[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.

[Exercise recommendation and catecholamines in patients with coronary artery disease]. / Belastungsdiagnostische Kenngrössen und Katecholamine bei Koronarpatienten.

Exercise training for patients with coronary artery disease (CAD) is recommended in a wide range between 40-85% of maximum functional capacity (MFC) or 55-90% of maximum heart rate (HR). During exercise, high levels of catecholamines and metabolic acidosis could induce arrhythmia and ischemia. But catecholamines have never been determined in CAD during constant load exercise in the upper range of recommended intensities. In 11 CAD patients (age 58+/-8 years, BMI 26.1+/-4.0 kg x m(-2), NYHA I n=7, II n=4) we tested the maximum functional capacity (MFC), norepinephrine (NE), epinephrine (E) and blood lactate ([Lac(-)](B)) in a symptom-limited incremental ergometer test. Related to the exercise recommendation, the kinetics of NE, E and [Lac(-)](B) were determined in two 30 min constant load tests in randomized order: one was performed at the anaerobic lactate threshold (CTAT), a second was performed 10% above the individual threshold intensity (CT+10%). In the incremental tests maximum workload and VO(2) were 141+/-54 W and 1766+/-532 ml x min(-1), respectively (85+/-22% of normal; [Lac(-)](B) 5.7+/-1.9 mmol x l(-1), HR 138+/-28 b x min(-1), NE 11.7+/-5.1, E 1.6+/-1.4 nmol x l(-1)). In CTAT the anaerobic threshold (63+/-7% of MFC) represented the mean range of recommended exercise intensity for CAD (40-85%) and could be validated as steady-state intensity because catecholamines and [Lac(-)](B) concentrations remained constant after the initial increase (workload 88+/-35 W, [Lac(-)](B) 3.3+/-1.4 mmol x l(-1), HR 117+/- 23 b x min(-1), NE 8.3+/-3.5, E 0.8+/- 0.7 nmol x l(-1)). In all patients CT+10% (71+/-7% of MFC) led to a continuous rise in [Lac(-)](B), to a NE overload and to earlier exhaustion, although the intensities were in the recommended training range (workload 100+/-38 W, [Lac(-)](B) 5.8+/- 1.9 mmol x l(-1), HR 129+/- 29 b x min(-1), NE 13.9+/-6.9, E 1.5+/- 1.7 nmol x l(-1); p<0.01 against CTAT for all except E). Conclusions In the upper range of recommended training intensity for CAD patients, norepinephrine and lactate were higher during endurance exercise than at MFC in incremental tests. Endurance exercise with intensities >70% of MFC could overload the cardiac patient and increase the risk of arryhthmia and ischemia. Therefore, endurance exercise should be performed below 70% of MFC or below 85% of maximum HR, respectively, whereas higher intensities should apply to interval exercise.

[Determining the extent of intensive physical performance in patients with coronary heart disease]. / Bestimmung des Bereichs intensiver Dauerleistungsfähigkeit bei Patienten mit koronarer Herzkrankheit.

Intensive physical exercise improves cardiac perfusion, skeletal muscle function and risk factors in patients with coronary artery disease (CAD). Otherwise, overdosed intensity can induce training adaptation as well as cardiac events. Therefore, we tested whether exercise intensity corresponding to an equilibrium between lactate production and elimination from the blood during incremental exercise tests represented the blood lactate [Lac-]B steady-state intensity during constant physical training. Randomized into two groups with 30 CAD patients each (T1: 25 male, 5 female; 59 +/- 7 years; T2: 26 male, 4 female; 60 +/- 9 years), the patients initially performed two successive incremental exercise tests. In the first test, workload was increased stepwise until exhaustion or symptom limitation (maximal workload: T1 142 +/- 48 watts, T2 145 +/- 45 watts) with the corresponding [Lac-]B accumulation of up to 6.7 +/- 2.6 (T1) or 6.5 +/- 2.0 (T2) mmol/l, respectively. After a seven minute active rest the second test began with 25 watts, increased with 5 (maximum workload in first test < 100 watts) or 10 watts per minute, respectively. During lower intensities in the second test, [Lac-]B initially decreased to an individual lactate minimum intensity (workload at LMI 83 +/- 32 in T1 or 86 +/- 29 in T2 watts, respectively; [Lac-]B at LMI 4.6 +/- 2.2 and 4.9 +/- 1.8 mmol/l, respectively) and then increased again. To check if the individual LMI represented the [Lac-]B steady-state workload in constant workload exercise, the patients performed 30 min constant load tests with the LMI (CT1) or a 30 min constant load test with an intensity 10% above the LMI (CT2), respectively. The workload in CT1 was 83 +/- 32 watts with a mean exercise time of 29.0 +/- 1.7 min. After 10 min of exercise the [Lac-]B steady state was reached at 3.3 +/- 1.4 mmol/l with no further increase in the last 20 min. The mean workload in CT2 was 95 +/- 31 watts with an exercise time of 23.3 +/- 8.3 min (p < 0.01). [Lac-]B increased from 4.4 +/- 1.7 mmol/l after 10 min to 4.7 +/- 2.0 mmol/l at the end (p < 0.01). Fifty percent of patients stopped CT2 before the 30 minute end. The results indicates that the LMI, estimated during lactic acidosis in two successive incremental tests, represented the individual lactate steady-state intensity also during constant load exercise. Therefore, training regimens for CAD patients could be deduced from LMI.

[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.