Exercising The Chd Patient The Need For Assessment And Risk Stratification

Exercise training in individuals with CHD has been the subject of numerous clinical trials, with the evidence strongly demonstrating that exercise-based cardiac rehabilitation is associated with a reduction in coronary mortality and morbidity. Early trials supporting this evidence by Oldridge, et al. (1988) and O'Connor, et al. (1989) have more recently been confirmed by SIGN (2002) and Jolliffe, et al. (2004). This supports the premise that the benefits outweigh the risks. Despite the low incidence of adverse events, most international CR guidelines, nevertheless, recommend that, prior to recruitment to the exercise programme, patients should undergo a comprehensive assessment, including risk stratification.

Although the data would suggest that the increased myocardial demands of vigorous exercise may precipitate cardiovascular events, i.e. ventricular fibrillation, the evidence indicates that mortality is lowest in those who are physically active. The risk of cardiac events during exercise is small, particularly where evidence of substantial cardiac disease is absent. Within supervised CR programmes the risk of serious exercise-related cardiac events is also small, with evidence from Paul-Labrador, et al. (1999) suggesting that it is approximately 50% of the incidence observed in joggers than in the general public (1 in 784000 versus 1 in 396000 respectively).

Verrill, et al. (1996) reviewed the literature to ascertain the occurrence of cardiac arrest during CR exercise programmes. At their cardiopulmonary research institute there were 25 cardiac arrests between 1968 and 1981 (374, 616hrs), nine of which occurred during the 'cool-down' period. The significance of this finding will be discussed further in Chapter 6.

Additionally, Vongvanich, et al. (1996) carried out a survey to determine the safety of medically supervised rehabilitation and confirmed that event rates are indeed low.

Incidents are most likely in the following categories:

• patients with marked ST-segment depression on ECG;

• patients with an above average exercise capacity;

• patients who have shown poor compliance to exercise intensity guidelines.

There is, however, little recent data that reflect the complexity and varied risk of exercise-related events for the patient group now eligible for CR. In addition, most of the available data are from the United States, where electrocardiogram (ECG) monitoring and trans-telephonic monitoring are standard, making it difficult to generalise this to other healthcare systems, where appropriate professional supervision is the predominant monitoring tool. In addition, Paul-Labrador, et al. (1999) concluded that contemporary American CR guidelines did not accurately predict complications during exercise. However, adverse events remained consistent with the 1970s data, suggesting that there was a trade-off between the general lowering of risk achieved by developments in treatment and medications and an increase in risk with the inclusion of more complex and older patients in CR exercise.

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