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1:30 PM-2:30 PM Thursday, September 6, 2012 Scientific Oral Presentations

Beginning Investigator Presentations



Miranda L. Menke, MS, Carl Foster, PhD; John P. Porcari, PhD; Mark Gibson, MS, ACT, PT; Terresa Bubbers, MS


Primary Institution: University of Wisconsin-La Crosse


Secondary Institution: Gundersen Lutheran Medical Center


Introduction: The Talk Test (TT) is a subjective submaximal exercise test based on the subject's ability to speak comfortably during exercise, and is a surrogate of the ventilatory threshold. In healthy populations, markers from the TT have been shown to be useful for guiding exercise training intensity.


Purpose: This study was designed to test the hypothesis that the responses observed during the TT could be used to define absolute training intensity in clinical populations, and to determine the magnitude of reduction in exercise intensity, from the TT response during incremental exercise, necessary to allow appropriate responses during exercise training.


Design: An observational trial of responses during 20 min steady state exercise training, with exercise intensity based on responses during an incremental exercise test terminated at the equivocal (EQ) stage of the TT.


Methods: Patients were enrolled in a Phase II or III cardiac rehabilitation program (n = 14). All patients performed an incremental exercise test, with the TT performed every 2 min stage. Patients rated their ability to speak comfortably after reciting a standard paragraph. TT markers were 1) the first time speech was not unequivocally comfortable (EQ), 2) the last stage during which speech was unequivocally comfortable (LP), 3) the two stages before LP (LP-1 & LP-2). Subsequently, subjects performed randomly ordered 20 min steady state exercise bouts at the absolute exercise intensity associated with EQ, LP, LP-1 & LP-2. Measures of speech comfort, heart rate and RPE were acquired every 5 min.


Results: The 20 min exercise training bout was fully completed by: EQ (n = 1), LP (n = 8), LP-1 (n = 13) and LP-2 (n = 14) patients. At 5 min (the last stage completed by all patients in all conditions) HR was 102, 98, 92 & 91) bpm, respectively. At 5 min, RPE was 12.3, 11.1, 10.8 & 9.9, and speech comfort (1 = comfortable speech, 2 = speech comfortable, but not completely, 3 = unable to speak comfortably) was 1.6, 1.1, 1.0 & 1.0. Patients discontinuing the exercise training bout reported reduced speech comfort (3.0) rather than high RPE. In the LP-1 stage (which is known to be appropriate for sedentary healthy individuals), speech was comfortable for 13/14 patients through 15 min.


Conclusions: The LP-1 stage of the TT appears to be an appropriate absolute exercise training intensity for patients in Phase II & III cardiac rehabilitation programs. In a small number of patients, after 10 min, exercise training intensity may need to be adjusted to allow appropriate RPE and speech comfort. The results demonstrate that a submaximal exercise test using the TT and the EQ stage as criteria for test termination can be used as both an outcome measure and as the basis for exercise prescription.




Hugo Gravel, MSc; Nagib Dahdah, MD; Anne Fournier, MD; Daniel Curnier, PhD


Primary Institution: Universite de Montreal


Secondary Institution: St. Justine Hospital


Introduction: It has been suggested that cardiac and vascular sequelae may persist late after Kawasaki disease (KD). Little is known about response to exercise late after the acute phase of KD.


Purpose: To assess exercise capacity and describe hemodynamic and chronotropic response to exercise in children and adolescents late after KD.


Design: This study is a retrospective analysis of data formerly obtained for an international multicenter clinical trial.


Methods: 117 subjects who had KD without coronary complications at the acute phase (Group 1) and 147 subjects who had KD with diagnosed coronary aneurysm(s) at the acute phase (Group 2) were compared to 45 age-matched healthy controls. All subjects had between 6 and 18 years old at time of testing. Included KD patients had been diagnosed with KD at least one year before testing. Subjects underwent an ECG monitored exercise test following Bruce protocol. Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were assessed at each stage of the test, at peak exercise and during recovery. Fraction of theoretical maximum heart rate attained at peak exercise (%HR max) and fraction of heart rate reserve attained at peak exercise (%HR res) were used as indicators of chronotropic competence. Analysis of variance was used to compare groups.


Results: Endurance times and heart rates measured during exercise and recovery did not differ significantly between the 3 groups. KD patients had lower SBP at baseline (Group 1: 108 +/- 14 mmHg, Group 2: 110 +/- 13 mmHg) and at the last completed stage of the Bruce protocol (Group 1: 134 +/- 27 mmHg, Group 2: 139 +/- 30 mmHg) compared to controls (Baseline: 119 +/- 12 mmHg, Last stage: 158 +/- 26 mmHg). The rise of SBP from baseline to peak, when expressed as a percentage of baseline SBP, was similar in all groups. SBP was significantly decreased in controls from the last completed stage to 1 min of recovery (p < .001), while no significant decrease could be observed in the KD groups. %HR max and %HR res were significantly lower in group 1 (87 +/- 5% and 76 +/- 9%) and group 2 (87 +/- 6% and 78 +/- 11%) than in controls (91 +/- 6% and 84 +/- 11%). No significant differences were found between group 1 and 2 for all studied data.


Conclusions: Blood pressure recovery after maximal exercise and chronotropic competence are impaired late after Kawasaki disease. However, exercise capacity is preserved. The results of the present study do not support the traditional assessment of KD severity based on coronary complications at the acute phase.




Jonathan A. Black; Vera Bittner, MD, MSPH


Primary Institution: University of Alabama at Birmingham


Introduction: More than two-thirds of patients with coronary heart disease (CHD) are overweight or obese and obesity is the most common cardiovascular risk factor in patients who have suffered a myocardial infarction. Cardiac rehabilitation/secondary prevention programs (CR) include education, counseling, exercise training, and behavior modification interventions.


Purpose: This study was designed to better understand the impact of obesity on CR outcomes. It was hypothesized that 1. Obese patients will be less likely to complete CR. 2. Obese patients who complete CR will improve cardiovascular risk factors and lifestyle measures, but not to the same degree as non-obese patients.


Design: Data were collected from a CR program based in an academic medical center that provides comprehensive secondary prevention services.


Methods: Patients were stratified into obese group (N = 754; BMI >= 30 kg/m2) and non-obese group (N = 793). Baseline characteristics and CR outcomes were compared using t-testing and chi-square testing as appropriate.


Results: Obese patients are less likely to complete CR than non-obese patients: 51.1% vs 61.1%, respectively, p = 0.04. Obese patients had greater risk factor and comorbidity burden at entry than non-obese patients. For many metrics, obese patients who complete CR improve as much as nonobese patients (hemoglobin A1C, systolic BP, 6 min walk distance, MCS and PCS component scores of SF 36). In some areas obese patients improve more than non-obese patients: BMI decreased 0.9kg/m2 compared to 0.3kg/m2 (p < 0.001); triglycerides decreased 45.1 and 20.1mg/dL (p = 0.01); diet score decreased 15.3 and 10.5 (p = 0.003); diastolic blood pressure dropped 2.6 and 1.6mmHg (p = 0.03)


Conclusions: Obese patients are less likely to complete CR, but those who complete CR benefit as much as non-obese patients. Future studies need to explore the reason for differential dropout so that CR programs can be tailored to better address the needs of obese patients and improve the health and quality of life of this patient population.




Kashish Goel, MD; Quinn Pack, MD; Brian Lahr, MS; Kevin L. Greason, MD; Francisco Lopez-Jimenez, MD, MSc; Ray Squires, PhD; Zixin Zhang, MD; Randal J. Thomas, MD, MS


Primary Institution: Wayne State University


Secondary Institution: Mayo Clinic


Introduction: Cardiac rehabilitation (CR) is associated with reduced mortality after myocardial infarction, PCI or CABG surgery, however no data is available in patients undergoing combined heart valve and CABG surgery (V + CABG).


Purpose: To assess the potential impact of CR on all-cause mortality following V + CABG surgery.


Design: The cardiovascular surgery database at Mayo Clinic was assessed to identify consecutive Olmsted county patients who underwent V + CABG surgery from 1996 to 2007.


Methods: CR participation was defined as attending at least one outpatient CR session within 6 months following surgery. To control for potential participation bias, propensity scores (PS) were developed using more than 40 patient, clinical, operative and post-operative characteristics. Cox-proportional hazards regression was used to assess the impact of CR on all-cause mortality via landmark analysis (i.e., conditional on 6 months of follow-up), PS regression adjustment and PS stratification techniques.


Results: A total of 201 patients were included, in whom 86 deaths occurred over a period of 10 years (mean +/- SD of 6.8 +/- 2.8 years). Majority of the subjects were elderly (mean +/- SD age, 73.1 +/- 10.6 y), cigarette smokers (65%), diabetics (24%), hypertensive (76%), had family history of CAD (32%), or were classified as having a NYHA class III or IV symptoms (75%). The overall CR participation rate was 47%, and a significant trend towards increased participation was noted from 1996 to 2007 (p for trend = 0.04). CR participation, conditional on 6-month survival, was associated with a significant reduction in all-cause mortality (HR 0.49, 95% CI 0.28-0.84; p = 0.009) using PS regression adjustment, after adjusting for CR propensity score and mortality risk factors in our study population. These results were almost similar using other statistical techniques (HR 0.50; p < 0.01). The number needed to treat with CR over a 10-year period, to prevent one death, was only seven. The results were not statistically different based on age, gender, emergent status or history of congestive heart failure, however a non-significant trend suggested a possible differential effect of CR on mortality based on valve type and history of arrhythmias.


Conclusions: To the best of our knowledge, this is the first study to report a significant mortality benefit of CR participation in a community-based sample of patients with combined valvular and atherosclerotic heart disease who have undergone combined V + CABG surgery. Our findings provide support for the use of CR/secondary prevention services in patients undergoing V + CABG surgery.


11:00 AM-12:00 PM Thursday, September 6, 2012 Scientific Oral Presentations

Physiology Presentations



Dalynn T. Badenhop, PhD; Steven Keteyian, PhD; Eric Leifer, PhD; Timothy McConnell, PhD; Gary Balady, MD; Joel Landzberg, MD; Brad A. Roy, PhD; Udho Thadani, MD


Primary Institution: University of Toledo


Secondary Institution: Henry Ford Hospital; National Heart, Lung and Blood Institute; Bloomsburg University, Boston University; Hackensack University Medical Center; Kalispell Regional Medical Center; University of Oklahoma Health Sciences Center; VA Medical Center, Oklahoma City


Introduction: Diabetes mellitus (DM) can promote the progression of heart failure (HF) which may result in decreased peak VO2 and changes in the ventilatory response to exercise. Peak VO2 and exercise ventilatory parameters are important for determining treatment and prognosis for HF patients.


Purpose: This study addresses whether a history of DM and use of insulin is associated with a lower exercise capacity in patients with HF.


Design: Baseline cardiopulmonary exercise (CPX) testing data from the HF-ACTION trial were assessed to clarify DM and insulin-effects on peak VO2, oxygen uptake at the ventilatory threshold (VT) and the slope of the ratio for minute ventilation and carbon dioxide


Methods: CPX testing was completed in HF patients with a goal to achieve a respiratory exchange ratio (RER) >1.10. Peak VO2 was determined as the highest relative VO2 (mL/kg/min) for a given 15- or 20-second interval within the last 90 seconds of exercise or the first 30 seconds of recovery. The 15 or 20-second averaged data for VO2 (mL/min), VCO2 (mL/min) and VE (L/min) were entered into a spreadsheet. From these data, the VE/VCO2 slope was calculated using all data between rest and peak exercise. The V-slope method was used to determine VT. For the univariate analyses of two comparison groups, continuous variables were compared using the equal or unequal variance t-test. For categorical variables, Pearson's chi-square test (d.f. = number of categories - 1) was used. An exact Pearson's version was used if there was a cell smaller than 5. Otherwise, a regular (asymptotic) Pearson was used. A multivariable linear regression model for peak VO2 was developed using a list of 32 demographic and clinical predictor variables. From the 32 variables, those with the highest likelihood ratio test p-values were eliminated one-at-a-time from inclusion in the multivariable model until all those remaining had partial R2 values >= 0.01. Similar models were developed for VT and VE/VCO2 slope. Statistical significance was defined at the two-tailed 0.05 level.


