[Phase III rehabilitation after heart transplantation]. / Phase III Rehabilitation nach Herztransplantation. Effekte auf Lebensqualität, Leistungsfähigkeit und kardiovaskuläre Risikofaktoren.

INTRODUCTION: Longterm treatment after heart transplantation (HTX) improves survival, although the quality of life and exercise tolerance decreased continuously between one and ten years after transplantation. The role of physical exercise and psychological support in longterm treatment after HTX has not been determined. We analyzed the effects of a one year outpatient rehabilitation program in combination with a home based, computer assisted training program on exercise capacity, coronary risk factors and quality of life. METHODS: 20 heart transplant recipients in an intervention group and 12 patients after HTX in a control group participated in the study (IG (CG); 5.1+/-2.2 (4.5+/-2.3) years after HTX; age: 55+/-7 (54+/-8) years; body mass index: 28.3+/-1.0 (28.7+/-0.9) kg.m(-2)). Before and after the intervention, maximum and constant load exercise capacity, and self-reported quality of life were evaluated. The 12 month intervention period included 10 days of exercise testing as well as medical and psychological support. Furthermore, the IG group performed a computer-assisted and controlled home ergometer training every second day. RESULTS: After one year with 114+/-18 exercise training sessions, maximum oxygen consumption increased in the IG from 18.8+/-4.2 to 20.1+/-4.2 ml.min(-1).kg(-1) (p<0.05; CG 19.3+/- 4.5 to 18.5+/-2.8 ml.min(- 1).kg(-1); p<0.01 IG vs CG). In the IG, lower back pain, body fat, and blood pressure were all reduced, while the self-reported quality of life, endurance exercise capacity and HDL cholesterol were increased. No significant changes occurred in the control group. CONCLUSIONS: When initiated years after heart transplantation, longterm rehabilitation reduced coronary risk factors and significantly improved both the subjects' quality of life, as well as a near to normal capacity for physical work.

[Health-related quality of life after heart transplantation]. / Lebensqualität im Langzeitverlauf nach Herztransplantation.

BACKGROUND: Quality of life late after heart transplantation is reported to be comparable with that of the general population. However, peak exercise capacity remained approximately 60% of what was normal between 1 and 10 years after transplantation. The gap between patients' good quality of life and their impaired exercise tolerance is not yet explained. The purpose of our study was to examine the relation between quality of life and exercise- related variables in heart transplant recipients (HTR). Then, the results of these examinations were compared with those of patients having congestive heart failure (CHF), with the use of controls (C), respectively. METHODS: (Mean values+/-SD) 29 HTR 4.4 +/- 2.1 years after transplantation, 29 CHF (NYHA II n = 22, III n = 7) and 29 C (age 54 +/- 9, 61 +/- 10, 56 +/- 10 years, body mass index 28 +/- 3, 29 +/- 5, 28 +/- 4 kg x m(-2), body fat 25 +/- 4, 27 +/- 6, 26 +/- 5%, respectively) performed cardiopulmonary exercise testing and were interviewed with the standardized German "Quality of life profile for chronic diseases" questionnaire. RESULTS: Peak oxygen consumption was impaired in HTR and in CHF compared with C (19.0 +/- 4.5, 18.6 +/- 4.3, and 30.2 +/- 6.6 ml x min x kg(-1), respectively; p < 0.01 vs. C each). HTR and CHF patients' quality of life in the physical scores were both impaired (p < 0.05 or p < 0.01 vs. C, respectively), but HTRs have reported better scores than CHF (p < 0.05). In the psychological role, CHF was impaired against C (p < 0.05), and HTR scores were comparable with C. In social functioning HTR and CHF patients both showed reduced quality of life dimensions. The Pearson correlation analysis showed that quality of life in physical functioning was related to peak oxygen consumption (p < 0.001) and percentage of predicted workload (p < 0.001). Quality of life in the social and psychological domains showed no association to exercise-related values. CONCLUSIONS: In HTR and in CHF, exercise testing variables were dominant predictors among the physical scales in quality of life, but not among social or psychological scales. Therefore, even late after heart transplantation, improving physical capacity should be a therapeutic goal with the intention of further increasing the quality of life.

[Ambulatory long-term cardiac rehabilitation--one year results]. / Ambulante kardiale Langzeitrehabilitation--1-Jahres-Ergebnisse.

After acute hospital therapy of myocardial infarction or bypass surgery the patient in Germany will be treated using an inpatient rehabilitation programme for 3-4 weeks. One year later only 10% of them are still active in outpatients groups. In our study 61 cardiac patients performed an one-year outpatient rehabilitation (instead of 4 weeks inpatient) programme with intense supervised exercise and behaviour therapy. The money input per patient was the same for the usual care 4 weeks inpatient (6000 DM) as for 1 year outpatient rehabilitation (5800 DM). The exercise capacity per heart rate-blood pressure-product was increased by 43% (p > 0.01) after 12 months. The maximum exercise capacity was reached in the 57th week. Without increased medical treatment, cholesterol and LDL-cholesterol were reduced after 12 months by 3.9% down to 195 +/- 25 mg/dl or by 6.6% down to 122 +/- 21 mg/dl, respectively (n.s.). HDL-cholesterol increased by 2.8% to 48 +/- 8 mg/dl (n.s.). This study shows results similar to outpatient rehabilitation programmes in the United States or in Sweden. The long intervention time and the intensity are main factors for the success of cardiac rehabilitation and patient health. Financial resources should primarily be concentrated on long-term outpatient rehabilitation programmes.

