ion Objective To compare home-based cardiac rehabilitation ( CR ) with usual care ( control group with no rehabilitation ) in elderly patients who declined participation in centre-based CR . Design R and omised clinical trial with 12 months follow-up and mortality data after 5.5 years ( mean follow-up 4½ years ) . Setting Rehabilitation unit , Department of Cardiology , Copenhagen , Denmark . Participants Elderly patients ≥65 years with coronary heart disease . Intervention A physiotherapist made home visits in order to develop an individualised exercise programme that could be performed at home and surrounding outdoor area . Risk factor intervention , medical adjustment , physical and psychological assessment s were offered at baseline and after 3 , 6 and 12 months . Main outcome measurements The primary outcome was 6 min walk test ( 6MWT ) . Secondary outcomes were blood pressure , body composition , cholesterol profile , cessation of smoking , health-related quality of life ( HRQoL ) , anxiety and depression . Results 40 patients participated . The study population was characterised by high age ( median age 77 years , range 65–92 years ) and high level of comorbidity . Patients receiving home-based CR had a significant increase in the primary outcome 6MWT of 33.5 m ( 95 % CI : 6.2 to 60.8 , p=0.02 ) at 3 months , whereas the usual care group did not significantly improve , but with no significant differences between the groups . At 12 months follow-up , there was a decline in 6MWT in both groups ; −55.2 m ( 95 % CI : 18.7 to 91.7 , p<0.01 ) in the home group and −52.1 m ( 95 % CI : −3.0 to 107.1 , p=0.06 ) in the usual care group . There were no significant differences in blood pressure , body composition , cholesterol profile , cessation of smoking or HRQoL after 3 , 6 and 12 months follow-up . Conclusions Participation in home-based CR improved exercise capacity among elderly patients with coronary heart disease , but there was no significant difference between the home intervention and the control group . In addition , no significant difference was found in the secondary outcomes . When intervention ceased , the initial increase in exercise capacity was rapidly lost OBJECTIVES This study assessed the effects of cardiac rehabilitation ( CR ) on survival in a large cohort of older coronary patients . BACKGROUND R and omized controlled trials and meta-analyses have shown that CR improves survival . However , trial participants have been predominantly middle-aged , low- or moderate-risk , white men . METHODS The population consisted of 601,099 U.S. Medicare beneficiaries who were hospitalized for coronary conditions or cardiac revascularization procedures . One- to 5-year mortality rates were examined in CR users and nonusers using Medicare cl aims and 3 analytic techniques : propensity-based matching , regression modeling , and instrumental variables . The first method used 70,040 matched pairs , and the other 2 techniques used the entire cohort . RESULTS Only 12.2 % of the cohort used CR , and those users averaged 24 sessions . Each technique showed significantly lower ( p < 0.001 ) 1- to 5-year mortality rates in CR users than nonusers . Five-year mortality relative reductions were 34 % in propensity-based matching , 26 % from regression modeling , and 21 % with instrumental variables . Mortality reductions extended to all demographic and clinical subgroups including patients with acute myocardial infa rct ions , those receiving revascularization procedures , and those with congestive heart failure . The CR users with 25 or more sessions were 19 % relatively less likely to die over 5 years than matched CR users with 24 or fewer sessions ( p < 0.001 ) . CONCLUSIONS Mortality rates were 21 % to 34 % lower in CR users than nonusers in this socioeconomically and clinical ly diverse , older population after extensive analyses to control for potential confounding . These results are of similar magnitude to those observed in published r and omized controlled trials and meta-analyses in younger , more selected population AIMS Cardiac rehabilitation including exercise training is of proven value in ischaemic heart disease . However , elderly patients frequently are not encouraged to participate in such programmes . This study evaluates the physiological effects and self-reported quality of life after an aerobic outpatient group-training programme in subjects above the age of 65 years . METHODS AND RESULTS A consecutive series of 101 patients ( males 80 % ) aged 65 - 84 ( mean 71 ) years recovering from an acute coronary event were r and omized to either a supervised out patient group-training programme ( n=50 ) or to a control group ( n=51 ) . The two groups were well balanced as regards clinical characteristics . The compliance in the training group was 87 % . Exercise tolerance increased in the trained group from 104 to 122 and 111 W after 3 and 12 months respectively . The corresponding values were 102 , 105 and 105 W among controls . Parameters , such as quality of life , self-estimated level of physical activity , fitness and well-being were grade d higher by the trained patients than those who served as controls on the two occasions of follow-up . CONCLUSIONS Aerobic group-training of elderly patients recovering from an acute coronary event beneficially influences physical fitness and several parameters expressing quality of life . Great care has to be taken to preserve the initial effects by continued training BACKGROUND High-intensity interval training has been shown to be superior to moderate continuous exercise training in improving exercise capacity and endothelial function in patients with coronary artery disease . The objective of this study was to evaluate this training model on in-stent restenosis following percutaneous coronary intervention for stable or unstable angina . METHODS AND RESULTS We prospect ively r and omized 40 patients after percutaneous coronary intervention with implantation of a bare metal stent ( n = 30 ) or drug eluting stent ( n = 32 ) to a 6-month supervised high-intensity interval exercise training program  ( n = 20 ) or to a control group ( n = 20 ) . At six months , restenosis , measured as in-segment late luminal loss of the stented coronary area , was smaller in the training group 0.10 ( 0.52 ) mm compared to the control group 0.39 ( 0.38 ) mm ( P = .01 ) . Reduction of late luminal loss in the training group was consistent with both stent types . Peak oxygen uptake increased in the training and control group by 16.8 % and 7.8 % , respectively ( P < .01 ) . Flow-mediated dilation improved 5.2 % ( 7.6 ) in the training group and decreased -0.1 % ( 8.1 ) in the control group ( P = .01 ) . Levels of high-sensitivity C-reactive protein decreased by -0.4 ( 1.1 ) mg/L in the training group and increased by 0.1 ( 1.2 ) mg/L in the control group ( P = .03 for trend ) . CONCLUSIONS Regular high-intensity interval exercise training was associated with a significant reduction in late luminal loss in the stented coronary segment . This effect was associated with increased aerobic capacity , improved endothelium function , and attenuated inflammation OBJECTIVE To evaluate the long-term effect of a cardiac rehabilitation and prevention program ( CRPP ) on quality of life ( QOL ) and its cost effectiveness . DESIGN Prospect i ve , r and omized controlled trial . SETTING University-affiliated outpatient cardiac rehabilitation and prevention center . PARTICIPANTS A total of 269 patients ( 76 % men ; mean age , 64+/-11 y ) with recent acute myocardial infa rct ion ( AMI ; n=193 ) or after elective percutaneous coronary intervention ( PCI ; n=76 ) were r and omized in a ratio of 2 to 1 . INTERVENTION Patients received either CRPP ( an 8-wk exercise and education class in phase 2 ) or conventional therapy without exercise program ( control group ) . They were followed until they had completed all 4 phases of the program ( ie , 2 y ) . MAIN OUTCOME MEASURES QOL assessment s , by using the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) and Symptoms Question naire , were performed at the end of each phase . Direct health care cost was calculated , whereas cost utility was estimated as money spent ( in US dollars ) per quality -adjusted life-year ( QALY ) gained . RESULTS In the CRPP group , 6 of the 8 SF-36 dimensions improved significantly by phase 2 and were maintained throughout the study period . Patients were less anxious and depressed , and felt more relaxed and