Results: Of the 2331 HF-ACTION patients 748 (32%) had a history of DM and of those with a history of DM 331 (44%) were on insulin at the beginning of the study. In multivariate models predicting baseline peak VO2 and VT, respectively, subjects with a history of DM had a peak VO2 and a VT that was significantly lower by 1.2 mL/kg/min and 0.7 mL/kg/min, respectively, compared to subjects without a history of DM. This accounted for 2% of the total variability of peak VO2 and VT. A history of DM was not identified as an independent predictor of baseline VE/VCO2 slope in a multivariate model. In the multivariate model of HF patients with a history of DM, use of insulin, had a partial R2 >= 0.01 for baseline peak VO2. Being treated with insulin had a partial R2 < 0.01 for VT and VE/VCO2 slope.


Conclusions: DM and insulin use appear to have a very modest independent impact on peak VO2 in patients with HF but not on VE/VCO2 slope.




Patrick D. Savage, MS; Philip Ades, MD


Primary Institution: Fletcher Allen Health Care


Introduction: Obesity is an independent yet modifiable coronary heart disease (CHD) risk factor and is a highly prevalent medical condition among participants in phase 2 cardiac rehabilitation (CR). While it is well documented that modest weight loss occurs during CR, little is known about change in weight between an index cardiac event and entry into CR.


Purpose: We examine the change in weight that occurs prior to and during CR.


Design: Prospective, observational.


Methods: Body weight was recorded at 3 time points: 1) in-hospital at the time of cardiac event (baseline); 2) at entry to CR (entry); 3) at completion (exit) of CR. Body mass index (BMI, weight [kg]/height [meters]2) was used to classify individuals as normal (BMI < 25) or overweight (BMI > 25). Individuals with a diagnosis of heart failure were excluded. Statistical methods included paired and non-paired t-tests and a p-value of < 0.05 was used to determine significance. Results are presented as mean + Standard Deviation.


Results: The entire cohort (n = 105, Males = 77) had CHD and a mean age, weight and BMI of 65.0 + 10.2 years, 87.7 + 16.9 kg and 30.5 + 5.3, respectively. The mean number of CR sessions attended was 28.5 + 8.9. Significant weight loss occurred from baseline to entry (2.4 + 3.0 kg, p < 0.001) and from entry to exit (2.5 + 4.4 kg, p < 0.01) and was similar between time groups (p = 0.46). Total mean weight loss from baseline to exit from CR was 4.9 + 4.8 kg, p < 0.001 and was similar by gender. At baseline, compared to non-surgical patients (n = 69), surgical (coronary artery bypass) patients were younger (63.0 + 10.1 vs 68.8 + 9.3 years, p < 0.001), weighed less (82.8 + 15.9 vs 90.3 + 33.4 kg, p < 0.05), entered CR later (39.3 + 10.9 vs 30.0 + 19.2 days, p < 0.001) and attended more sessions (31.4 + 6.5 vs 26.9 + 9.7, p < 0.02) (all, p < 0.05). Total mean weight loss was similar between diagnostic groups (P = 0.76); however, surgical patients lost more weight between baseline and entry (4.2 + 3.1 vs 1.5 + 2.5kg, p < 0.0001) while non-surgical patients lost more from entry to exit (0.9 + 4.1 vs 3.3 + 4.3 kg, p < 0.01). Regardless of BMI category, all subjects experienced significant weight loss from baseline to exit; overweight individuals, however, lost significantly more weight than normal weight patients (5.4 + 4.9 vs 1.6 + 2.3 kg, respectively) (p < 0.001)


Conclusions: Cardiac patients lose significant weight between hospital admission and entry to CR. Nearly half of the total weight loss that patients experience from cardiac event to completion of CR occurs prior to enrolling in CR.




Alban De Schutter, MD; Carl J. Lavie, MD; Dharmendrakumar A. Patel, MD; Richard Milani, MD


Primary Institution: Cleveland Clinic Florida


Secondary Institution: Ochsner Clinic Foundation


Introduction: Many studies of coronary heart disease (CHD) and heart failure(HF) cohorts have demonstrated an inverse relationship between obesity, as determined by both body mass index (BMI) and percent body fat (BF), on subsequent prognosis (the "obesity paradox").


Purpose: To examine the impact of central obesity on prognosis.


Design: We retrospectively studied 393 patients referred for phase II cardiac rehabilitation.


Methods: They were divided into low (< 32" for women and < 38" for men), medium (>= 32" and < 35" for women and >= 38" and < 41" for men), and high waist circumference WC (>= 35" for women and >= 41" for men). Three groups were analyzed for total mortality over 3-year follow-up by National Death Index: low WC (n = 84), medium WC (n = 102) and high WC (n = 207).


Results: During 3-year follow-up, mortality was highest in the Low WC group (7.1%), which was significantly higher (p = 0.02) than the other 2 groups combined (2.9% and 2.4% respectively; Figure). There was no significant difference in mortality between the medium and high WC groups. In multivariate logistic regression analysis for mortality after adjusting for age, gender, ejection fraction and peak exercise oxygen consumption, higher WC was an independent predictor of lower mortality (OR 0.86; CI 0.75-0.99).


Conclusions: Although the impact of central obesity on prognosis in HF and CHD have been conflicting, our data suggests that the "obesity paradox" remains intact in CHD even when considering central obesity. Patients with CHD and low WC have particularly high mortality risk.




Gregory Lam, MD; Michelle La Londe, MA; Daniel Mudrick, MD, MPH; Lynn Shaffer, PhD; Anne Albers, MD; Kathy Spencer, MSN, RN; Teresa Caulin-Glaser, MD


Primary Institution: McConnell Heart Health Center


Secondary Institution: Ohio Health


Introduction: The prevalence of obesity in the United States has more than doubled in the last 30 years and has become a significant public health problem. Cardiac rehabilitation programs (CR) have been effective in helping overweight and obese patients lose weight, however not all patients enrolled in CR are successful in weight loss.


Purpose: We sought to identify predictors of successful weight loss in overweight and obese patients in a CR cohort.


Design: A retrospective cohort study.


Methods: 1,228 non-surgical enrollees in phase II CR between 1/1/2004 and 3/31/2011 with a BMI >= 25 kg/m2 were included in this analysis. All participants completed the CR program with complete entry and exit collection of lipids, stress tests, blood pressure, anthropometrics, Beck Depression Inventory II (BDI-II) and SF-36. Participants also completed a personal health assessment questionnaire. Participants were dichotomized as "successful" or "unsuccessful" with weight loss based on NIH clinical guidelines. NIH recommends a 10% weight loss over six months. We extrapolated this recommendation to define a successful CR weight loss of 0.42% per week of participation. Descriptive analysis was performed using chi-square analysis for frequency data and paired t-tests for continuous data to identify important differences based on weight loss status. Logistic regression was performed to determine predictors of weight loss success.


Results: Approximately 17% of participants achieved successful weight loss. For each MET increase in exercise capacity there was a 16% increase in likelihood of successful weight loss (p = 0.006). With each 5 point increase in entry SF-36 physical function scores, likelihood of successful weight loss increased by 12% (p = 0.01). Mean sessions attended per week was also predictive of weight loss success. For each additional mean session per week, participants were nearly 2.4 times more likely to achieve successful weight loss. There was also significant interactions between age and low health status ratings as well as age and diet stage of change (p = 0.002 and p = 0.03, respectively). Low health status ratings and active diet stage of change were both predictive of success for older participants but not for younger participants.


Conclusions: Psychosocial and behavioral factors such as compliance with CR sessions, dietary stage of change, and self-perceptions of physical function may be useful predictors of successful weight loss for patients enrolled in a CR program. Identifying these factors may be important in stratifying participants and tailoring therapies to achieve maximum risk-reduction in this high-risk population.


3:00 PM-4:30 PM Friday, September 7, 2012 Scientific Oral Presentations

Program Presentations



Lisa Benz Scott, PhD; Thomas R. Sexton, PhD; Sabrina Brzostek, PhD; Ceylan Cizmeli, ABD; David L. Brown, MD


Primary Institution: Stony Brook University


Introduction: Enrollment into outpatient cardiac rehabilitation (OCR) among eligible men and women is suboptimal. Thus, it is important to identify new approaches to improving enrollment in OCR.


Purpose: This study examined the effect of cardiac patient navigation (PN) on OCR enrollment rates compared to usual care (UC).


Design: Patients with myocardial infarction (MI), PCI, CABG, or stable angina were consented during inpatient care at a participating academic medical center, and randomly assigned to either PN (n = 90) or UC (n = 91).


Methods: The PN group was provided with a trained lay health advisor (non-clinician) who delivered OCR-focused education/support at the bedside, and/or telephone-based education to facilitate the patient's selection of an OCR program from a list. PN patients discharged prior to navigation were mailed information to their home which was reviewed by telephone with a navigator within 1 week. Navigators contacted the OCR program selected by each patient to provide staff with pertinent information to facilitate patient contact. All study participants were interviewed by phone at 1 and 3 months post-discharge to assess self-reported OCR enrollment. Study personnel verified enrollment (defined as >1 OCR session). After the 3-month interview, UC were also mailed educational information about OCR in the event they did not learn about it from a provider. Group differences in enrollment rates were assessed using Fisher's Exact Test (one-tailed, alpha .05). Patients who died < 1 month after hospitalization (1 PN, 2 UC) were removed from analysis.


Results: The sample was primarily male (n = 119, 65.7%), white, non-Hispanic (n = 163, 90%), insured (n = 153, 85%), and recovering from MI (n = 108), PCI (n = 107), CABG (n = 30), and/or stable angina (n = 6). The mean age was not significantly different between PN (x = 60.44 years, SD = 10.21 years) and UC groups (x = 61.04 years, SD = 11.17 years). Only 5/89 UC (6%) and 16/89 PN (18%) enrolled in an OCR program (p = 0.009). Gender analyses showed that 15% of women in PN enrolled in OCR (5 of 32), vs. 7.1% of women in UC (2 of 28), p = 0.272. Among men, 19.3% in PN enrolled in OCR (11 of 57) vs. 4.8% in UC (3 of 62), p = 0.016. Only 2 PN patients refused navigation and 7 PN patients declined to select an OCR program after learning about the benefits.


Conclusions: Although still suboptimal, OCR enrollment rates within 3 months of hospitalization were significantly higher among patients assigned to navigation by trained lay advisors compared to UC, with significantly greater improvement in enrollment rates among male patients.




Mary N. Hanna, RN, BSN; Kathy Jo Ellison, RN, DSN; Bonnie Sanderson, PhD, RN; Kathe Briggs, MEd


Primary Institution: Auburn University


Secondary Institution: East Alabama Medical Center


Introduction: The Centers for Medicare and Medicaid Services (CMS) is targeting heart failure (HF) readmission (RA) rates in an effort to reduce overall health care costs. Beginning in FY2013, CMS will deny full reimbursement (1% reduced in 2012; up to 3% in 2017) for all CMS reimbursements regardless of diagnosis if the health care facility is above national average. To effectively reduce HF RA, facilities will need to accurately predict which HF patients are at high risk for RA and target additional transitional care to these high risk HF patients.


Purpose: The aims of this paper are: 1) to evaluate the effectiveness of five Risk Stratification (RS) tools used to retrospectively identify patients who were re-admitted for heart failure symptoms in a large Southeast acute care referral center, and 2) identify the proportion of HF RA who were referred to the HF telemonitoring program. The following question guides this study: In adult patients admitted to an acute care facility with a diagnosis of HF, which Risk Stratification tool (including the one currently used) most accurately identified a 30-day RA rate?