[Ambulatory long-term rehabilitation of heart patients]. / Ambulante Langzeitrehabilitation von Herzpatienten.

In Germany cardiac rehabilitation contains a comprehensive 3 to 4 week inpatient program. The aim of our study was to perform an outpatient long-term rehabilitation including intense exercise and behavior therapy. In this setting the health benefits could be increased over the first 6 months. Hundred and twelve patients (94 men and 18 women, age 55 +/- 11 years) after myocardial infarction (52%), bypass-surgery (37%), PTCA (23%), and others (15%) were included in the ongoing study. Cholesterol and LDL-cholesterol diminished significantly. HDL-cholesterol was increased significantly after 6 months. The endurance exercise capacity per rate-pressure-product was increased by 46% during the 6 months period. The intake of cholesterol could significantly be diminished from 307 +/- 25 to 258 +/- 19 mg per day. Five of 16 patients became free from smoking. The first results from the long-term outpatient program show that the time of intervention and also the intensity of the medical, exercise and the behavior therapy are important factors for a successful rehabilitation.

Nicotine gum assisted group therapy in smokers with an increased risk of coronary disease--evaluation in a primary care setting format.

Smoking cessation with the aid of nicotine chewing gum in a primary care setting format is reported to be more effective when additional behavioural training is introduced. We developed a standardized comprehensive treatment programme using nicotine chewing gum (Nicorette 2 mg) in conjunction with nutritional information for the prevention of weight gain, behavioural training for the promotion of self-management techniques and the prescription of a date when to quit. The programme was conducted by 11 family physicians in a group setting format with 12 weekly 90 min sessions and three booster sessions. After an introduction to the programme, each physician selected smokers with additional risk factors for coronary heart disease from the files. Experimental and control subjects were matched for age, gender, cigarette consumption and duration since smoking onset. Complete data were obtained from 86 treated and 53 control subjects. The drop-out rate among the treated subjects was 5.8%. After the 3 month follow-up, data assessment shows an abstinence rate of 63.9% in the experimental subjects, a fact verified by CO measurements. Compared to the control group, blood pressure, heart rate, cholesterol and glucose levels did not change significantly during treatment. Weight increased by 1.7 kg. After a 12 month follow-up, abstention rates decreased to 52.3%. Abstainers reported less physical complaints and increased well-being when compared to control subjects or to treatment failures at both follow-up assessments. Changes in the risk profile, apart from smoking, were not verified.

Psychological group treatment of obese essential hypertensives by lay therapists in rural general practice settings.

Two hundred and sixty-one obese essential hypertension patients from 15 rural general practices were assigned to either an experimental group (n = 155) or to waiting control group (n = 106). The experimental group underwent psychological group treatment aimed at weight reduction, improvement of stress coping, and reduction of salt-intake. Sixteen therapy sessions were conducted in each of the general practices by specifically trained lay therapists who applied a standardized, highly structured therapy programme. During the time of the study, both experimental group and waiting control group received intensified medical attention. After the 6-months therapy, health knowledge and health behaviour of the patients had improved. Mean weight reduction was 5.2 kg. Blood pressure had decreased by a mean of 14.4 mm Hg (systolic)/7.4 mm Hg (diastolic). After a follow-up period of four months, the beneficial effects of the group treatment were confirmed: Patients needed less anti-hypertensive medication and consistent reduction of body weight prevailed.

Psychological group treatment of essential hypertension in general practice.

One hundred and seven obese patients with essential hypertension from eight general practices received one of the following psychological group therapy procedures: (1) modification of nutritional patterns; (2) modification of nutritional patterns plus self-monitoring of blood pressure and training in social competence; (3) modification of nutritional patterns plus Jacobson's relaxation training; (4) information about the causes and consequences of high blood pressure. An approximately equal number of patients served as a waiting-control group. All patients had received pharmacological treatment for at least a year. Each procedure was administered by a psychologist with groups of up to 15 patients in 12 weekly sessions. The blood pressure values measured before and after intervention showed a clear reduction; this fall is greatest when the initial values were high. Even when the magnitude of the initial values was statistically controlled there was a distinctly greater reduction in blood pressure in the treatment groups than in the waiting-control group. No differential effect between the various therapy procedures could be demonstrated, however. The changes in general health behaviour of the treatment groups was statistically confirmed. In addition, there was a distinct reduction in body weight. Medication compliance also improved in the treatment groups. Since group procedures were accepted both by the doctors and the patients involved, they should be included to a great extent in the basic care of hypertensive patients in the future.