contented . In the control group , none of the SF-36 dimensions were improved by phase 2 , and bodily pain was increased . In phase 4 , only 4 dimensions were improved . Symptoms were unchanged except for increased hostility score . There was a significant gain in net time trade-off in the CRPP group after phase 2 . The direct health care expenses in the CRPP and control groups were 15,292 dollars and 15,707 dollars per patient , respectively . Therefore , the cost utility calculated was 640 dollars saved per QALY gained . Savings attributable to CRPP were primarily explained by the lower rate ( 13 % vs 26 % of patients , chi2 test=3.9 , P < .05 ) and cost of subsequent PCI ( P = .01 ) . CONCLUSIONS In an era of managing patients with coronary heart disease , a short-course CRPP was highly cost effective in providing better QOL to patients with recent AMI or after elective PCI . In addition , the improvement of QOL was quick and sustained for at least 2 years after CRPP BACKGROUND Current guidelines broadly recommend comprehensive cardiac rehabilitation ( CCR ) , although evidence for this is still limited . We investigated the 12-month effect of hospital-based CCR versus usual care ( UC ) for a broadly defined group of cardiac patients within the modern therapeutic era of cardiology . METHODS We conducted a central ly r and omized single-center clinical trial with blinded assessment of the primary outcome : registry-based composite of total mortality , myocardial infa rct ion , or acute first-time readmission due to heart disease . Other outcomes were hospitalization , risk profile , and quality of life . The trial included 770 participants ( 20 - 94 years ) with congestive heart failure ( 12 % ) , ischemic heart disease ( 58 % ) , or high risk of ischemic heart disease ( 30 % ) .  Comprehensive cardiac rehabilitation is composed of 6 weeks of intensive intervention and systematic follow-up for 10.5 months . RESULTS We r and omized 380 patients to CCR versus 390 to UC . R and omization was well balanced . The primary outcome occurred in 31 % of both groups ( relative risk 0.96 , 95 % confidence interval 0.78 - 1.26 ) . Compared with the UC group , CCR significantly reduced length of stay by 15 % ( 95 % confidence interval 1.1%-27.1 % , P = .04 ) , mean number of cardiac risk factors above target ( 4.5 vs 4.1 , P = .01 ) , patients with systolic blood pressure below target ( P = .003 ) , physically inactivity ( P = .01 ) , and unhealthy dietary habits ( P = .0003 ) . Short-Form-36 and Hospital Anxiety and Depression Scale did not differ significantly . CONCLUSION At 12 months , the CCR and UC groups did not differ regarding the primary composite outcome . Comprehensive cardiac rehabilitation significantly reduced length of hospital stay and improved cardiac risk factors IMPORTANCE Cardiovascular disease prevention , including lifestyle modification , is important but underutilized . Mobile health strategies could address this gap but lack evidence of therapeutic benefit . OBJECTIVE To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors . DESIGN AND SETTING The Tobacco , Exercise and Diet Messages ( TEXT ME ) trial was a parallel-group , single-blind , r and omized clinical trial that recruited 710 patients ( mean age , 58 [ SD , 9.2 ] years ; 82 % men ; 53 % current smokers ) with proven coronary heart disease ( prior myocardial infa rct ion or proven angiographically ) between September 2011 and November 2013 from a large tertiary hospital in Sydney , Australia . INTERVENTIONS Patients in the intervention group ( n = 352 ) received 4 text messages per week for 6 months in addition to usual care . Text messages provided advice , motivational reminders , and support to change lifestyle behaviors . Patients in the control group ( n=358 ) received usual care . Messages for each participant were selected from a bank of messages according to baseline characteristics ( eg , smoking ) and delivered via an automated computerized message management system . The program was not interactive . MAIN OUTCOMES AND MEASURES The primary end point was low-density lipoprotein cholesterol ( LDL-C ) level at 6 months . Secondary end points included systolic blood pressure , body mass index ( BMI ) , physical activity , and smoking status . RESULTS At 6 months , levels of LDL-C were significantly lower in intervention participants , with concurrent reductions in systolic blood pressure and BMI , significant increases in physical activity , and a significant reduction in smoking . The majority reported the text messages to be useful ( 91 % ) , easy to underst and ( 97 % ) , and appropriate in frequency ( 86 % ) . [ table : see text ] . CONCLUSIONS AND RELEVANCE Among patients with coronary heart disease , the use of a lifestyle-focused text messaging service compared with usual care result ed in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors . The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12611000161921 BACKGROUND Although recent meta- analysis trials have shown that exercise training may improve survival after myocardial infa rct ion , the mechanism of this beneficial effect is still unknown . The purpose of this study was to detect possible interactions between exercise training and predictors of prognosis after a first myocardial infa rct ion . METHODS AND RESULTS Patients with uneventful clinical courses after a first myocardial infa rct ion were r and omly assigned to a  4-week training period ( 125 patients , group 1 ) or to a  control group ( 131 patients , group 2 ) . Before r and omization , all patients underwent a symptom-limited exercise test ( 28 + /- 2 days after myocardial infa rct ion ) , 24-hour Holter monitoring , and coronary arteriography ( 31 + /- 3 days after the acute episode ) . After a mean follow-up period of 34.5 months , 18 patients had cardiac deaths ( 5 in group 1 and 13 in group 2 ) . Multivariate analysis by Cox regression model showed that ejection fraction was the only independent prognostic indicator ( P = .03 ) . Evidence existed of an interaction between ejection fraction and exercise training , showing an effect of physical training on survival that depended on the patient 's ejection fraction . Among patients with ejection fractions < 41 % , the relative risk for an untrained patient was 8.63 times higher than for a trained patient ( P = .04 ) , whereas for ejection fractions > 40 % , the estimated risks for trained and untrained patients were similar . CONCLUSIONS These data show that exercise training may prolong survival in post-myocardial infa rct ion patients with depressed left ventricular function . A r and omized trial in such patients seems warranted CONTEXT The Lifestyle Heart Trial demonstrated that intensive lifestyle changes may lead to regression of coronary atherosclerosis after 1 year . OBJECTIVES To determine the feasibility of patients to sustain  intensive lifestyle changes  for a total of 5 years and the effects of these lifestyle changes ( without lipid-lowering drugs ) on coronary heart disease . DESIGN R and omized controlled trial conducted from 1986 to 1992 using a r and omized invitational design . PATIENTS Forty-eight patients with moderate to severe coronary heart disease were r and omized to an  intensive lifestyle change group  or to a  usual-care control group  , and 35 completed the 5-year follow-up quantitative coronary arteriography . SETTING Two tertiary care university medical centers . INTERVENTION Intensive lifestyle changes ( 10 % fat whole foods vegetarian diet , aerobic exercise , stress management training , smoking cessation , group psychosocial support ) for 5 years . MAIN OUTCOME MEASURES Adherence to intensive lifestyle changes , changes in coronary artery percent diameter stenosis , and cardiac events . RESULTS Experimental group patients ( 20 [ 71 % ] of 28 patients completed 5-year follow-up ) made and maintained comprehensive lifestyle changes for 5 years , whereas control group patients ( 15 [ 75 % ] of 20 patients completed 5-year follow-up ) made more moderate changes . In the experimental group , the average percent diameter stenosis at baseline decreased 1.75 absolute percentage points after 1 year ( a 4.5 % relative improvement ) and by 3.1 absolute percentage points after 5 years ( a 7.9 % relative improvement ) . In contrast , the average percent diameter stenosis in the control group increased by 2.3 percentage points after 1 year ( a 5.4 % relative worsening ) and by 11.8 percentage points after 5 years ( a 27.7 % relative worsening ) ( P=.001 between groups . Twenty-five cardiac events occurred in 28 experimental group patients vs 45 events in 20 control group patients during the 5-year follow-up ( risk ratio for any event for the control group , 2.47 [ 95 % confidence interval , 1.48 - 4.20 ] ) . CONCLUSIONS More regression of coronary atherosclerosis occurred after 5 years than after 1 year in the experimental group . In contrast , in the control group , coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred The British Heart Foundation and the Chest , Heart and Stroke Association have allocated funds to develop cardiac rehabilitation programmes . We have recently completed and now evaluate an exercise-based rehabilitation course reinforced with advice about return to normal activity for 110 patients who had suffered acute myocardial infa rct ion . Patients admitted to the Plymouth cardiac care unit were r and omised into groups : a control group to receive st and ard hospital care , and a rehabilitation group who , in addition , received an exercise programme reinforced with advice . Patients were assessed at entry to the study and at intervals thereafter . Assessment was by question naire and objective tests consisting of a 12-minute walking test and weekly outpatient pedometry . In the rehabilitation group patients were able to walk further and faster , return to work earlier , undertake more housework , and resume normal sexual activity ; they were less short of breath and did not experience more angina . However , the rehabilitation course brought little benefit to the patients ' perception of well-being and their anxiety about health or their outlook on life .  Exercise and advice are important components of a rehabilitation programme , but more attention needs to be given to the psychological aspects of recovery from a heart attack BACKGROUND Disease management programs in which drugs are prescribed by dietitians or nurses have been shown to improve the coronary risk factor profile in patients with coronary heart disease . However , those disease management programs in which drugs are not prescribed by allied health professionals have not improved coronary risk factor status . The objective of the Coaching patients On Achieving Cardiovascular Health ( COACH ) study was to determine whether dietitians or nurses who did not prescribe medications could coach patients with coronary heart disease to work with their physicians to achieve the target levels for their total cholesterol ( TC ) and other risk factors . METHODS Multicenter r and omized controlled trial in which 792 patients from 6 university teaching hospitals underwent a stratified r and omization by cardiac diagnosis within each hospital : 398 were assigned to usual care plus The COACH Program and 394 to usual care alone .  Patients in The  COACH Program group  received regular personal coaching via telephone and mailings to achieve the target levels for their particular coronary risk factors . There was one coach per hospital . The primary outcome was the change in TC ( DeltaTC ) from baseline ( in hospital ) to 6 months after r and omization . Secondary outcomes included measurement of a wide range of physical , nutritional , and psychological factors . The analysis was performed by intention to treat . RESULTS The COACH Program achieved a significantly greater DeltaTC than usual care alone : the mean DeltaTC was 21 mg/dL ( 0.54 mmol/L ) ( 95 % confidence interval [ CI ] , 16 - 25 mg/dL [ 0.42 - 0.65 mmol/L ] ) in The COACH Program vs 7 mg/dL ( 0.18 mmol/L ) ( 95 % CI , 3 - 11 mg/dL [ 0.07 - 0.29 mmol/L ] ) in the usual care group ( P<.0001 ) . Thus , the reduction in TC from baseline to 6 months after r and omization was 14 mg/dL ( 0.36 mmol/L ) ( 95 % CI , 8 - 20 mg/dL [ 0.20 - 0.52 mmol/L ] ) greater in The COACH Program group than in the usual care group . Coaching produced substantial improvements in most of the other coronary risk factors and in patient quality of life . CONCLUSIONS Coaching , delivered as The COACH Program , is a highly effective strategy in reducing TC and many other coronary risk factors in patients with coronary heart disease .  Coaching has potential effectiveness in the whole area of chronic disease management Aims To investigate the effects of exercise training ( ET ) on left ventricular ( LV ) volumes , cardiopulmonary functional capacity and N-terminal pro-brain natriuretic peptide ( NT-proBNP ) levels in postinfa rct ion patients with moderate LV dysfunction . Methods Sixty-one postinfa rct ion patients were r and omized into two groups : group T [ n = 30 , LV ejection fraction ( EF ) 41.6 ± 11.3 % , mean ± SD ] entered a 6-month ET programme , whereas group C ( n = 31 , EF 42.0 ± 7.6 % , P = NS ) did not . NT-proBNP assay , Doppler-echocardiography and cardiopulmonary exercise test  were performed upon enrolment and at sixth months . Results At sixth months , trained patients showed an improvement in workload ( + 26 % , P<0.001 ) , Vo2peak ( + 31 % , P<0.001 ) , LV end-diastolic volume index ( LVEDVI ; −9 % , P<0.001 ) , a reduction in NT-proBNP ( −71 % , P<0.001 ) and a significant correlation between changes in NT-proBNP and in LVEDVI ( r=0.858 , P<0.001 ) . Baseline NT-proBNP correlated with changes in LVEDVI in both trained ( r=0.673 , P<0.001 ) and untrained ( r=0.623 , P<0.001 ) patients . Group C showed unfavourable LVEDVI dilation ( + 8 % , P<0.001 ; T vs. C group , P<0.001 ) and a smaller reduction in NT-proBNP ( −40 % , P<0.001 ; T vs. C group , P<0.001 ) . Conclusions Six month ET induced a favourable LV remodelling and a marked fall in NT-proBNP that could predict LV remodelling in postinfa rct ion patients with moderate LV dysfunction This study evaluated long-term effects of 12 weeks of supervised training , of at least 45 minutes duration with two sessions per week , on physical performance and  psychological well-being after myocardial infa rct ion ( MI ) . Sixty-nine patients were r and omized to either an exercise or a nonexercise group .  Maximum exercise capacity 6 weeks post-MI was inversely related to the acute peak aspartate aminotransferase values in serum , as an index of infa rct size . One year post-MI , the increase in level of fitness ( 10 % ) in the training group did not significantly exceed ( p = .10 ) that of the controls ( 2 % ) . No intergroup differences were registered in self-rated psychological well-being and physical scores or in the return to work rate . In the training group , but not in the controls , the change in perceived dyspnoea at leisure-time activities was positively related to the objective ly measured peak exercise capacity . We conclude that after MI only marginal improvements in physical performance are achieved 6 months after training is finished , with no long-term psychological benefits apparent versus a usual care program . The adaptive implication s of supervised conventional exercise programs post-MI are therefore question ed The aim of this study was to determine the long-term effects on myocardial infa rct ion ( MI ) patients of a six-month comprehensive rehabilitation programme ( CRP ) conducted by an interdisciplinary team regarding cardiac events , physical and psychological conditions , life habits , and cardiac health knowledge . The results of a multivariate analysis carried out five years after the MI showed that cardiac events and psychological condition were not significantly influenced by the CRP . However , it was found that the physical condition of the patients benefited from the CRP ;  self-reported physical fitness ( p < 0.002 ) and physical exercise test ( p < 0.007 ) . CRP participation was linked to significant modifications of life habits ( diet change ; p < 0.04 , sexual activity ; p < 0.000 ) . The cardiac health knowledge was significantly improved by participation in the CRP ( basic cardiac knowledge ; p < 0.005 ; knowledge about misconceptions ; p < 0.04 ) . In conclusion , CRPs have had positive long-term effects on physical condition , life habits and cardiac health knowledge . No such effects , however , were found regarding either cardiac events or psychological condition This investigation was design ed to determine the impact of a brief period of cardiac rehabilitation , initiated within 6 weeks of acute myocardial infa rct ion ( AMI ) , on both disease-specific and generic health-related quality of life , exercise tolerance and return to work after AMI . With a stratified , parallel group design , 201 low-risk patients with evidence of depression or anxiety , or both , after AMI , were r and omized to either an 8-week program of exercise conditioning and behavioral counseling or to conventional care . Although the differences were small , significantly greater improvement was seen in rehabilitation group patients at 8 weeks in the emotions dimension of a new disease-specific , health-related Quality of Life Question naire , in their state of anxiety and in exercise tolerance . All measures of health-related quality of life in both groups improved significantly over the 12-month follow-up period . However , the 95 % confidence intervals around differences between groups at the 12-month follow-up effectively excluded sustained , clinical ly important benefits of rehabilitation in disease-specific ( limitations , -2.70 , 1.40 ; emotions , -4.86 , 1.10 , where negative values favor conventional care and positive values favor rehabilitation ) and generic health-related quality of life ( time trade-off , -0.062 , 0.052 ; quality of well-being , -0.042 , 0.035 ) or in exercise tolerance ( -38.5 , 52.1 kpm/min ) ; also , return to work was similar in the 2 groups ( relative risk , 0.93 ; confidence interval , 0.71 , 1.64 ) . ( ABSTRACT TRUNCATED AT 250 WORDS Objective : Few exercise trials have focused on patients with both type 2 diabetes and coronary artery disease . We investigated the effects of 1 year of exercise training on HbA1c and VO2peak in these patients . Methods : Patients with type 2 diabetes and coronary artery disease ( n = 137 ) were r and omised to combined exercise training or control group .  HbA1c was measured at the beginning and end of the study . Changes in VO2peak , and also ventilatory threshold and time to exhaustion , were assessed by cardiopulmonary exercise testing . Results : No differences in changes between the r and omised groups were observed in HbA1c and VO2peak , whereas ventilatory threshold and time to exhaustion increased significantly in the exercise group compared with the controls ( p = 0.046 and p = 0.034 ) . In patients without previous acute myocardial infa rct ion and diabetes microvascular complications ( n = 46 ) , the exercise group did improve HbA1c and VO2peak compared with the controls ( p = 0.052 and p = 0.035 ) . Conclusion : No significant effects of exercise training on HbA1c or VO2peak were observed in patients with type 2 diabetes and coronary artery disease , although improvements were seen in patients without vascular complications beyond coronary artery disease , implying that the degree of vascular disease may influence exercise responses . Ventilatory threshold and time to exhaustion did increase significantly , indicating improved exercise performance despite the minor change in VO2peak Six weeks after acute myocardial infa rct ion , 303 men were r and omly divided into exercise and control groups . The exercise group attended the hospital gymnasium twice weekly for a three-month supervised exercise course . Both groups were exercise tested before and after the course and at subsequent follow-up . The exercise group increased their physical fitness greatly compared with the control group . Eight per cent of the exercise group died during the period of follow-up , compared with 14 per cent of the control group ; this difference is not significant . There was an apparent improvement in mortality in those with inferior MI who completed the exercise course , which was not seen in those with MI in other sites . For many patients after MI progressive exercise is safe , improves physical fitness and may reduce mortality for those after inferior MI BACKGROUND Cardiac rehabilitation ( CR ) is widely accepted as beneficial for patients with myocardial infa rct ion ( MI ) and coronary artery bypass graft ( CABG ) . A need exists to evaluate how different formats of delivery can best meet CR service dem and s. METHODS AND RESULTS Cardiac patients ( n = 60 ) were r and omly assigned to either a st and ard 10-week ( 30 sessions ) or a 4-week ( 20 sessions ) multifactorial rehabilitation program . Patients underwent exercise testing using the Bruce protocol before , immediately after , and then 6 months after CR . Patients also completed the SF-36 quality of life question naire and the Hospital Anxiety and Depression scale at each time point . Compared with pre-CR , exercise time and metabolic equivalents attained were significantly increased , and heart rate significantly decreased both immediately ( P<.05 ) and 6 months after CR ( P<.05 ) in both groups , with no between-group differences . Significant improvements ( P<.05 ) in energy , pain , and general health were reported after CR , and in energy and emotional and social well-being at 6 months after CR . No differences were seen between the groups . CONCLUSIONS Cardiac rehabilitation after MI and CABG significantly improved exercise capacity and general health and well-being . No significant differences were detected between groups undergoing a 10-week or 4-week course . These preliminary data suggest that shortened courses of CR may be beneficial to cardiac patients and such courses may also facilitate more widespread use of CR Table . SI Units Systematic modification of coronary risk factors is not integrated into the medical care provided to most of the more than 1 million patients treated annually in the United States for acute myocardial infa rct ion by percutaneous transluminal coronary angioplasty or coronary artery surgery .  Most of such patients have lipoprotein abnormalities [ 1 ] , and nearly one half smoke [ 2 ] . These risk factors , which contribute to subsequent morbidity and mortality , remain highly prevalent after acute cardiac events . Failure to integrate comprehensive risk factor modification into the st and ard medical care provided to patients after acute cardiac events primarily reflects the lack of an organizational framework or system . This deficiency in re source allocation for preventive and rehabilitative aspects of care in turn reflects the predominant orientation of the U.S. health care system to the management of acute illness [ 3 ] . Several clinical research studies have shown the effectiveness of risk factor modification , especially treatment of lipoprotein abnormalities [ 4 - 7 ] , in achieving regression of coronary artery lesions and reducing the clinical consequences of coronary artery disease [ 6 , 7 ] . However , risk factor interventions shown to be effective in clinical trials may not prove equally effective in clinical practice because of a paucity of re sources , especially nonphysician personnel . The lack of effective management systems limits the expected reduction in morbidity and mortality and the corresponding reduction in medical care costs that motivates current efforts to orient the priorities of the American health care system toward preventive and rehabilitative care . This r and omized , controlled trial compared the effectiveness of a physician-directed , nurse-managed , home-based case-management system for coronary risk factor modification with that of usual medical care . Outcomes were measured in both groups immediately after the end of the first year after acute myocardial infa rct ion . The term case-management system has been used in various context s. As used here , it refers to a system in which a nurse case-manager , working with different health care specialists ( a psychiatrist , a cardiologist , a lipid specialist , a nutritionist , and a nurse coordinator ) , managed coronary risk factors . Methods Enrollment and Orientation Program nurses enlisted patients on hospital day 3 or as soon as their medical condition stabilized . Study participants gave written informed consent to be r and omly assigned to a treatment group . Immediately after r and omization , program nurses introduced patients to the special intervention with the aid of a videotape . Usual Care The 585 patients in our study were cared for by 215 internists and 34 cardiologists in the five participating medical centers who were organized into practice groups of 5 to 10 physicians each . Cardiology consultation was often provided during hospitalization , but primary responsibility for follow-up care was generally assumed by internists . The usual care offered by the Kaiser Permanente Medical Care Program included physician counseling on smoking cessation and nutritionist counseling on dietary change during hospitalization and physician-managed , lipid-lowering drug therapy after hospital discharge . Group outpatient smoking cessation programs were available for a $ 50 fee . Group exercise rehabilitation , not generally provided by the Kaiser Permanente Medical Care Program during this study , was available to patients at various community facilities at an average cost of $ 1800 to $ 2700 for 3 months ' participation . Special Intervention The behavioral interventions in our case-management system , which were offered to the 293 patients in the intervention group in addition to usual care , were derived from social learning theory [ 8 , 9 ] and modified for medical problems [ 10 ] . In this model , persons must learn how to monitor the health habits they seek to change , set attainable sub goals to motivate and direct their efforts , use feedback of progress in ways that promote health , and enlist incentives and social support to sustain the effort needed to succeed [ 8 , 9 ] . In the hospital , patients were instructed on how to complete  self-reports [ status reports ] of smoking , dietary intake , and exercise .  