Design: A descriptive, retrospective analyses of the index hospitalization of RA HF (n = 23) during the 4th quarter 2011.


Methods: Chart review was conducted on the patients readmitted and the accuracy of the RS tool in identifying high risk patients for RA. The five tools included three previously published RS tools: 1) LACE (van Walraven, 2010), 2) Krumholtz et al. (2000), 3) Philbin and DiSalvo (1999), and two unpublished RS tools: 4) the current hospital tool, and 5) an assembly of independent predictors. Accuracy of forecasting RA was attributed if the RS tool correctly identified the index hospitalization as High Risk; however, failure was defined as a RS tool that recognized the index hospitalization as Low or Medium Risk.


Results: Among the 23 HF RA, the average was age 66.74 years old with a Charlson score of 5.39, has a history of diabetes (56.5%), other heart disease (87.0%), pulmonary disease (26.1%), and renal insufficiency (73.9%). Three of the five RS tools (LACE, and Krumholtz et al., and the assembled independent predictors) accurately forecast the HF RA as High Risk (69.6%, 65.2%, and 78.3% respectively); however, two of the five did not (Philbin & DiSalvo, 4.3%; EAMC, 34.8%). Missed opportunities were defined as HF RA either 1) not identified as High Risk, or 2) identified as High Risk but the telemonitoring program not consulted [assembled independent predictors, 14 (60.9%); LACE, 13 (56.5%); Krumholtz et al., 17 (73.9%); EAMC, 15 (65.2%)].


Conclusions: Three of the five RS tools were fairly accurate in identifying HF RA in this patient population. However, even when HF patients were identified as high risk for RA, there were missed opportunities for post discharge follow-up in an available HF program.




Quinn R. Pack, MD; Lezlie Johnson, RN; Stephanie R. Daniels, BS; Anne Wolter, BS; Ray Squires, PhD; Randal J. Thomas, MD, MS


Primary Institution: Mayo Clinic


Introduction: Recent studies have demonstrated a dose-response benefit from cardiac rehabilitation (CR). Patients who attend more CR sessions have lower subsequent mortality rates than those who attend fewer sessions.


Purpose: To describe results of a series of quality improvement activities aimed at increasing attendance in early outpatient (Phase II) CR.


Design: Retrospective quality improvement analysis.


Methods: In February 2010, the Mayo Clinic CR program changed from a policy of prescribing the number of CR sessions based on patient characteristics and progress toward goals, to a new policy that recommended a "full dose" of CR to provide maximal benefits from CR. Furthermore, in October of 2010 we introduced a 5 minute video describing the benefits of CR for all eligible inpatients and new Phase II CR enrollees. In June 2011, a brochure on CR survival benefits was incorporated for both inpatients and outpatients. In August 2011, we introduced an incentive program in the Phase II program which rewarded patients with parking passes, T-shirts, tote bags, water bottles, and sweatshirts after every 6th CR session attended. We identified 100 sequential patients enrolled in CR during 5 separate 3-month time periods (August 2009, 2010, and 2011; February 2010 and 2011). We then limited our analysis to Olmsted County, MN patients. The number of sessions attended was determined through billing records. Program completion was defined as attending a formal Phase II CR exit interview.


Results: For August 2009, February 2010, August 2010 and February 2011, the number of eligible patients in the study cohort was 75, 62, 66, and 66, respectively. The number of session per patient (+/- SD) was 15.4 +/- 11.6, 17.6 +/- 13.4, 18.9 +/- 12.7, and 18.6 +/- 14.6, respectively, p = 0.14 for trend. When limited to those completing the program (42, 42, 39, 40 patients, respectively), the numbers of sessions were 18.6 +/- 11.5, 19.8 +/- 12.7, 25.3 +/- 10.6, 27.4 +/- 10.3, per group respectively, p = 0.0008 for trend. Preliminary results for August 2011 showed 20.7 +/- 14.3 sessions per patient (n = 19), but was excluded from analysis due to lack of enough follow-up time (>150 days) to complete CR for this cohort.


Conclusions: Quality improvement activities, including policy changes, educational materials, and incentive programs appear to improve CR attendance and completion at least in those completing CR, but may not significantly affect other enrolled patients. Evaluation of the incentive program is ongoing.




Michelle La Londe, MA; Lynn Shaffer, PhD; Gregory Lam, MD; Daniel Mudrick, MSN, RN; Anne Albers, MD; Kathy Spencer, MD; Teresa Caulin-Glaser, MD, MPH


Primary Institution: McConnell Heart Health Center


Secondary Institution: Ohio Health


Introduction: Personal awareness of lipid status allows patients to actively participate in risk modification. Despite increased rates of lipid profile screening, only 50.4% of adults with hypercholesterolemia report being told they had high cholesterol in 2005-2006 (NHANES).


Purpose: We evaluated the personal health awareness of patients with abnormal lipid levels regarding their lipids levels upon entry to cardiac rehabilitation (CR).


Design: A retrospective cohort study.


Methods: This analysis included 511 individuals who entered CR between 10/14/2008 and 11/11/2011 with abnormal lipid levels. All individuals included in this analysis had lipid profiles collected upon program entry and exit and completed a personal health assessment (PHA) upon program entry. Abnormal lipid status was defined using ATP III guidelines. Individuals were categorized as being health aware or health unaware based on their response (yes/no) to the question: 'Have you ever been told your cholesterol or lipid profile was abnormal?' A logistic regression model identified characteristics which distinguish between patients who are aware and unaware of their lipid status. Descriptive analysis using chi-square analysis for frequency data and t-tests for continuous data identified candidate variable for logistic regression modeling.


Results: Based on entry lipid profiles, the prevalence of lipid abnormalities was 34% elevated LDL (>100 mg/dl), 17% elevated cholesterol (>200 mg/dl), 51% elevated triglycerides (> = 150 mg/dl), 62% low HDL (<40 mg/dl). In 32% of patients, low HDL was the only lipid abnormality. Seventy-nine percent of patients were aware of their abnormal lipid status. Individuals with a known history of hypertension were 1.8 times more likely to be lipid health aware than those with no known history of hypertension (p = 0.02). Individuals with a known history of diabetes were 1.7 times more likely to be lipid health aware compared to those with no known diabetic history. Patients with higher entry LDL levels were also more likely to be aware of their lipid status. For each 5 mg/dl above ATP III LDL goal, patients were 4% more likely to be aware of their lipid status (p = 0.009).


Conclusions: Despite recent intensive interaction with the healthcare system, 21.0% of dyslipidemic individuals entering CR were unaware of their abnormal lipid status. Individuals with experience with chronic disease (hypertension and/or diabetes) appeared to have a higher level of lipid health awareness. Based on this analysis, there is an opportunity to improve lipid health awareness among patients entering CR.




Shauna Miller, MS; Michelle La Londe, MA; Lynn Shaffer, PhD; Gregory Lam, MD; Daniel Mudrick, MD; Anne Albers, MD; Kathy Spencer, MSN, RN; Teresa Caulin-Glaser, MD


Primary Institution: McConnell Heart Health Center


Secondary Institution: Ohio Health


Introduction: With the advent of risk stratification in cardiac rehabilitation (CR) programs, fewer patients are participating in 36 sessions of CR.


Purpose: We evaluated the impact of number of CR sessions attended on achievement of goals for LDL and blood pressure (BP) upon program completion.


Design: A retrospective cohort study.


Methods: This analysis included 443 patients entering CR between 10/14/2008 and 11/11/2011. All patients included in this analysis had entry and exit lipids and BPs. Exit BP was defined as the mean resting BPs from the patient's final three sessions. BP goal was defined as a mean exit systolic BP less than 120 mm Hg and a mean diastolic BP less than 80 mm Hg. LDL goal was defined per ATP III guidelines. All patients also had a risk stratification level, number of sessions completed and personal health assessment available for analysis. Logistic regression models assessed the impact of sessions attended on LDL and BP goal attainment after adjustment for other significant predictors of goal attainment. Descriptive analysis was performed using chi-square analysis for frequency data and t-tests for continuous data to identify candidate variables for logistic regression. ANOVA examined the difference in the number of sessions attended by risk stratification level.


Results: Patient distribution and mean sessions attended by risk stratification level was 12.4% low risk (19.0 +/- 3.5 sessions), 48.3% medium risk (23.5 +/- 3.2 sessions) and 39.3% high risk (32.2 +/- 5.4 sessions). The mean sessions attended was significantly different by risk stratification level (p < 0.0001). LDL goal was achieved by 93% of low risk patients, 85% of moderate risk patients and 83% of high risk patients upon program exit (p = 0.22). Number of sessions attended was not a significant factor in LDL goal attainment upon program exit (p = 0.95) after adjustment for gender, change in MET level and LDL goal status upon program entry. BP goal was achieved by 53% of low risk patients, 50% of moderate risk patients and 41% of high risk patients upon program exit (p = 0.12). Number of sessions was also not a significant factor in BP goal attainment upon exit (p = 0.09) after adjustment for gender, weight change, entry BMI level and BP goal status upon program entry.


Conclusions: Compared to the traditional 36 session CR, risk stratification resulted in an overall reduction of 27% in sessions attended. However, this reduction did not have a significant impact on attainment of LDL or BP goals.




Michelle La Londe, MA; Lynn Shaffer, PhD; Gregory Lam, MD; Daniel Mudrick, MD; Anne Albers, MD; Kathy Spencer, MSN, RN; Teresa Caulin-Glaser, MD


Primary Institution: McConnell Heart Health Center


Secondary Institution: Ohio Health


Introduction: With the advent of risk stratification in cardiac rehabilitation (CR) programs, fewer patients are participating in 36 sessions of CR.


Purpose: We evaluated the impact of number of CR sessions attended on achievement of a bundled goal of both LDL and blood pressure (BP) upon program completion.


Design: A retrospective cohort study.


Methods: This analysis included 443 patients entering CR between 10/14/2008 and 11/11/2011. All patients included in this analysis had entry and exit lipids and BPs. All patients also had a risk stratification level, number of session completed and personal health assessment available for analysis. Exit BP was defined as the mean resting BPs from the patient's final three sessions. BP goal was defined as a mean exit systolic BP less than 120 mm Hg and a mean diastolic BP less than 80 mm Hg. LDL goal was defined per ATP III guidelines. Bundled goal was defined as meeting goals for both LDL and BP upon program completion. Logistic regression models assessed the impact of sessions attended on bundled goal attainment after adjustment for other significant predictors of goal attainment. Descriptive analysis was performed using chi-square analysis for frequency data and t-tests for continuous data to identify candidate variables for logistic regression. ANOVA examined the difference in the number of sessions attended by risk stratification level.


Results: Patient distribution and mean sessions attended by risk stratification level was 12.4% low risk (19.0 +/- 3.5 sessions), 48.3% medium risk (23.5 +/- 3.2 sessions) and 39.3% high risk (32.2 +/- 5.4 sessions). The mean sessions attended was significantly different by risk stratification level (p < 0.0001). Bundled goal was achieved by 40% of patients. Number of sessions attended was not a significant factor in bundled goal attainment upon program completion (p = 0.32) after adjustment for obesity status, change in weight, and bundled goal status upon program entry. Patients who had a BMI >= 30 kg/m2 upon program entry were 47% less likely to achieve bundled goal (p = 0.004). For each pound of weight loss during CR, patients were 4% more likely to achieve bundled goal (p = 0.006). Patients who were at bundled goal upon program entry were 1.66 times more likely to achieve bundled goal upon program completion (p = < 0.0001).


Conclusions: Compared to the traditional 36 session CR, risk stratification resulted in an overall reduction of 27% in sessions attended. However, this reduction did not have a significant impact on attainment of a bundled goal for both LDL and BP.


