Functional capacity and heart rate response: associations with nocturnal hypertension.

BACKGROUND: Absences of normative, 10-20 % declines in blood pressure (BP) at night, termed nocturnal non-dipping, are linked to increased cardiovascular mortality risks. Current literature has linked these absences to psychological states, hormonal imbalance, and disorders involving hyper-arousal. This study focuses on evaluating associations between nocturnal non-dipping and indices of functional cardiac capacity and fitness. METHODS: The current study was a cross-sectional evaluation of the associations between physical capacity variables e.g. Metabolic Equivalent (MET) and Maximum Heart Rate (MHR), Heart rate reserve (HRR), and degree of reduction in nocturnal systolic blood pressure (SBP) or diastolic blood pressure (DBP), also known as 'dipping'. The study sample included 96 cardiac patient participants assessed for physical capacity and ambulatory blood pressure monitoring. In addition to evaluating differences between groups on nocturnal BP 'dipping', physical capacity, diagnoses, and medications, linear regression analyses were used to evaluate potential associations between nocturnal SBP and DBP 'dipping', and physical capacity indices. RESULTS: 45 males and 14 females or 61.5 % of 96 consented participants met criteria as non-dippers (<10 % drop in nocturnal BP). Although non-dippers were older (p = .01) and had a lower maximum heart rate during the Bruce stress test (p = .05), dipping was only significantly associated with Type 2 Diabetes co-morbidity and was not associated with type of medication. Within separate linear regression models controlling for participant sex, MHR (ß = 0.26, p = .01, R(2) = .06), HRR (ß = 0. 19, p = .05, R(2) = .05), and METs (ß = 0.21, p = .04, R(2) = .04) emerged as significant but small predictors of degree of nighttime SBP dipping. Similar relationships were not observed for DBP. CONCLUSIONS: Since the variables reflecting basic heart function and fitness (MHR and METs), did not account for appreciable variances in nighttime BP, nocturnal hypertension appears to be a complex, multi-faceted phenomena.

Cardiac rehabilitation services in Ontario: components, models and underserved groups.

AIMS: Cardiac rehabilitation programs develop in accordance with guidelines, but also in response to local needs and resources. This study evaluated features of Ontario cardiac rehabilitation programs in accordance with guidelines, emerging evidence and treating underserved populations. METHODS: In this cross-sectional study, all Ontario cardiac rehabilitation programs were mailed an investigator-generated survey. Responses were received from 38 of 45 (84.4%) programs. RESULTS: Twenty-seven (71.1%) cardiac rehabilitation programs were located within a hospital. Twenty-four (63.2%) programs reported that they offer two sessions of exercise and education per week. Twenty-six (68.4%) programs offered an alternative model of program delivery other than on-site, with 10 (27.0%) programs reporting they tailored their programs to rural patients. Twenty-three (62.2%) programs provided services to patients with a noncardiac primary indication. Twenty-six (68.4%) programs systematically screened patients for depressive symptoms. Twenty-seven (71.1%) offered resources to patients postgraduation. CONCLUSION: Most cardiac rehabilitation programs offered alternative models of care, such as home-based rehabilitation. Cardiac rehabilitation sites are well integrated within their community, enabling smooth postcardiac rehabilitation transitions for patients. Cardiac rehabilitation programs continue to offer proven comprehensive components, while simultaneously attempting to adapt to meet the needs of patients with other chronic diseases.

Ambulatory surveillance of patients referred for cardiac rehabilitation following cardiac hospitalization: a feasibility study.

BACKGROUND: Our purpose was to examine the feasibility of implementing an ambulatory surveillance system for monitoring patients referred to cardiac rehabilitation following cardiac hospitalizations. METHODS: This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance at cardiac rehabilitation, waiting times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse. RESULTS: Among the 1208 consecutive patients referred, only 44.7% attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 18.9% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths), with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program, 114 (25.9%) had adverse clinical events while in the queue; 46 of these events required cardiac hospitalization and 8 patients died. CONCLUSIONS: Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs, underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.

The relationship between need and capacity for multidisciplinary cardiovascular risk-reduction programs in Ontario.

BACKGROUND: Available evidence has demonstrated survival benefits associated with multidisciplinary cardiovascular risk-reduction (CR) (ie, cardiac rehabilitation) programs. The degree to which program capacity meets eligible service demands in Ontario is unknown. We sought to estimate the supply-need care-gap associated with CR programs across regions (Local Health Integration Networks [LHINs]) in Ontario. METHODS: We conducted a cross-sectional, population-based study during 2006. Administrative data provided estimates of the population eligible for multidisciplinary CR services due to (1) recent cardiovascular hospitalizations and (2) incident diabetes. An Ontario-wide survey of CR programs provided service supply estimates. The coverage rate and the absolute supply-need mismatch were use to quantify the care-gap by LHIN. RESULTS: Based on cardiac hospitalizations alone, 53,270 patients in Ontario in 2006 (508.7 per 100,000) were eligible for CR services; 128,869 patients (1245 per 100,000) would have been eligible if newly diagnosed (incident cases) diabetic patients were included. Capacity for CR services was 18,087 patients, corresponding to 34% coverage of the eligible population (absolute unmet needs of 35,189 individuals) if capacity was entirely dedicated to recent hospitalizations and 14% coverage (absolute unmet needs of 110,782) if services were extended to include incident diabetes patients. Marked variation in disease burden, service capacity, and supply-need mismatch was observed across regions, in which supply was not correlated with need. CONCLUSION: Despite proved benefits of multidisciplinary CR programs, unmet population needs remain high in Ontario and are unequally distributed across regions. The magnitude of unmet needs and the lack of correlation between supply and disease burden necessitate broader provincial strategies to plan, allocate, and subsidize CR programs.