Scheduled interactions between case managers and patients after discharge took three forms : 1 ) nurse-initiated telephone contacts ; 2 ) computer-generated progress reports mailed to patients based on question naires completed by patients and mailed to the nurses ; and 3 ) visits to the program nurse for treadmill exercise testing , initiation of lipid-lowering drug therapy , if indicated , and a single counseling session after a smoking relapse . The maximum number of treatment contacts during the year , including outcome measurement at 6 and 12 months , was as follows : 14 nurse-initiated telephone contacts , 8 patient visits to the blood chemistry laboratory , and 4 patient visits to the nurse case manager . Smoking Intervention Smoking was defined as the use of cigarettes , cigars , cigarillos , pipe tobacco , or any other form of tobacco in the 6 months before admission . Forty-three percent of patients were smokers . Patients who had smoked during the 6 months before hospitalization received the same intensive smoking cessation intervention during hospitalization ; this intervention has been described previously [ 11 ] . Physicians used a written script that enabled them to provide st and ardized counseling in less than 2 minutes . The hospital-based smoking cessation counseling focused on relapse prevention . Nurses conducted a st and ardized smoking history to evaluate patients ' addiction to smoking . Patients ' reported self-efficacy or confidence to resist smoking in each of 28 potentially high-risk situations was measured ; patients were then counseled on how to manage the situations in which they reported less than 70 % confidence . Patients also received a relapse prevention manual and a relaxation audiotape . They were advised that the nurse would telephone them 48 hours and 1 week after hospital discharge and at monthly intervals for as long as 6 months . Patients who relapsed were offered one additional visit with the nurse for further counseling . Nicotine polacrilex or transdermal nicotine patches were reserved for highly addicted patients who relapsed after hospital discharge . Nutritional Counseling A computer-based expert system developed by the investigators was used to provide nutritional counseling on a National Cholesterol Education Program [ 12 ] Step 2 diet that was low in cholesterol and saturated fat . A food frequency question naire design ed by the investigators was scored using the Cholesterol and Saturated Fat Index developed by Connor and colleagues [ 13 ] . Calculations of cholesterol and saturated fat totals were based on weekly rather than daily average food intakes . Data from the food frequency question naires , mailed by patients to the Stanford coordinating center and entered into a microcomputer , were used to generate progress reports that characterized patients ' dietary patterns , prioritized dietary change goals , and provided guides for managing difficult situations by directing patients to relevant sections of a nutrition workbook entitled Good Eating for Good Health developed by the program nutritionist . Patients in the intervention group completed a food frequency question naire during hospitalization that described their eating habits in the previous month . Patients also completed food frequency question naires 6 , 11 , and 26 weeks after admission . Progress reports were mailed to patients within 48 to 72 hours after the food frequency question naires were received . Detailed strategies for maintenance of dietary change were incorporated into the 26-week progress report . Question naires to evaluate outcomes were also completed at 36 and 52 weeks . Lipid-Lowering Drug Therapy The therapeutic goal of a plasma low-density lipoprotein (LDL)-cholesterol value of 2.46 mmol/L ( 95 mg/dL ) adopted for this trial was based on the mean post-treatment level of LDL cholesterol found in patients in the study by Blankenhorn and colleagues [ 4 ] . Patients with mean plasma LDL cholesterol values ( based on measurements in two separate blood sample s drawn 75 and 90 days after infa rct ion ) that exceeded this value were given initial drug therapy according to the four algorithms shown in Table 1 . Patients unable to tolerate bile acid-binding resin or nicotinic acid because of comorbid conditions or potentially adverse interactions with these agents received lovastatin or gemfibrozil . During a visit 90 days after discharge , the nurses did a brief physical examination and obtained a history relevant to hyperlipidemia . They provided detailed counseling to patients regarding the rationale for lipid-lowering drug therapy and ways to maximize drug efficacy and minimize drug side effects , and they advised patients on the schedule of laboratory visits and nurse-initiated follow-up telephone contacts . Table 1 . Initial Drug Therapy * Changes in drug therapy at 120 , 150 , and 180 days , which were coordinated by nurse-initiated telephone contacts , were based on three types of responses to initial therapy : 1 ) if lipoprotein levels returned to normal , the effective drug therapy was continued ; 2 ) if the response was incomplete , the dose of the effective medication was increased or another drug was added , or both ; and 3 ) if comorbid conditions worsened or blood chemistry abnormalities or intolerable side effects occurred , drug dosage was reduced or the patient was switched to another agent or both . A physician lipid specialist and a Stanford-based senior nurse-coordinator provided telephone consultation to the case managers . Before initiating lipid-lowering drug therapy at 90 days and at each subsequent step , nurses review ed the patients ' blood chemistry and lipoprotein values and elicited any symptoms requiring a change in therapy . The Background — Although preventive drug therapy is a priority after acute coronary syndrome , less is known about adherence to behavioral recommendations . The aim of this study was to examine the influence of adherence to behavioral recommendations in the short term on risk of cardiovascular events . Methods and Results — The study population included 18 809 patients from 41 countries enrolled in the Organization to Assess Strategies in Acute Ischemic Syndromes ( OASIS ) 5 r and omized clinical trial . At the 30-day follow-up , patients reported adherence to diet , physical activity , and smoking cessation . Cardiovascular events ( myocardial infa rct ion , stroke , cardiovascular death ) and all-cause mortality were documented to 6 months . About one third of smokers persisted in smoking . Adherence to neither diet nor exercise recommendations was reported by 28.5 % , adherence to either diet or exercise by 41.6 % , and adherence to both by 29.9 % . In contrast , 96.1 % of subjects reported antiplatelet use , 78.9 % reported statin use , and 72.4 % reported angiotensin-converting enzyme/angiotensin receptor blocker use . Quitting smoking was associated with a decreased risk of myocardial infa rct ion compared with persistent smoking ( odds ratio , 0.57 ; 95 % confidence interval , 0.36 to 0.89 ) . Diet and exercise adherence was associated with a decreased risk of myocardial infa rct ion compared with nonadherence ( odds ratio , 0.52 ; 95 % confidence interval , 0.4 to 0.69 ) . Patients who reported persistent smoking and nonadherence to diet and exercise had a 3.8-fold ( 95 % confidence interval , 2.5 to 5.9 ) increased risk of myocardial infa rct ion/stroke/death compared with never smokers who modified diet and exercise . Conclusions — Adherence to behavioral advice ( diet , exercise , and smoking cessation ) after acute coronary syndrome was associated with a substantially lower risk of recurrent cardiovascular events . These findings suggest that behavioral modification should be given priority similar to other preventive medications immediately after acute coronary syndrome . Clinical Trial Registration Information— URL : http:// clinical trials.gov/ct2/show/NCT00139815 . Unique identifier : NCT00139815 One hundred six postmyocardial infa rct ion subjects who either achieved a mean work load of less than seven mets on treadmill testing , who were rated as anxious and /or depressed , or who met both criteria , participated in a controlled study comparing the rehabilitation effectiveness of exercise therapy and group counseling . Each intervention lasted 12 weeks . Follow-up evaluations were scheduled at three months , six months and one year . Exercise substantially increased mean work capacity , decreased fatigue , lessened anxiety and depression , and promoted independence and sociability .  