Scientific Poster Presentations

Posters available for viewing:

10:30 AM-3:00 PM Friday, September 7, 2012

Authors will be present:


1:00 PM-3:00 PM


Poster #: S101




Kimberly Varnado, PT, DPT, OCS; Donald Shaw, PT, PhD, D.Min.; Eder Garavito, BA; Sudhindra Gadagkar, PhD


Primary Institution: Midwestern University


Classification: Cardiac


Introduction: Clinically, the words "heart rate" (electrical event) and "pulse rate" (mechanical event) are often used interchangeably. However, some contractions of the left ventricle fail to produce peripheral pulse waves and occasionally manually palpated rates are estimated using abbreviated (10 s, 15 s, 30 s) counts; either scenario raises possible documentation consistency and patient safety concerns.


Purpose: The purpose of this study was to determine if significant differences exist among four different rate measurement devices and four different rate measurement time intervals when each device was used in combination with each time period at rest.


Design: A two-factor (method by time in seconds) repeated measures design was used to assess differences among four measurement methods and four time intervals


Methods: Thirty-two (9 males, 24.7 +/- 2.1yrs; 23 females, 24.1 +/- 2.1yrs) physical therapy students were randomly selected to participate in the study. Following acquisition of informed consent, subjects were positioned supine while the heart and pulse rates were obtained simultaneously at 10 s, 15 s, 30 s, and 60 s from four sources: radio telemetry ECG (RT ECG); hand held ECG (HH ECG); pulse oximeter (PO) and, manual palpation of the radial artery (MP). The procedure was repeated following a brief rest if either device or investigator measurement difficulties were encountered during the first trial.


Results: The analysis revealed significant overall differences (p ~ 0) in the pulse rate measurements among the devices and among the time intervals. Within-subject contrasts revealed that all rate measurements were significantly different (p ~ 0) for all the devices when compared to RT ECG, all calculated 60 s time intervals from abbreviated counts (10 s, 15 s, 30 s) were significantly different (p ~ 0) from 60 s. Within-subjects contrasts also indicated significant interaction terms between the device and time intervals. The following interaction terms were significant: RT ECG v HH ECG at time intervals 10 s v 60 s (p < 0.03), and 30 s v 60 sec (p < 0.01); RT ECG v MP at time intervals 10 s v 60 s and 15 s v 60 s (p < 0.01). Effect size analysis revealed medium to high effect sizes among device contrasts and low to medium effect sizes for time interval contrasts.


Conclusions: We conclude, that although rate differences between methods were small, they were non-the-less significant and appear worthy of clinical consideration - especially for the elderly and for those with cardiac dysrhythmias. Of particular interest was the inconsistency seen between most all methods, whether pulse or heart rate. This appears to support the notion that rates should be obtained from the same device whenever possible to minimize variations due to method. The rate differences observed between ECG methods cannot be explained, however, 60 s MP rates calculated from abbreviated 10 s and 15 s counts clearly lacked precision since they are estimates only.


Poster #: S102




Eder Garavito, BA; Kimberly Varnado, PT, DPT, OCS; Donald Shaw, PT, PhD; Brittany Dichraff, BA; Dustin Glew, BA; Nipaporn Somyoo, BA


Primary Institution: Midwestern University


Classification: Cardiac


Introduction: Manual palpation (MP) of the radial artery is often utilized for resting pulse rate determination, however, clinicians frequently estimate pulse rates on the basis of an abbreviated 1 min count (10 s, 15 s, or 30 s). Given that pulse rate accuracy is a function of measurement time, clinical implications may be profound for those with cardiac dysrhythmias when counts are shortened; additionally, differences in rate may occur between MP and ECG since peripheral pulse waves are not always propagated.


Purpose: The purpose of this study was to determine if significant differences exist between resting MP and ECG values obtained from the same subjects over four separate time intervals.


Design: A 2 factor (method by time in seconds) repeated measures design was used to assess differences among 2 rate determination methods and 4 time intervals at rest.


Methods: Thirty-two (9 males and 23 females) physical therapy students were randomly selected to participate in the study. Following acquisition of informed consent, subjects were placed supine on a treatment table. Once the radial pulse was located and monitoring electrodes were affixed, telemetered ECG and MP rates were obtained simultaneously at 10 s, 15 s, 30 s, and 60 s intervals. A second trial was initiated if the first trial failed. Intraclass correlation for the MP technician was .79 with a priori power testing indicating an n = 13 was required for a power of .80 (P = 0.05).


Results: Analysis of MP and ECG means (63.6 v 67.7 beats.min-1) revealed significant rate differences between the two methods overall (P ~ .000). Within-subjects contrasts of time intervals rendered significant differences between MP and ECG at 10 s v 60 s (P ~ .000) and 15 s v 60 s (P < .002). Significant pairwise differences were also found between 1 min MP's estimated from abbreviated counts (i.e., 10 s x 6, 15 s x 4, 30 s x 2): 10 s vs. 60 s (P ~ .000), 15 s vs. 60 s (P ~ .000), 30 s vs. 60 s (P = .017).


Conclusions: We conclude MP is not consistent with ECG in providing the same rate counts. We further conclude that pulse rates estimated from shortened counts may pose a risk for patients who require close monitoring and for patients who have pulse irregularities that may go undetected.


Poster #: S103




Kenneth Sparks, PhD; Jamie Schofield, MEd


Primary Institution: Clevland State University


Classification: Cardiac


Introduction: The use of a dry electrode (DE), which does not rely on electrolytic solution, may circumvent many of the potential disadvantages of the wet electrode (WE). An investigation of the signal quality of the two different types of disposable electrodes is necessary as the accuracy of the ECG signal is vital.


Purpose: The purpose of this study was to investigate if differences in signal quality, reflected by the signal-to-noise ratio (SNR), existed between the standard gel 3MTM Red DotTM 2560 electrode (WE) and the Orbital Research Incorporated (ORI) dry electrode (DE) over a 96 hour period of continuous wear. Assessments were made both within electrode types, comparing potential signal deterioration within the electrode throughout 96 hours of wear, and also between the two electrode types, comparing the differences in SNR over 96 hours. It was hypothesized that there would be no significant difference in SNR within or between the electrodes


Design: Twenty healthy adult volunteers (10 males, 10 females) completed the research protocol, each simultaneously wearing the two pairs of electrodes for 96 hours continuously in a lead II configuration.


Methods: ECG tracings were collected simultaneously on two different telemetry channels once a day over five consecutive days. The collection period consisted of six three minute stages, totaling 18 minutes. The six stages included two bouts of rest, supine and standing, followed by three submaximal exercise stages, ending with one additional stage of standing rest. Data collected using the telemetry unit was de-noised by MatlabTM using sixth order Daubechies wavelet transform technology. Signal-to-noise ratio for each electrode at each stage every day was calculated. Repeated measures ANOVAs were utilized to assess differences amongst the mean SNR (db) values (p < .05). Paired t tests were used to specify the sources of the difference (p < .05).


Results: No significant differences existed within the DE SNRs over time, indicating that the SNR did not deteriorate over time. Although significant differences existed within the WE SNRs over time in the initial standing stage of testing, the noise was reduced; therefore, the signal did not deteriorate over time. A significant difference existed between the WE and DE SNRs four of the five days in the supine stage, favoring the WE.


Conclusions: Signal quality did not significantly deteriorate over time for either the WE or the DE. Although a significant difference existed between the electrode types over time at one of the six stages of testing, it likely would not affect clinical assessment.


Poster #: S104




John F. Greany, PhD, PT; Kristin A. Greany, PhD, RD; Heather Fortuine, SPT


Primary Institution: University of Wisconsin - La Crosse


Classification: Prevention/Wellness


Introduction: Dynamic exercise results in decreased blood pressure (BP). Consumption of flavanols, a substance found in cocoa has been shown to decrease resting blood pressure.


Purpose: This pilot study sought to determine whether flavanol consumption, when paired with exercise, would augment the post-exercise hypotension (PEH).


Design: Repeated measures study


Methods: 18 subjects (14 females, 4 males; 6 pre-hypertensive/hypertensive (pre/HTN), 12 normotensive (NTN)) were recruited (mean age (+/- SD) 25.9 +/- 6.7 years). Each subject participated in three sessions approximately one week apart. Session 1 consisted of gathering baseline data and performing a treadmill max test. Sessions 2 and 3 consisted of 30 minutes of exercise at 65%-75% of maximal heart rate reserve followed by 60 minutes of rest with blood pressure (BP) monitoring using the Oscar 2 Ambulatory Monitor (SunTech Medical, Morrisville, NC). Subjects were randomly assigned to ingest 750 mg of cocoa flavanols (CocoaVia, MARS, Inc) prior to one of the exercise sessions. In addition to hemodynamic monitoring, subjects completed questionnaires to assess compliance with dietary and activity restrictions. A repeated measures ANOVA and paired t-tests were conducted to evaluate PEH with and without the addition of flavanol supplements.


Results: The mean systolic blood pressure (SBP) at baseline was 116.0 +/- 10.4 mmHg; post exercise 110.5 +/- 9.8 mmHg; post exercise/flavanol 110.9 +/- 7.5 mmHg. The mean diastolic blood pressure (DBP) at baseline was 70.0 +/- 8.7 mmHg; post exercise 67.5 +/- 9.0 mmHg; post exercise/Flavanol 67.5 +/- 7.0 mmHg. There were significant reductions in 1 hour SBP after exercise and after exercise/flavanol supplementation (-6.6 +/- 1.5 mmHg; -6.5 +/- 1.5 mmHg; P < 0.01); the addition of flavanols to an acute bout of exercise resulted in no additional reductions in SBP. There were no changes in DBP after either treatment. Subjects with pre/HTN demonstrated a greater PEH systolic response than NTN subjects (-10.3 +/- 5.2 mmHg versus -2.7 +/- 6.0 mmHg; P < 0.001).


Conclusions: This study confirms that 30 minutes of moderate intensity exercise results in a decrease in SBP following exercise. Individuals with pre/HTN experienced a greater PEH response than NTN subjects. There were no significant changes in DBP for either condition. There was no difference in SBP reductions between the exercise and exercise/flavanol supplementation groups. Further studies examining a longer duration of flavanol supplementation should be conducted on a larger sample size of hypertensive individuals to determine potential benefits of cocoa flavanols on PEH.


Poster #: S105




Juan Pablo Rodriguez-Escudero, MD; Virend K. Somers, MD, PhD; Randal J. Thomas, MD, MS; Ray Squires, PhD; Quinn Pack, MD; Francisco Lopez-Jimenez, MD, MSc


Primary Institution: Mayo Clinic


Classification: Prevention/Wellness


Introduction: The biologic definition of obesity is the presence of excessive adipose tissue (body fat). The diagnostic performance of body mass index (BMI) and the skinfold (SKF) assessment to correctly identify or rule out excessive body fat (obesity) in patients enrolled in outpatient cardiac rehabilitation has not been evaluated.


Purpose: We assessed the diagnostic performance of body mass index (BMI) and skinfold (SKF) assessment to detect obesity in patients enrolled in outpatient cardiac rehabilitation.


Design: Retrospective cross-sectional study


Methods: We performed a study of outpatients attending phase II cardiac rehabilitation who underwent air displacement plethysmography (ADP) to assess body composition. Body weight, height, waist and hip circumference were measured using standard techniques. BMI was calculated as weight in kilogram divided by the square of height in meters (Kg/m2). We measured body fat percentage (BF %) using a 3-site SKF method utilizing a Harpenden caliper calculated through Jackson-Pollock equation. ADP calculated BF % using a bicompartmental model, deriving the body composition after the direct calculation of body density (BD), using the Siri equation [(BF% = 495/BD)-450]. We constructed Pearson correlation coefficients to assess the linear dependence between BMI and SFK vs. ADP. We then calculated the diagnostic performance of BMI and SFK to detect obesity utilizing a cut-off >=30 kg/m2 for BMI and a BF% cut-off of >= 35% in women and >= 25% in men by SKF and ADP to define obesity.


