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Section I Introduction

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The concept of exercise as a fundamental part of a healthy lifestyle has its origin in ancient Greece.

Lost for many hundred years, it re-emerged in the British Isles, rapidly spreading into Western soci- eties. As a therapeutic modality, the preventive aspect was discovered early. As a treatment concept for heart patients, it was a controversial issue for many years, now even being accepted in heart failure, a condition regarded as a strict con- traindication only a few years ago.

Cardiac rehabilitation programs improve out- come, recent meta-analyses have revealed. A reduction in cardiac events, increase in functional status, and an improvement of the quality of life are the sustained beneficial effects. Initially reserved for the patient with an uncomplicated myocardial infarction, these programs are now extended to all cardiac patients with a condition that endangers their functional capacity.

Although the interventions vary considerably in the different parts of the world, rehabilitation programs improve the process of care, coronary risk factor profiles, functional status, and the quality of life. Particularly in aging societies, but also beginning in the developing world, such pro- grams are a means of preserving an independent lifestyle for the elderly, thus preventing an overuse of nursing services, which the majority of coun- tries are unable to provide.

Risk factor profiles give us a good guideline for the management of the coronary patient. In the field of prevention, they are helpful in targeting the high-risk individual. Since the majority of patients fall into the average category of risk, it will be mandatory to identify those at risk in this

large group more clearly. Newer diagnostic con- cepts such as the coronary calcium score or the intima–media thickness of the carotid artery as determined by ultrasound are promising steps in this direction.

Main Messages

Chapter 1: From Exercise Training to Comprehensive Cardiac Rehabilitation

Following the initial description of the gradual healing of a myocardial infarction, utmost care was taken to avoid any exercise for the patient.

Much to the surprise of the medical profession, it turned out that a sizeable portion of the patients who had survived this treatment reached their previous functional level. Gradually, a more active approach was adopted, including a formal exercise prescription as a therapeutic aspect. Later, educa- tional counseling and psychosocial support were added. The current is best defined by the WHO definition: “The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as possible in the society.”

Chapter 2: The Evidence Base for Cardiac Rehabilitation

Cardiac rehabilitation programs improve out- comes for patients with coronary disease.

Section I

Introduction

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2 Introduction

Meta-analyses confirm that rehabilitation pro- grams not only reduce the risk of recurrent myocardial infarction and death, but also improve risk factor profiles, use of therapies, functional status, and quality of life. Benefits did not differ among the types of programs, those that incorpo- rated education and counseling about coronary risk factors with or without a supervised exercise program, and those that consisted of a structured exercise program only. Rehabilitation and sec- ondary prevention programs improve processes of care, coronary risk factor profiles, functional status, and quality of life.

Chapter 3: Indications for Cardiac Rehabilitation

Cardiovascular diseases constitute the leading cause of morbidity and premature mortality in Western societies, while they are increasing in numbers in developing countries. Whereas reha- bilitation and secondary prevention were once seen as valuable only to patients with an uncom- plicated myocardial infarction, they are now regarded as a treatment option for all patients with heart disease. Improvement in functional status, reduction in morbidity, improvement of the quality of life, and maintenance of an inde- pendent lifestyle are valuable aims in the treat- ment of any form of heart disease.

Chapter 4: Prevention Guidelines:

Management of the Coronary Patient

The effective prevention of myocardial infarction and death from coronary disease requires accu- rate identification of persons at risk. Risk factor stratification has recently been redefined to allow a more precise identification for the different areas in Europe.

Chapters 5 to 10: Practice Worldwide

Different programs and approaches have been developed in the different areas of the world,

all aiming at a similar outcome, utilizing a variety of methods. The Anglo-Saxon countries have largely preferred a primarily ambulatory approach, favoring long-term exercise-based rehabilitation programs, to which educational, psychological, and social components are being added in a stepwise fashion. Countries with a long-standing spa tradition such as Germany, Austria, and some eastern and southern European countries including Italy have adopted an inpatient residential center approach, with a rather short duration, consisting of an intense, gradually increasing exercise program, where educational, psychological, and social compo- nents are begun during the very first days of the program. Formidable differences in availability, distance, funding, and acceptance have led to an increasing diversity of rehabilitation services worldwide.

Chapter 5: Cardiac Rehabilitation: Europe Chapter 6: Cardiac Rehabilitation: United States Chapter 7: Cardiac Rehabilitation: Canada Chapter 8: Cardiac Rehabilitation: Australia Chapter 9: Cardiac Rehabilitation: South Africa Chapter 10: Cardiac Rehabilitation: China

Chapter 11: New Concepts for Early Diagnosis of Coronary Artery Disease

In the effort to identify the person at risk of myocardial infarction and death, an ideal and valuable additional tool should be a proven inde- pendent risk factor, providing additional infor- mation without inherent risk and with wide availability. A sizeable number of studies have shown that a high calcium score is a predictor of cardiac events, independent of the traditional risk factors, thus providing additional information.

The two approaches – conventional risk estima- tion and calcium scoring – should enable the physician to better delineate the individual risk in the “intermediate-risk category,” which is of such an importance because of the sheer number of people in this category.

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