Counseling substantially reduced depression and promoted a sense of friendliness , and decreased interpersonal friction as well as greater independence and sociability . The control group reported no substantial change on any measured factor . Neither counseling nor exercise had an effect on mortality though subjects in the exercise group reported fewer major cardiovascular sequelae Two hundred patients who had suffered an acute myocardial infa rct ion 4 - 6 weeks before entered a r and omised controlled trial of  exercise treatment  at a community sports centre supervised by a general practitioner . Eighty one per cent of the treatment group continued to exercise until they returned to work and 73 % completed three months ' exercise . There were no serious complications of the exercise course . The prevalence of angina pectoris fell by 10 % in the treatment group but rose by 60 % in the control group . The perceived energy level rose by significantly more in the treatment group than in the controls . The rise in predicted maximum oxygen uptake was significantly greater in the treatment group than in the control group as was the reduction in the double product ( a reflection of myocardial workload ) at peak exercise . Coronary rehabilitation in the community can be both safe and effective Patients are generally advised to return to full normal activities , including work , 6 to 8 weeks after acute myocardial infa rct ion ( AMI ) . We assessed the outcomes of early return to normal activities , including work at 2 weeks , after AMI in patients who were stratified to be at a low risk for future cardiac events . Patients were considered for r and omization before discharge if they had no angina , had left ventricular ejection fraction > 40 % , a negative result from a symptom-limited exercise stress test for ischemia ( < 2 mm ST depression ) at 1 week , and achieved > 7 METs . Patients with left ventricular ejection fraction < 40 % were included only if they did not have inducible ventricular tachycardia at electrophysiologic studies . Seventy-two patients were r and omized to return to normal activities at 2 weeks and 70 patients to undergo st and ard cardiac rehabilitation and return to normal activities at 6 weeks after AMI . There were no deaths or heart failure in either group . There was no significant difference in the incidence of reinfa rct ion , revascularization , left ventricular function , lipids , body mass index , smoking , or exercise test results at 6 months . In conclusion , return to full normal activities , including work at 2 weeks , after AMI appears to be safe in patients who are stratified to a low-risk group . This should have significant medical and socioeconomic implication The effects of a rehabilitation programme  one year after myocardial infa rct ion ( MI ) were investigated in 171 patients under 65 years of age . These patients were allocated at r and om to rehabilitation and control groups before discharge from hospital . The groups were comparable with regard to age , sex and clinical data . The programme included physical exercise , counselling of patients and relatives , and social measures over a 3-month period during the convalescent stage . One year after MI patients in the rehabilitation group showed lower systolic blood pressure at rest and lower diastolic pressure on submaximal exercise than controls . No differences were found with regard to mean work capacity , days off work , return to work , psychological status , and underst and ing of the illness . At 12 months all patients were less physically and socially active than before MI , they were more dependent on their relatives than before , and they had poor underst and ing of their illness The study was set up to evaluate the long-term effects on mortality of a comprehensive rehabilitation and secondary prevention programme lasting 3 years after acute myocardial infa rct ion . The study group consisted of 375 consecutive , non-selected patients under 65 years of age r and omly allocated to an intervention group ( 188 patients ) or a control group ( 187 patients ) . After 15 years follow-up significantly lower incidence of sudden death ( 16.5 % vs 28.9 % , P = 0.006 ) and coronary mortality ( 47.9 % vs 58.5 % , P = 0.04 ) were seen in the intervention group compared with controls . Total mortality was 64.4 % and 66.8 % , respectively ( ns ) . The incidence of cancer death was 16 in the intervention group and three in the controls . Cardiac failure , enlarged heart , New York Heart Association functional class II or more and membership in the control group were significantly associated with coronary mortality during the first 3 years , and after 3 years enlarged heart , diabetes and reinfa rct ion were associated with late coronary death . Thus , comprehensive multifactorial intervention after acute myocardial infa rct ion had favourable long-term effects on coronary mortality and sudden death but no effect on total mortality This study enrolled 651 men with myocardial infa rct ion in five participating centers in a r and omized 3 year clinical trial of the effects of prescribed supervised exercise .  The subjects , aged to 30 to 64 years , were screened for eligibility 2 to 36 months after their qualifying myocardial infa rct ion . The men in the exercise group pursued intensive exercise in the laboratory for 8 weeks and then in a gymnasium for 34 months . The experience of the exercise group was more favorable than that of the control group in most of the comparisons made . The cumulative 3 year total mortality rate was 7.3 percent for the control group and 4.6 percent for the exercise group ; the 3 year rate for recurrent myocardial infa rct ion was 7.0 and 5.3 percent , respectively . Mortality rates in the two groups did not differ significantly , but the data were consistent with an assumption of substantial benefit from exercise . Adjustment for small differences in baseline variables by multivariate methods did not material ly alter the estimate of effect of exercise . Certain subgroups showed a greater benefit from exercise BACKGROUND Rehabilitation is an important part of the treatment of patients with ischemic heart disease . Therefore , many patients undergoing coronary artery bypass surgery ( CABS ) also participate in cardiac rehabilitation programs . This study was conducted to investigate whether rehabilitation influences quality of life and work status after CABS . METHODS Consecutive patients undergoing elective CABS were r and omly assigned to a rehabilitation group ( R , N = 119 ) and a hospital-treatment group ( H N = 109 ) . All patients received usual medical care .  