Results: Our sample (n = 310) was 80% men, 60.2 +/- 11 years of age, had a mean weight of 89.8 +/- 17 kg, height 173.3 +/- 8 cm, BMI 29.7 +/- 5 kg/m2, waist circumference 100 +/- 14 cm, and waist-to-hip ratio 0.96 +/- 0.09. The correlation coefficients between SKF BF% and BMI with BF% by ADP were 0.75 and 0.60, respectively, p < 0.001. SFK underestimated BF% by an average of 7.1%. The evaluation of the diagnostic performance of SKF and BMI to detect obesity (by ADP) showed sensitivities of 57% and 51%; specificities of 93% and 89%; positive predictive values of 97% and 96%; and negative predictive values of 33% and 29% for SKF and BMI, respectively. SKF and BMI misclassified 49% and 43% of obese patients as non-obese.


Conclusions: Although BMI and SKF significantly correlate with BF% measured with ADP, they underestimate BF% in cardiac rehabilitation patients. Our findings underscore the importance of using more accurate methods to assess body fat in patients attending cardiac rehabilitation.


Poster #: S106




Kris Greany, PhD, RD; Megan Knutson, BS; John P. Porcari, PhD; John F. Greany, PhD, PT


Primary Institution: University of Wisconsin - La Crosse


Classification: Behavior Modification (Motivational Program, Risk Reduction)


Introduction: Chronic stress is a prevalent problem that contributes to a myriad of health conditions. Stress management techniques such as yoga and meditation are advocated to reduce the psychological and physiological effects of stress. LifeMoves(TM), a novel stress management approach, is a DVD based program that guides the participant through upper body movements choreographed to meditative music.


Purpose: The objective of this study was to quantify the acute effects of LifeMoves(TM) participation on blood pressure, heart rate, respiratory rate, and perceived stress.


Design: This study was a repeated measures design.


Methods: 27 male and female volunteers (mean age 68.1 +/- 12.5 years) completed the study. Participation included three, 20-minute practice sessions of LifeMoves(TM) and chair yoga and three testing sessions (one each for LifeMoves(TM), chair yoga, and sitting quietly i.e. control). During the testing sessions, subjects performed 10 minutes of LifeMoves(TM), chair yoga, or sitting quietly in a room with minimal distractions. Blood pressure, heart rate, and respiratory rate were measured and perceived stress assessed on a visual analog scale prior to and following each testing session. Paired t-tests were conducted to assess the effects of each condition on blood pressure, heart rate, respiratory rate, and perceived stress, and repeated measures ANOVA performed to evaluate differences between conditions.


Results: Systolic blood pressure, respiratory rate, and perceived stress decreased following LifeMoves(TM), chair yoga, and sitting quietly. Heartrate and diastolic blood pressure did not decrease with any treatment. There were no differences in the pre-post changes of any variable between the treatments.


Conclusions: Ten minutes of LifeMoves(TM), chair yoga, or sitting quietly all decreased blood pressure, respiratory rate, and perceived stress. This study demonstrates that a brief practice of LifeMoves(TM), chair yoga, or sitting quietly can acutely lower physiological and psychological measures of stress.


Poster #: S107




Leonard A. Kaminsky, PhD; Katrina Riggin, MS; Cemal Ozemek, MS; Nicole L. Koontz, MS; Scott J. Strath, PhD


Primary Institution: Ball State University


Secondary Institution: Ball Memorial Hospital; University of Wisconsin - Milwaukee


Classification: Cardiac


Introduction: The six-minute walk test (6MWT) is commonly performed in cardiac rehabilitation (CR) programs as an indicator of functional capacity.


Purpose: The purpose of the study was to determine the association of commonly measured patient characteristics with 6MWT distance.


Design: An observational design was used to assess relationships between six-minute walk test distance and subject characteristics.


Methods: Subjects were 88 patients (66 men, 22 women, mean age 61 +/- 10 years) entering a maintenance CR program. Patient characteristics assessed at entry included: age, gender, 7-day physical activity profile via accelerometer, body composition (body mass index [BMI], waist circumference [WC], body fat %, lean mass [via dual energy x-ray absorptiometry]), and resting heart rate. All subjects performed a standardized 6MWT on an indoor walking track in the CR center. Measures of central tendency (mean +/- SD) and Pearson correlation coefficients were analyzed using IBM SPSS version 19.


Results: At entry to the CR program, patients' 6MWT distance was 1590 +/- 302 feet and they were obtaining 12 +/- 12 min/day of moderate-intensity physical activity. Univariate analysis revealed that 6MWT distance was significantly correlated with age (r = -.32), body fat % (r = -.39), lean body mass (r = .46), moderate-intensity physical activity minutes/day (r = .39), and total activity counts/day (r = .39). BMI, WC, light-intensity physical activity minutes/day, and resting heart rate were not significantly related to 6MWT distance.


Conclusions: These findings suggest that specific measures of both body composition and physical activity are associated with 6MWT distance in CR patients. Both body fat percentage and lean mass, but not BMI or WC, were associated with 6MWT distance. Likewise, both moderate-intensity and total physical activity, but not light-intensity physical activity, were associated with 6MWT distance.


Poster #: S108




Francois Lalonde; Denis Arvisais, MSc; Daniel Curnier, PhD


Primary Institution: Universite de Montreal


Classification: Cardiac


Introduction: Physical training can give a new protective perspective by the release of endothelial progenitor cells. These cells are: involved in endothelial repair; contribute to neovascularization process which promotes the regeneration of vascular tissues; are associated with lower risk of cardiovascular events.


Purpose: The aim of this study is to establish a link between physical activity and chronic stimulation of progenitor cells.


Design: A meta-analysis is used in this study.


Methods: A systematic review was conducted in the following electronic databases: PubMed, Embase, Web of Science, Cochrane and CINAHL from 1966 to 2011. The keywords used were: exercise training, progenitor cells, stem cells and physical activity, limited to randomized control group with humans of all ages. A manual search was subsequently performed according to the references of articles found in databases.


Results: 10 studies (556 patients) met the selection criteria. The average differences between the trained group compared to the sedentary group was 117.87 [104.25 to 131.5] 1/ml blood, p = 00001 for the CD34 +/KDR + and 101.28 [67.65 - 134.88] 1/ml blood, p = 00001 for the CD34 + cells based on meta-analysis statistics.


Conclusions: Physical training improves circulation of endothelial progenitor cells. This observation could be both a preventive and protective mechanism induced by exercise in healthy subjects and in subjects with cardiovascular diseases.


Poster #: S109




Francois Lalonde; Paul Poirier, MD, PhD; Denis Arvisais, MSc; Edith Simeon, MSc; Daniel Curnier, PhD


Primary Institution: Universite de Montreal


Secondary Institution: Institute Universitaire de cardiologie et de pneumologie de Quebec; Centre de Recherche du Centre Hospitalier de l'Universite de Montreal; Quintiles


Classification: Cardiac


Introduction: Brief intervals of ischaemic burden followed by reperfusion of an organ results in the ability to withstand subsequent prolonged periods of ischemia. Ischaemic preconditioning (IPC) by exercise can be demonstrated when angina is induced by a first exercise and is attenuated after a short period of rest before a second subsequent exercise at the same or greater intensity.


Purpose: The aim of this study is to summarise the current litterature on the effect of prior exercise on iscemia during a subsequent exercise.


Design: Meta-analysis cross-over design was used.


Methods: Literature search was performed in January 2011 using PubMed, Embase, CINAHL Plus with Full Text and Web of Science. The main key words were: ischemic preconditioning, warm-up phenomenon and exercise. The analysed parameters on ECG were: total stress test time, time to 1 mm (ST segment depression) STD, rate-product at 1 mm STD, maximal STD, maximal rate- product and recovery time. All the papers were analysed by two reviewers.


Results: 32 articles (1 033 patients) fulfilled the selection criteria. Time to 1 mm STD was greater in subsequent test: Standardised mean differences (SMD): 0.77 (0.56-0.98, p < 0.0001; rate-product at 1mm STD: SMD: 0.61 (0.36-0.86, p < 0.0001; maximal STD: SMD -0.82 (-1.08- -0.56, p < 0001; recovery time: SMD -1.00 (-1.53- -0.48, p = 0.0002).


Conclusions: This is the first meta-analysis showing that exercise-induced IPC have positives outcomes on ECG and clinical parameters. Data summary show that CAD patient can improve their exercise performance on a second stress test after a short period of rest. Sommation of such mechanism during an exercise training program could provide a long time protection for patients with cardiovascular diseases. Patients with low level of exercise induced angina could clearly benefits of IPC.


Poster #: S110




Daniel Curnier, PhD; Francois Lalonde; Marie-Eve Mathieu, PhD; Anne Fournier, MD; Jean-Luc Bigras, MD; Joaquim Miro, MD; Nagib Dahdah, MD


Primary Institution: Universite de Montreal


Secondary Institution: St. Justine Hospital


Classification: Cardiac


Introduction: The improvement in medical diagnosis and treatment, from pharmacology to surgery, induced an increased survival in children with congenital diseases. In adults with cardiovascular diseases several randomised control trials show beneficial effects of exercise training and meta analyses have validated the benefits of cardiovascular rehabilitation but none in children with congenital heart diseases.


Purpose: Determine the benefits of cardiovascular rehabilitation using meta analysis methods in children with congenital heart diseases.


Design: Meta-analysis was used in this study.


Methods: Research criteria used were: exercise training, rehabilitation, readaptation, heart disease, heart failure, limited to article in English or French, for subjects' age < 25 years and to randomised control trials (RCT) published between January 1966 and August 2011 in database from Pub Med, Embase, Web of Science and CINAHL. All the references were reviewed by 2 independent scientists.


Results: 5 RCT studies (n subjects = 173) met the selection criteria. The mean differences reach: 4,21 [1,69-6,73], p = 0,001 for maximal oxygen uptake (; 9,4 [3,2-15,6], p = 0,003 for maximal power (watts) and 5,9 [-0,4-12,2], p = 0,03 for heart rate (beat.min-2) at maximal exercise.


Conclusions: The results observed in children with congenital heart disease are in agreement and conformity with those observed in adult subjects for the parameters analysed. Exercise training improved significantly maximal oxygen uptake and peak power at maximal exercise. Despite these positive observations, this meta analysis suffer from the limited number of subjects and the lack of data concerning the major acute cardiovascular events which do not permit to extrapolate the entire benefits observe in an adult population. To our best knowledge there is no study evaluating the impact of exercise training in morbidity and mortality in a congenital heart disease population from children to adults.


Poster #: S111




Alban De Schutter, MD; Carl J. Lavie, MD; Ivonne Mclean, Brent Murchie, MD; Jose Muniz, MD; Richard Milani, MD


Primary Institution: Cleveland Clinic Florida


Secondary Institution: Ochsner Clinic Foundation


Classification: Prevention/Wellness


Introduction: Despite its many known shortcomings, body mass index (BMI) rather than body fat (BF) is the most widely used measure of obesity, in part because of practicality. In order to overcome the difficulties of measuring BF, a number of equations have been proposed to calculate BF from BMI.


Purpose: We examine here their clinical applicability by examining the correlation and agreement between measured BF and calculated BF.


Design: We retrospectively studied 4107 patients referred for cardiopulmonary stress testing.


Methods: BMI and BF were measured as weight divided by height squared and the sum of the skin-fold method, respectively. BF was calculated based on BMI, age and gender according to several equations (as proposed by Deurenberg, Jackson-Pollock, the Heritage Family Study and Gallagher). The population was divided according by BMI (using the WHO cutoff points: 18.5, 25, 30) and by BF (using an age and gender adjusted classification).


Results: There was a moderate correlation (Table 1) between BMI and BF (r 0.58; p < 0.0001) and good correlation between BF and calculated BF (r 0.79; p < 0.0001; no difference between equations). There was moderate agreement on classification of obesity between WHO BMI and measured BF (kappa 0.45 CI [0.43-0.47]), only outperformed by the Jackson-Pollock equation for BF (kappa 0.48 CI [0.46-0.51]). BMI was less sensitive but more specific for obesity (sensitivity 0.77, specificity 0.79) than for any of the calculated BF categories (sensitivity 0.79-0.87, specificity 0.53-0.78).

Table. No title avai... - Click to enlarge in new windowTable. No title available.

Conclusions: The BF equations are a more sensitive tool to pick up obesity, an important feature in primary care. They carry a small but important advantage over BMI to define obesity, at a very low cost .


Poster #: S112




Marianne da Silva, MSc; Fernanda Tomasi, MSc; Vinicius Maldaner, MSc; Alexandra Lima, MSc; Luiz Giollo; Gaspar Chiappa; Gerson Cipriano, MD


Primary Institution: Universidade de Brasilia


Secondary Institution: Universidade Federal do Rio Grande do Sul; Faculdade de Medicina de Sao Jose do Rio Preto


Classification: Cardiac


Introduction: The Transcutaneous Electrical Nerve Stimulation (TENS) has been recent applied to produce sympathetic reduction, increasing regional blood flow and reducing the heart frequency. The influence of TENS on central blood pressure remains unclear on scientific literature. This information is relevant to surrogate future treatments for hypertension patients, which is an important predictor for various diseases such as myocardial infarction, stroke, heart failure and endothelial dysfunction.


Purpose: To evaluate the acute effect of ganglionar TENS on central blood pressure in healthy adult and middle aged men using the of arterial applanation tonometry (AAT) method.


Design: experimental cross-sectional study.


Methods: Forty-eight men, comprehending 24 adults (27.25 +/- 5.53 years) and 24 middle-aged (54.83 +/- 5.10years), were included in this crossover, randomized controlled trial after informed consent. Each volunteer was submitted to two different protocols (TENS and placebo) applied on different days with 72 hours interval. The TENS was applied for 45 minutes to ganglionar region (C7 to T4) (Frequency = 80 Hz, Pulse Width 150[mu]s, intensity was adjusted to maximum sensory threshold). The placebo was equally applied to ganglion region but no electrical stimulation was given. The evaluation of AAT was performed before and after each protocol. To compare the responses (placebo x TENS x age), factorial ANOVA was used for parametric data and Mann-Whitnney test for non-parametric data. The significance level adopted was p <= 0.05.


Results: There was a significant reduction of the systolic central blood pressure (after Ganglionar TENS application compared to placebo group in the adult group (p = 0, 045). The remaining parameters of AAT also demonstrated decreasing pattern on both groups after TENS application.


Conclusions: The acute application of ganglion TENS attenuated the systolic central blood pressure in adults and could emerge as effective therapeutic to the management of arterial blood pressure. Additional longitudinal studies are needed to evaluate the impact of this intervention.


Poster #: S113




Jayme L. Rock-Willoughby, DO; Debra Boardley, PhD, RD/LD; Jodi Tinkel, MD; Dalynn T. Badenhop, PhD


Primary Institution: Division of Cardiovascular Medicine, University of Toledo Medical Center


Classification: Cardiac


Introduction: The clinical profile and specific needs for secondary prevention in patients admitted into a phase II cardiac rehabilitation (CR) program have changed over the last decade. It is important to identify these changes to provide effective treatment for this population.


Purpose: This study reviews and analyzes changes in the clinical profile of patients admitted into a phase II CR between 2000 and 2010.


Design: A retrospective review and analysis was performed on the clinical and demographic data of all patients admitted into the phase II CR in 2000 and 2010 at the University of Toledo Medical Center. This specifically focused on patients' cardiovascular (CV) d


Methods: In 2000, 105 patients were admitted into phase II CR compared to 154 patients in 2010. Age, sex, admission diagnosis, CV disease risk factors, medication number, body mass index (BMI), and performance on initial 12 minute walk test were collected on all patients. A Student's t-test was used to analyze continuous variables, and for categorical variables, a chi-square test was used.


Results: There was no statistical difference in age among the two populations. While there were considerably less women enrolled (31.4% and 31.8%, respectively) than men, there was no statistical difference between the two cohorts. In 2000, chronic stable angina (35.6%) was the most common diagnosis leading to CR admission, followed by myocardial infarction (MI) (23.1%) and coronary artery bypass grafting (CABG) (21.2%). In 2010, percutaneous intervention (PCI) was the most common diagnosis (29.2%), followed by CABG (22.1%) and MI (20.8%). The 2010 population had more CV disease risk factors (2.70 +/- 1.07 and 3.37 +/- 1.26, p = < 0.01), with more hypertension (HTN) (66.7% vs. 80.5%, p = 0.013), but less smoking (36.2% vs. 20.9%, p = 0.01). Patients in 2010 were also taking more medications (9.99 vs. 8.03, p = 0.01). There was no difference in performance on the initial 12 minute walk test. Although there was no statistical difference in BMI between the two groups, there was a trend toward higher BMI in the 2010 population (29.21 +/- 5.86 vs. 30.25 +/- 6.28, p = 0.18).


Conclusions: In our phase II CR population, patients in 2010 had a greater number of CV disease risk factors with more HTN, were prescribed more medications, and were less likely to have smoked. More patients were admitted into CR after PCI than previously. Women are still not being routinely referred to CR, which is clearly an area where public health outreach and education needs to be improved.


Poster #: S114




Kathleen Kennedy, MS; Jenny Adams, PhD; Dunlei Cheng, PhD


Primary Institution: Cardiac Rehabilitation, Baylor Hamilton Heart and Vascular Hospital


Secondary Institution: Biostatistics, The University of Texas School of Public Health


Classification: Cardiac


Introduction: Exercise tests are used in cardiac rehabilitation programs to determine patients' peak functional capacity, thereby allowing staff to develop accurate exercise prescriptions. Until the recent implementation of symptom-limited testing in our program, we used a protocol that stopped patients at a predetermined metabolic equivalent (MET) level; common clinical practice also suggests stopping patients at an equation-derived heart rate.


Purpose: To compare results from the new exercise test protocols with 1) an equation-derived heart rate limit suggested in the literature and 2) the MET limit from the old test.


Design: Thirty charts were retrospectively reviewed; peak heart rates, equation-derived heart rate limits, and MET levels were analyzed.


Methods: A symptom-limited exercise test was implemented on the first and last day of rehabilitation to assess functional capacity. The resulting pre- and post-rehabilitation peak heart rates for each patient were compared with a heart rate limit calculated as follows: 0.7 x (220 - age). The patients' MET levels were compared with the old test's limit of 8.5 METs. A paired t test was used to analyze the heart rate data, and a z test was used for the MET levels.


Results: The mean peak heart rate during the pretest was 126, significantly higher than the mean calculated limit (difference, 14; p = 0.003). Imposing the old test's limit (8.5 METs) would have stopped 7 patients (23.33%) prematurely during their pretest. Moreover, 21 of the 30 patients (70%) would have been stopped prematurely during their posttest. A z test revealed that more than 50% of the patients would not have reached their target MET level at least once (pretest or posttest) if the limit had been imposed (p = 0.009).


Conclusions: Patients need to be tested according to a protocol that is appropriate for them and is based on their gait, functional capacity, and knowledge of the treadmill; the test should be limited only by their symptoms. Our findings show that stopping patients at a certain MET level or equation-derived heart rate can mask their peak performance and thus hinder the primary goal in any rehabilitation setting: to develop and document increased fitness in participants. Therefore, patients need to be allowed to exercise to fatigue with an adequate test that enables them to reach their functional maximum.


Poster #: S115




Stephanie McCray, RN-BC; Jenny Adams, PhD; Jack Schmid, BSc; Robert Parker, PhD; J Richard Coast, PhD; Dunlei Cheng, PhD; Kathleen Kennedy, MS; Aaron Killian, PharmD, BCPS; Danielle Strauss, MSN, RN-BC; Rafic Berbarie, MD; Anne Lawrence, RN-BC


Primary Institution: Cardiac Rehabilitation, Baylor Hamilton Heart and Vascular Hospital


Secondary Institution: Northern Arizona University; The University of Texas School of Public Health; Baylor University Medical Center


Classification: Cardiac


Introduction: Patients recovering from coronary artery bypass graft (CABG) and/or valve surgery are told to avoid lifting more than 1 to 3 lbs for a minimum of 5 weeks, yet they can repeatedly withstand a sneeze without damaging the sternotomy. Determining the force exerted on the sternum when subjects sneeze and while they perform resistance training exercise could provide more realistic criteria for safe versus unsafe forces across a sternotomy.


Purpose: To compare the intrathoracic force exerted on the sternum during chest press resistance exercise with the force exerted during a sneeze, an event that post-CABG and/or valve patients can withstand, even immediately after surgery.


Design: In a prospective, non-randomized study involving 17 healthy volunteers (12 women, 5 men), intrathoracic force was evaluated during chest press exercise (with and without the Valsalva maneuver) and during induced sneezing.


Methods: On day 1, height, weight, and sternum length were measured. A one repetition maximum (1-RM) test was done, and 40% of 1-RM was calculated. On day two, after nasal anesthesia was administered, a balloon-tipped esophageal catheter was inserted through the nose and advanced into the thoracic cavity. The catheter was attached to a transducer to measure the intrathoracic pressure differential during the study activities. First, the subject performed the chest press at 40% of 1-RM, with and without Valsalva (12 repetitions each). Next, an investigator induced a sneeze by introducing various nasal irritants into the subject's nostril. Forces on the sternum were calculated from the pressure differential measurements; calculations of chest press force included the external force of the weight lifted plus the force from Valsalva or breathing. A sign test was used to analyze the median differences of the force values.


Results: The mean force values were as follows: sneeze, 73 lbs (SD, 42); chest press/Valsalva, 63 lbs (SD, 34); and chest press/breathing, 48 lbs (SD, 26). The sneeze force was significantly higher than the chest press/breathing force (median difference, 29 lbs; p = 0.013) and the chest press/Valsalva force (median difference, 13 lbs; p = 0.049).


Conclusions: Sneezing exerted significantly more force on the sternum than performing the chest press at 40% of 1-RM. Nevertheless, it is common for post-CABG and/or valve patients to tolerate the force from sneezing (73 lbs in this study) without damaging the sternotomy. Therefore, reevaluation of the extremely conservative recommendation to lift only 1 to 3 lbs might be warranted.


Poster #: S116




Rachel J. Le, MD; Stephen Kopecky, MD


Primary Institution: Mayo Clinic


Classification: Cardiac


Introduction: Aggressive dosing of vasoactive medications can lead to significant adverse effects. These medications are often rapidly up-titrated after ACS. Post-hospital adverse effects of vasoactive medications have not been well studied.


Purpose: To assess possible 30-day negative sequelae of vasoactive medications (long-acting nitrates, calcium channel blockers, ACEI/ARB, [beta]-Blockers, [alpha]-Blockers and diuretics) in patients with newly diagnosed CAD presenting as ACS.


Design: Single center cohort study of patients presenting with ACS in 2008 or 2009.


Methods: All patients from Olmsted County. MN presenting with ACS as their first symptoms of CAD who received primary care at our institution were included. Patients hospitalized > 10 days or undergoing CABG were excluded. All medical records were reviewed for 30 days after hospital discharge including prescriptions, healthcare contacts (telephone, clinic visits, ER or hospitalizations), reported vasoactive symptoms and vital signs. Data are presented as number and percent or means and standard deviations where appropriate. Statistical comparisons were done using t-test and Pearson chi-square analyses.