Group R participated in a rehabilitation program based on exercise and counseling . The follow-up time was 5 years . The measured domains of health-related quality of life were heart symptoms , functional class , exercise capacity , use of medication , depression , the patients ' perception of health , and overall life situation . The Nottingham Health Profile as a measure of perceived distress was used . RESULTS Symptoms , use of medication , exercise capacity , and depression scores did not differ between groups R and H. Five years after the CABS , the patients in group R reported less restriction in physical mobility on the Nottingham Health Profile than patients in group H ( P = 0.005 ) , and more patients in group R than in group H perceived their health ( P = 0.03 ) and overall life situation ( P = 0.02 ) as good . The increase in the proportion of subjects working was higher in group R than group H at 3 years after the CABS ( P = 0.02 ) , but not at other follow-up times . CONCLUSION A cardiac rehabilitation program in conjunction with usual medical care after CABS may induce a perception of improved health . The influence on return to work is limited Background Lifestyle measures of coronary heart disease ( CHD ) prevention have been overshadowed by the efficacy of drug treatments . This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering , anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials . Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects . Objectives The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years . In addition , an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study . Design A total of 197 patients with proven coronary heart disease were included and r and omised to a lifestyle intervention programme or to usual care . Follow-up was after a period of two years . Methods Intervention comprised a low fat diet , regular exercise , smoking cessation , psychosocial support and education , delivered by nurses on the rationale for pharmacological and lifestyle measures . Usual care comprised follow-up in the routine outpatient clinic . Both groups were given the same comprehensive medication according to recent guidelines . Results Patients in the lifestyle intervention group reduced the intake of saturated fat , sugar and cholesterol ( P<0.001 ) , increased their exercise level ( P<0.01 ) and stopped smoking ( P<0.05 ) when compared with the usual care group . A sub analysis of the influence of five-year CHD calculated risk in males result ed in a relative risk reduction of 22 % ( 95 % confidence intervals 9 - 35 ) . Although significant , this result must be interpreted with caution due to poor statistical power and reproducibility of the method . Conclusions In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet , exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males OBJECTIVE Heart rehabilitation programmes improve the quality of life of coronary patients and the prognosis of the illness . Implementing these therapeutic systems into practice would be easier if their economic efficiency was proven . MATERIAL AND METHODS The expenses created by 180 survivors of a myocardial infa rct ion have been studied at the first and sixth year after the acute episode . The survivors were divided , at r and om , into two groups of 90 . One of them ( RG ) underwent a rehabilitation programme ( physical training , psychological action and control guidelines of risk factors ) . The other ( CG ) served as a control . RESULTS The profits , analyzing the direct expenses ( readmissions to hospital ) were of 5,074,039 ptas . the first year ( CG : 19,901,578 ; RG : 14,827,539 ) , and of 17,451,910 ptas . at the end of the study ( CG : 54,370,249 ; RG : 36,918,339 ) . Better results were obtained when review ing the indirect expenses ( derived from return to work ) , since the profits were of 26,000,000 ptas . after the first year ( CG : 54,750,000 ; RG : 28,750,000 ) and of 209,750,000 at the sixth year ( CG : 438,000,000 ; RG : 228,250,000 ) . The saving per patient was of 272,437 ptas . during the first 12 months and of 2,415,220 at the end of the follow-up . CONCLUSIONS These results justify the fact that the Public Administration and private Insurance Providers are taking into account the adequacy of implementing these therapeutic systems into practice The effect of a three-phase multifactorial institution-based rehabilitation programme on coronary heart disease ( CHD ) risk factors was studied in an open r and omised trial comprising 228 patients undergoing coronary artery bypass surgery allocated into a rehabilitation ( R ) group ( n = 119 ) and a hospital ( H = control ) group ( n = 109 ) . Follow-up examinations were performed at 6 and 12 months . Serum total cholesterol and triglyceride levels decreased significantly in both groups during follow-up . These decreases were not significantly different between the R and H groups . Serum high density lipoprotein ( HDL ) cholesterol level increased significantly at 6 and 12 months in the R group , but not in the H group . The differences in the changes between the groups were not significant . The ratio of serum HDL cholesterol to total cholesterol increased significantly in the R group from the preoperative value of 0.154 to 0.179 ( P less than 0.001 ) at 6 months and to 0.180 ( P less than 0.001 ) at 12 months . In the H group these values were 0.152 , 0.166 ( P less than 0.001 ) and 0.168 ( P less than 0.001 ) , respectively . The significance of the differences in the changes between the groups were P = 0.01 at 6 months and 0.06 at 12 months . These differences were more obvious in patients aged 55 years or under . There was a significant decrease ( P = 0.005 ) in the proportion of smokers in the R group and a significant increase in the proportion of patients taking regular exercise in both groups as assessed by question naire . ( ABSTRACT TRUNCATED AT 250 WORDS This study focused on the effects of hospital supervision and type of prescribed home exercise in  cardiac rehabilitation programs  on aerobic fitness , anxiety , and depression .  Men who had a myocardial infa rct ion were r and omly assigned to four exercise programs : The first program consisted of purely hospital-based exercise . The second and third programs combined hospital and home exercise , including either bicycling or walking at home . In the fourth program , patients were encouraged to exercise at home , but were given no specific guidance . Fifty-two patients finished the eight-week exercise program and 35 completed the psychologic question naires . At the end of the eight weeks , there were significant differences in the programs ' effects on aerobic fitness . Purely hospital-supervised exercise and the combination of hospital-supervised bicycling with home walking increased aerobic fitness more than completely unsupervised exercise . Furthermore , there were differences in the programs ' effects on manifest anxiety . The combination of home and hospital bicycling was less beneficial than home walking and hospital bicycling or even completely unsupervised exercise at home . The results indicate that the degree of hospital supervision and the type of prescribed home exercise are important design features which may affect the success of cardiac rehabilitation exercise programs . No effects of the different exercise programs on patients ' depression could be found . In general , a close relationship between aerobic fitness and anxiety or depression could not be demonstrated . Implication s of these findings for the design of cardiac rehabilitation exercise programs are discussed The Ontario Exercise-Heart Collaborative Study was a multicenter r and omized clinical trial of high Intensity exercise for the prevention of  recurrent myocardial infa rct ion in men . The 4-year recurrence rate among 379 patients on a program of high intensity exercise  did not differ significantly from that among 354 control patients on a program of light exercise , despite the greater reduction in heart rate in the former group . The relative odds of recurrence in the high intensity group were 1.09 , with 95 % confidence limits of 0.61 and 1.96 PURPOSE The convalescent period after myocardial infa rct ion ( MI ) has been associated with a " spontaneous " improvement in functional aerobic capacity that may be because of normal recovery processes unrelated to formal exercise training . The purpose of this study was to determine whether the frequency of formal training sessions is an important variable affecting the magnitude of improvement in cardiorespiratory fitness during phase II cardiac rehabilitation . METHODS The effect of exercise training frequency on cardiorespiratory fitness was evaluated during a 5-week early ( phase II ) cardiac rehabilitation program in 50 low-risk , male patients recovering from acute MI . Baseline grade d treadmill tests to fatigue endpoints , with direct measurement of maximal oxygen uptake ( VO2max ) , were administered 4 weeks after MI . The subjects were then r and omly assigned to either a control group ( n = 12 ) and restricted to " very light " physical activity ( requiring < 50 % of VO2max ) at home , or to one of three training groups which , in addition to very light home activity , performed moderately intense ( approximately 70 % of VO2max ) aerobic exercise for 30 to 35 minutes either once per week ( n = 13 ) , twice per week ( n = 13 ) , or three times per week ( n = 12 ) in the hospital-based phase II program . The four groups were similar in age , clinical status , and use of beta- and calcium channel blockers . RESULTS Submaximal and maximal cardiorespiratory responses were initially similar in all four groups . Each of the four groups demonstrated significant ( P < .05 ) increases in maximal treadmill duration at follow-up . However , VO2max increased significantly only in the three training groups . The spontaneous improvement in treadmill duration in the control group , in the absence of formal exercise training , may simply reflect recovery from the acute cardiac event . Those training two and three sessions per week also showed significant , comparable decreases in submaximal exercise heart rate and rate-pressure product and similar increases in maximal treadmill duration and VO2max . CONCLUSIONS Results suggest that two exercise sessions per week is as effective as three per week for cardiorespiratory conditioning in the early weeks of phase II cardiac rehabilitation Abstract The purpose of the trial was to analyze whether supervised physical training could reduce death and nonfatal reinfa rct ion in a nonselected series of postinfa rct patients . All patients born in 1913 and later , who were hospitalized for a myocardial infa rct ion during 1968–1970 in Goteborg Sweden , were r and omized to a training group ( 158 patients ) and a control group ( 157 patients ) . Other treatment was exactly the same and st and ardized for the two groups . Twenty-seven percent were excluded from training . Training started 3 months after the infa rct and was scheduled for three times a week . The training group had higher physical working capacity after 1 yr than the control group . Blood pressure was lower , but there was no differences in blood lipids . During 4 yr of follow-up , 28 patients died in the training group and 35 in the control group . The numbers of nonfatal reinfa rcts were 25 and 28 , respectively . Within the training group patients adhering to the program had lower mortality than those who did not , but the former also had lower initially predicted risk of dying . A special analysis of patients who attended the training program in comparison to matched controls also showed a lower mortality . No differences in mortality between the training group and the control group were statistically significant , however Complex interventions are more than the sum of their parts , and interventions need to be better theorised to reflect this Many people think that st and ardisation and r and omised controlled trials go h and in h and . Having an intervention look the same as possible in different places is thought to be paramount . But this may be why some community interventions have had weak effects . We propose a radical departure from the way large scale interventions are typically conceptualised . This could liberate interventions to be responsive to local context and potentially more effective while still allowing meaningful evaluation in controlled design s. The key lies in looking past the simple elements of a system to embrace complex system functions and processes . The suitability of cluster r and omised trials for evaluating interventions directed at whole communities or organisations remains vexed.1 It need not be.2 Some health promotion advocates ( including the WHO European working group on health promotion evaluation ) believe r and omised controlled trials are inappropriate because of the perceived requirement for interventions in different sites to be st and ardised or look the same.1 3 4 They have ab and oned r and omised trials because they think context level adaptation , which is essential for interventions to work , is precluded by trial design s. An example of context level adaptation might be adjusting educational material s to suit various local learning styles and literacy levels . Lead thinkers in complex interventions , such as the UK 's Medical Research Council , also think that trials of complex interventions must “ consistently provide as close to the same intervention as possible ” by “ st and ardising the content and delivery of the intervention.”5 By contrast , however , they do not see this as a reason to reject r and omised controlled trials . These divergent views have led to problems on two fronts . Firstly , the field of health promotion is being turned away from r and omised OBJECTIVE This study evaluated the effects of a home-based rehabilitation program for Chinese patients with myocardial infa rct ion in terms of health-related quality of life and psychological status . METHODS This was a r and omized , controlled trial with data collected at 2 university-affiliated public general hospitals in Xian ( Shaanxi Province , People 's Republic of China ) . One hundred and sixty patients with a myocardial infa rct ion were r and omly assigned to either the interventional group ( a home-based cardiac rehabilitation program using a self-help manual ) or the control group ( usual care ) . Health-related quality of life ( generic , Chinese Short Form 36-Item Health Survey ; disease-specific , Chinese Myocardial Infa rct ion Dimensional Assessment Scale ) and psychological status ( the Chinese Hospital Anxiety and Depression Scale ) were measured at baseline , program completion ( 6 weeks ) , and 3 and 6 months after hospital discharge . RESULTS Significant differences were evident in the main outcomes when the home-based group was compared with the usual care group at 6 weeks , 3 months , and 6 months . The home-based group had significantly higher scores on 4 of the 8 domains of the Chinese Short Form 36-Item Health Survey and on 3 of the 7 dimensions of the Chinese Myocardial Infa rct ion Dimensional Assessment Scale , with significantly lower scores on the anxiety , but not the depression , subscale of the Chinese Hospital Anxiety and Depression Scale . CONCLUSIONS A simple , home-based cardiac rehabilitation program for patients with acute myocardial infa rct ion , using a self-help manual , improves health-related quality of life and reduces anxiety . It appears feasible and acceptable , and does not produce inferior outcomes compared with usualcare in China 375 consecutive patients below 65 years who had an acute myocardial infa rct ion ( AMI ) took part in a r and omised rehabilitation and secondary prevention trial ( part of a W.H.O.-coordinated project ) design ed to study the effects of a multifactorial intervention programme on morbidity , mortality , return to work , & c. After three years ' follow-up the cumulative coronary mortality was significantly smaller in the intervention group than in the controls ( 18.6 % versus 29.4 % , p = 0.02 ) . This difference was mainly due to a reduction of sudden deaths in the intervention group ( 5.8 % versus 14.4 % , p less than 0.01 ) . The reduction was greatest during the first six months after AMI . 18.1 % in the intervention group and 11.2 % in the controls ( p less than 0.10 ) presented with non-fatal reinfa rct ions . The number of patients with new Q-QS findings at the end of the three years was , however , almost the same in both groups . The results suggest that organised aftercare during the first six months after AMI with special emphasis on optimum medical control and health education contributes significantly to a reduction in the number of sudden deaths
target: Conclusions Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease .
  While our analysis was constrained by the quality of included trials and missing information about intervention components , there appears to be little differential effect of variations in exercise intervention , particularly on mortality outcomes .
background: Background While the clinical benefits of exercise-based cardiac rehabilitation are well established , there is extensive variation in the interventions used within these trials .
  It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes .
  This study aims to systematic ally examine the relationship between individual components of the exercise intervention in cardiac rehabilitation ( such as intensity and frequency ) and clinical outcomes for people with coronary heart disease .