Results: Of the 86 patients included in the study 59 (69%) were male. The mean age was 63 +/- 15.5 years. The mean hospital stay was 3.1 +/- 1.4 days. Vasoactive medications were prescribed to 84 (98%) patients at discharge; 65 (76%) patients were prescribed two or more vasoactive medications. At hospital discharge and during 30 day follow-up SBP was < 90 mmHg in 1 and 6 patients respectively; HR was < 60 bpm in 18 and 44 patients respectively. Hypotension or bradycardia at follow-up were more commonly seen in older patients (p = 0.001) and those with pre-discharge hypotension or bradycardia. There were 233 healthcare contacts in 30 days, of which 90 (39%) were unscheduled. Hospitalizations accounted for 14 contacts, 2 were planned revascularizations. There was a marginally significant association between having any unscheduled healthcare contacts and a greater number of prescribed vasoactive medications, both pre-ACS (p = 0.045) and upon hospital discharge (p = 0.051). Symptoms were reported in 34 (40%) patients, including fatigue in 17 patients, dizziness in 15 patients, depressed mood in 11 patients and syncope in 1 patient. There was no relationship between patients with symptom complaints and those without in regards to baseline characteristics. Patients who experienced symptoms had significantly more total (p < 0.001) and unscheduled healthcare contacts (p < 0.001).


Conclusions: Vasoactive medications are prescribed in almost all (98%) post ACS patients upon hospital discharge. There is a high incidence of healthcare contacts within 30 days after ACS and increased healthcare utilization in this time period was associated with the occurrence of symptom complaints. Prescription of a greater number of vasoactive medications is associated with having unscheduled healthcare contacts after hospitalization for first episode of ACS.


Poster #: S117




Maria L. Buckley, PhD; Sidney S. Braman, MD; Justin Nash, PhD; Cerissa Blaney, MA; Jacqueline F. Pierce, BS


Primary Institution: The Miriam Hospital


Secondary Institution: Brown University


Classification: Behavior Modification (Motivational Program, Risk Reduction)


Introduction: The literature related to the effects of ameliorating depression symptoms from pre- to post-PR on improving quality of life is limited.


Purpose: The goal of this study was to determine whether there was a difference between initially depressed and nondepressed subjects in improvement in quality of life. We also predicted that the reduction of depression symptoms would result in clinically significant improvements in quality of life from pre- to post- PR.


Design: This study was a retrospective consecutive chart review of patients enrolled in an outpatient PR program of a university-affiliated teaching hospital.


Methods: The Geriatric Depression Scale (GDS) and the self-report version of the Chronic Respiratory Questionnaire were administered to patients who were age >55 years. Independent t-tests were conducted to compare between group differences in improvement in quality of life in subjects who presented with positive versus negative depression screens at baseline. Chi square analyses were performed to compare differences in improvement in quality of life between subjects whose depression remitted and those who remained depressed from the beginning until the completion of the Program. We also applied chi square analyses to evaluate gender differences in improvements in quality of life.


Results: The sample in this study included 80 subjects, 42 females and 38 males with COPD. One subject carried both COPD and Pulmonary Fibrosis diagnoses. Mean age was 71.65 (SD = 8.0). Mean FEV1 was 36.7% (SD = 14.4), indicative of severe disease. The sample was primarily Caucasian (96.2%) with a small number of African Americans (3.8%). Thirty-nine percent of the sample screened positive for depression. The analyses included those patients with complete data. Subjects were categorized as depressed if they had a score of at least 11 on the GDS. Independent t-tests revealed that baseline depression was associated with less improvement in fatigue t (36) = - 2.49 = .017 and emotional functioning following PR, t (35) = -2.41 = .021. Group differences in quality of life improvements were also examined in subjects whose depression persisted compared with those whose depression remitted by discharge. These groups differed as we found a clinically significant improvement in the nondepressed group at post-treatment in the fatigue domain, [lambda]2 (1,11) = 6.52, p = .01.


Conclusions: Our hypothesis that baseline depressive symptoms would predict poorer improvement in quality of life was supported in this investigation. It appears that depression upon entry to PR is associated with reduced treatment gains in fatigue and emotional functioning by the end of PR and that improvement in depression from pre- to post-PR is related to a clinically significant reduction in fatigue at discharge. The lack of associations between depression and improvements in dyspnea and mastery may be a function of our small sample size resulting in a lack of sufficient power to detect additional between group differences.


Poster #: S118




Ruei-Yi Lin, BS; Mei Wun Tsai, PhD


Primary Institution: National Yang-Ming University


Classification: Prevention/Wellness


Introduction: Metabolic syndrome (MS) is a precursor of other chronic disease, and obesity is one of the main risk factors. Recent studies have investigated the exercise performance of population with MS, but most of these participants were overweight, and the role of MS on affecting the muscle strength, cardiopulmonary fitness and exercise efficacy in non-obese person was still unknown.


Purpose: To investigate the performance of muscle strength, cardiopulmonary fitness and exercise efficacy in non-obese persons with MS and compare with healthy population.


Design: Case-control study.


Methods: Subjects who have been diagnosed with MS but BMI < 27 and waist circumference < 90 cm in male, and < 80 cm in female were recruited. The subjects with hypertension, cardiovascular disease, and diabetes were excluded. Non-obese healthy subjects were as the control group. Demographic data and muscle strength were assessed and 3-minute step test was used to assess the cardiopulmonary fitness. A questionnaire with 7 questions about exercise habit, confidence, and cognition was conducted to evaluate exercise self-efficacy. The descriptive statistic was used to describe the physical characteristics. Independent T-test and chi-square were used to compare the differences between two groups. All analyses were performed using SPSS (version 16.0). The significant level was set at 0.05.


Results: 612 subjects were recruited: 105 in non-obese MS group and 507 in control group. The mean age was 41.52 +/- 8.85 years old. Body weight, BMI, and waist circumference were significantly higher in non-obese MS group (P < 0.001). Non-obese MS group also have lower performance in muscle strength and step index (P < 0.05). Compared with control group, non-obese MS group generally thought their health condition was poorer (P < 0.05). The total score of exercise self-efficacy was significantly lower in non-obese MS group (P = 0.003).


Conclusions: Non-obese persons with MS still have higher BMI and waist circumference, and lower cardiopulmonary fitness than healthy people means that MS still affects the population without obese and other co-morbidities. According to the result of exercise self-efficacy questionnaire, non-obese MS group generally got lower score than healthy people. From this study, most of the non-obese persons with MS claimed that they are willing to engage in exercise. However, they have no confidence to develop and maintain the exercise habits and don't know what exercise is suitable for them. Further study is recommended to find out the suitable interventions to maintain the health of this kind of subjects.


Poster #: S119




Kenneth Sparks, PhD; Aaron Rood, MS; David Dashesvky, MS; Jennifer E. Cummings, MD; Katie Giether, BS


Primary Institution: Cleveland State University


Secondary Institution: Orbital Research


Classification: Cardiac


Introduction: Arrhythmias are one of the most common types of heart disease often increasing morbidity and mortality. Detection of these arrhythmias using long-term monitors is difficult in clinical and ambulatory ECG (aECG) studies due to physical limitations and low resolution of the sensors at the patient interface. Methods to perform long-term ambulatory collection and analysis of ECGs are currently limited to monitors using wet (gel) based electrodes. Current standard of care recorders that use wet, adhesive secured electrodes have limited application/wear periods and are uncomfortable to the patient leading to poor compliance and compromised data." A dry electrode has been developed, patented with FDA clearance for all ECG applications. These dry ECG sensors are easily embedded into a wearable harness. This combination improves comfort and operational longevity resulting in increased patient comfort and compliance.


Purpose: The purpose of the study was to compare simultaneous ECG using the Mason-Likar lead system (with gel, adhesive based electrodes) to a derived ECG with lead set held in place with the a harness using an off-sternal EASI configuration featuring dry electrodes.


Design: Simultaneous ECG was collected using the Mason-Likar lead system (with gel, adhesive based electrodes) and compared to the novel lead set held in place with the a harness and featuring dry electrodes. Signal quality and clinical merit was evaluated and c


Methods: In 20 subjects, simultaneous collection of ECG data was performed using ten 3m Red Dot(TM) 2560 gel electrodes in the standard Mason-Likar configuration (control) and the novel harness using dry electrodes in an off-sternal EASI configuration (experimental). Data was collected twice first standing then supine. All traditional electrodes were applied using standard of care skin prep methods. Signals collected from the off-sternal configured harness were digitally transformed into a standard 12-leads ECG using established methods and confinements of Field et al. The resultant data was compared to that collected using the standard gel electrodes and analyzed for goodness of fit between the experimental (harness) and control (Mason-Likar) data sets. Signal quality and clinical merit was evaluated and compared.


Results: Data indicates a strong similarity in goodness of fit between the experimental and control lead sets. Eleven of 12 leads had an R-value of .85-.99. Very little clinical difference was noted with control figuration when compared to the experimental lead configuration.


Conclusions: This study demonstrates that novel dry electrodes when embedded in a harness using the off sternal EASI configuration collects clinically and electronically equivalent data as compared to the current standard of care electrodes. This would suggest that using a dry electrode harness does not compromise data collection, but may also improve comfort and compliance in long-term arrhythmia monitoring.


Poster #: S120




Marianne da Silva, MSc; Vinicius Maldaner, MSc; Alexandra Lima, MSc; Fernanda Tomasi, MSc; Laura Neves, MSc; Ana Xavier; Gaspar Chiappa; Gerson Cipriano, MD


Primary Institution: Universidade de Brasilia


Secondary Institution: Universidade Federal do Rio Grande do Sul


Classification: Cardiac


Introduction: Patients with ischemic (IHF) or Chagasic (CHF) heart failure have reduced exercise tolerance, regardless of age. However, it is not known if the etiology of the disease determines the magnitude of this reduction in subjects with severe HF.


Purpose: To compare the cardiovascular adjustments in response to maximal exercise test in middle-aged men with IHF and CHF.


Design: experimental cross-sectional study


Methods: Seventeen men (54 +/- 7 years) with IHF (n = 09) and CHF (n = 08), with ejection fraction < 35% underwent incremental maximal exercise test on a treadmill (General Electrics, T2100, USA). The variables measured were: heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) time tolerance test (Tlim) and maximal oxygen consumption (VO2max). It were used: KS distance test to check the distribution of test data and Student's t-test for comparison between groups (p <= 0.05).


Results: HR at peak exercise was greater in the IHF group (138 +/- 4.5) compared to the CHF group (114 +/- 3.9). SBP tended to be lower in the IHF group (146 +/- 4.4) compared to the CHF group (159 +/- 8.8). The PAD, Tlim and VO2max were similar between groups.


Conclusions: The cardiovascular adjustments to exercise against a tendency to have different behavior in middle-aged individuals with IHF and CHF. However, the etiology of the disease does not influence performance on the test.


Poster #: S121




Hsin-Chun Tseng, MS; Yi Chi Chiu, MS; Mei Wun Tsai, PhD; Mu-Jung Kao, MD


Primary Institution: National Yang-Ming University


Secondary Institution: Taipei City Hospital


Classification: Behavior Modification (Motivational Program, Risk Reduction)


Introduction: The benefits of weight control and improving metabolic risk factors from exercise training and diet intervention in overweight, postmenopausal women with metabolic syndrome (MS) have been investigated in many studies. However, the improvements were hard to maintain after stopping the interventions, and the establishment of exercise habits and healthy behaviors was important to keep the benefits.


Purpose: To investigate whether the improvement of waist circumference still maintained at 3-month follow-up after the 12-week intervention and to examine the relation between the benefit maintenance and the changes of exercise behavior in middle-age women.


Design: Quasi-experimental study design.


Methods: 43 women with BMI [greater than over equal to] 24kg/m2 or waist circumference(WC) [greater than over equal to] 75cm were recruited in this study. All subjects were encouraged to participate a 12-week exercise training program or maintained usual daily activities by individual willing. The WC, body weight(BW), BMI, cardio- respiratory and muscle fitness were assessed. The transtheoretical model(TTM) and diet questionnaires were used to evaluate exercise and diet behavior. All the measurements were performed pre-, post-intervention, and followed at 3-month. For data analyses, all participants were divided into 5 groups by TTM stage that was measured at 3-month follow-up. One way ANOVA and chi-square were used to compare the differences between five groups. Pearson correlation coefficient was be used to identify relationships between the change of WC and the behavior performance using TTM by adjusting age, WC, BW, hypertension, diabetes, and participated program or not in baseline. The level of significance is 0.05 for all analyses.(SPSS; version 18.0)


Results: 38 participants (mean age:50.89 +/- 9.84 years old, BMI:26.39 +/- 3.78kg/m2, WC:84.99 +/- 8.53cm) completed all the measurements at the 3-month follow-up. Compared to pre-intervention, many participants got progress on their exercise behaviors to action stage of TTM at post-intervention and well-maintained at 3-month follow-up (from 33.9% to 55.6%, and 55.2%). The decreases of mean WC (-3.12cm, 95% CI: -4.36 to -1.88) and BMI (-0.42kg/m2, 95% CI:-0.79 to -0.05) was statistically significant at 3-month follow-up compared to pre-intervention. There was a significant correlation (p = 0.001) between TTM stage and the change percent rate of WC at follow-up. Subjects in pre-contemplation and maintenance stage had significant difference in the decrease of WC (0.95 +/- 3.30 and -7.19 +/- 4.24%; p = 0.003), BW (2.14 +/- 0.66 and -4.57 +/- 4.54%; p = 0.039) and BMI (0.67 +/- 0.24 kg/m2 and -1.11 +/- 1.13; p = 0.05) at follow-up.


Conclusions: From the result, half number of participates develop well exercise behaviors through the 12-week exercise training and/or lifestyle modification instructions. The improvements in WC, BWand BMI in overweight middle-aged women were still existed, especially in higher stage of TTM. The benefits from exercise training and/or lifestyle modification instructions could be maintained with improved exercise behaviors.


Poster #: S122




Marianne da Silva, MSc; Alexandra Lima, MSc; Vinicius Maldaner, MSc; Fernanda Tomasi, MSc; Joao Cardozo; Laura Neves, MSc; Jose Martin, MD; Luiz Giollo; Gaspar Chiappa; Gerson Cipriano, MD


Primary Institution: Universidade de Brasilia


Secondary Institution: Universidade Federal do Rio Grande do Sul; Universidade de Medicina de Sao Jose do Rio Preto; Centro Universitario de Brasilia


Classification: Cardiac


Introduction: It is expected as immediate cardiovascular response to high intensity exercise the occurrence of hypertension and bradycardia. The applanation tonometry (AT) of the radial artery is a noninvasive and validated for the assessment of central systolic blood pressure (CSBS) and the frequency of central pulse (Pulse). Despite this peripheral response to exercise is already established, there is anecdotal evidence of correlation of these with the media center.


Purpose: Describe and correlate the central and peripheral cardiovascular behavior after maximal exercise test in middle-aged healthy individuals.


Design: Experimental Cross-Sectional Study.


Methods: 14 men (58 +/- 5 years) who underwent incremental exercise test on a treadmill (General Electrics, T2100, USA) and evaluation of TA (Omron HEM-9000AI, Omron, Tokyo, Japan) before and after exercise. The variables measured were: flattening index (AI), CSBS, systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse and radial pulse (Pr). It were used: KS distance test to check the distribution of data, one-way ANOVA, and Pearson correlation (p <= 0.05).


Results: We observed an increase in SBP (pre: 113 +/- 14, Post: 118 +/- 16 mmHg) and PASC (113 +/- 15, Post: 118 +/- 17 mmHg) and a decrease in pulse (Pre: 72 +/- 13, Post: 67 +/- 12 bpm) and Pr (Pre: 73 +/- 12, Post: 69 +/- 13 bpm). There was a correlation between CSBS and SBP (r = 0.99) and between the Pulse and Pr (r = 0.98).


Conclusions: The cardiovascular behavior had immediately after exercise is similar to the way central and peripheral, with increased and decreased SBP, CSBS Pulse and Pr in middle-aged healthy individuals.


Poster #: S123




Kent A. Eichenauer, PsyD; Glenn A. Feltz, PsyD; Jeffrey Brookings, PhD; Julia Smith, BA; Josephine Wilson, PhD, DDS; Michael Hoehn, MS


Primary Institution: Delta Psychology Center


Secondary Institution: Wittenberg University; Wright State University; Mary Rutan Hospital


Classification: Behavior Modification (Motivational Program, Risk Reduction)


Introduction: AACVPR's publication of the Core Components of Cardiac Rehabilitation recommends identifying psychosocial risk factors such as depression, anxiety, anger/hostility and social isolation. The Psychosocial Risk Factor Survey (PRFS) has been validated on cardiopulmonary patients as an initial screening tool for these factors, but its sensitivity to change has previously not been specifically analyzed for use as a post-measure.


Purpose: This study was designed to assess the sensitivity to change of the Psychosocial Risk Factor Survey. Since the PRFS was designed to be used as a psychosocial outcomes tool as well as a screening tool, it is hypothesized that the PRFS will possess acceptable sensitivity to change.


Design: Patients in a cardiac rehabilitation program completed the PRFS upon initiation and completion of the program.


Methods: Each patient was administered the PRFS as part of standard protocol when starting the rehab program and on the last visit of the Phase 2 portion of the rehab program for one year. Patients who did not complete the program were not included since it was typically unknown which visit was the last. This sample consisted of 11 female and 34 males who ranged in age from 48 to 94 years (mean = 67, SD = 9.9). A paired samples analysis was used to determine change in PRFS scores on all scales from pre- to post-test administrations.


Results: This analysis yielded a statistically significant improvement in the PRFS Depression Scale (p = .02) and a change that approached statistical significance on the PRFS Anxiety Scale (p = .07). However, the measured change was not statistically significant on the PRFS scales of Anger/Hostility, Social Isolation and Emotional Guardedness.


Conclusions: Based on this relatively small sample, the PRFS exhibits general sensitivity to change on the Depression and Anxiety Scales. However, change was not noted on scales of Anger/Hostility, Social Isolation and Emotional Guardedness. These results might be explained by the nature of the constructs measured. Depression and anxiety can be considered more variable states that can be more amenable to change. Anger/hostility and emotional guardedness are considered more stable traits that are less amenable to change without focused and purposeful intervention. Similarly, the quality of social relationships, as measured by the Social Isolation Scale, is less likely to change without specific intervention. It would be advantageous to study sensitivity to change in cardiac rehabilitation programs that offer specific intervention in these typically more stable factors.


Poster #: S124




Sheila V. Kamath, MS, RRT; Victoria Burt, MN, FNP-C; Mary Goolsby, EdD, NP-C; Lorraine Thomas, RN, BSN


Primary Institution: University Hospital


Classification: Cardiac


Introduction: Our outpatient cardiac rehabilitation (OCR) program outcomes have consistently been impressive. However, the recommended OCR plan of 36 sessions, is individualized/adapted to fewer sessions (usually 12-20) when needed to support patient returning to work, travel distance/transportation or high copayments.


Purpose: Our purpose was to compare the gains made by interdisciplinary OCR patients, based on number of sessions completed. We compared gains in QOL, METS, and feet walked in six minutes by those who completed up to or more than 20 exercise sessions. We also repeated analysis based on age, gender, and initial distance walked.


Design: A comparative analysis was performed to determine what, if any, differences in psycho/physical outcomes were associated with whether patients completed 20 or more interdisciplinary OCR sessions.


Methods: The interdisciplinary OCR program was individualized based on many factors including number of possible sessions. Measures included pre- and post-OCR scores on the Ferrans and Powers QOL Index Survey (QOLS) categories, six-minute walk distance, and METS. Percent gains in each score were compared among patients who completed up to or more than 20 sessions, in addition to comparisons based on age, gender, and initial feet walked (< 1210 vs >1505) for all patients who completed OCR in 2011, with measures recorded on entry to and last day of OCR. Statistical analyses included descriptive tests, paired T-tests (overall pre/post score differences), independent sample T-tests (by category of sessions completed), and descriptives.


Results: The 258 patients who completed the OCR program had a mean age of 65.6 years, with 31.7% female, 78% caucasian and averaged 28 exercise sessions. Most common primary diagnoses were post-coronary bypass grafts (38%), myocardial infarction (22%) and stent placement (33%). With the exception of METS, there were no statistically significant differences in the percentage of change (gain) between patients who completed up to or more than 20 exercise sessions, although average gains were made in each measure. There was statistically significant (p < .01) difference in the gains by patients completing up to 20 sessions (75% increase) versus those completing over 20 sessions (100% increase). Other comparisons (age, gender, initial feet walked) resulted in no statistically significant differences.


Conclusions: A critical OCR goal is to return the patient to successful function within their home and community. Achievement requires individual consideration with documented quality psycho/bio/physical outcomes. Overall gains were statistically similar for both groups studied. The addition of 8 sessions was associated with significantly greater change in the METS scores indicating improved functionality and workload tolerance. The presentation also will summarize outcomes based on demographics and beginning functionality.


Poster #: S125




Jonathan Gallagher, MPsychSc; Mark Heverin, MPsychSc; Caroline McHugh, MSc; Thelma Graham, BA; Breda Hannon, RGN; Niall Pender, PhD; Brendan McAdam, MD


Primary Institution: Beaumont Hospital


Classification: Cardiac


Introduction: The effectiveness of Cardiac Rehabilitation (CR) for both reducing mortality and secondary prevention is well established. Rates of CR enrolment and attendance remain sub-optimal however, and detailed information on barriers to CR in Ireland is lacking.


Purpose: To undertake a systematic investigation of barriers to Cardiac Rehabilitation (CR) uptake and attendance in Irish cardiac patients. The influence of age and gender on reported barriers was also examined.


Design: A retrospective study design was employed with a cohort of cardiac patients having attended a hospital-based CR programme during the previous 12 months.


Methods: 307 patients [76% male; mean age 68.12 (SD = 10.44)] completed a postal survey investigating barriers to CR uptake and attendance. In addition to demographic information, both attendees and non-attendees were requested to complete the Cardiac Rehabilitation Barriers Scale (CRBS) (Shanmugasegaram et al., 2011). The CRBS is a 21-item questionnaire addressing the patient's perceptions of the extent to which personal, logistical and systemic barriers impact upon CR participation. All data were analyzed using SPSS 18.0. The relationships of gender and age with barriers were tested with independent samples t-tests and the Pearson correlation respectively.


Results: Already exercising at home (mean = 2.42), the perception of exercise as tiring or painful (mean = 2.19), and cost issues (e.g. parking/petrol) (mean = 2.18) were the most frequently reported barriers to participation in CR by this sample. Older patients were more likely to cite the barriers of distance (p = 0.039), not knowing about CR (p < 0.001), the perception that they didn't need CR (p = 0.007), lack of doctor's encouragement to attend (p = 0.006), and their confidence to self-manage their condition (p = 0.014). Female patients were more likely to report transportation difficulties (p = 0.048) and the perception of exercise as tiring or painful (p = 0.003) as barriers to CR. Both older and female cardiac patients were more likely to view themselves as being too old for CR (p < 0.0001 and p = 0.016 respectively), and to endorse the belief that many patients don't attend CR and are fine (p < 0.001 and p = 0.042 respectively).


Conclusions: Attitudinal, physician-related and logistical factors significantly contribute to CR participation by Irish cardiac patients. CR programmes should endeavour to address logistical barriers where practicable in addition to targeting age- and gender-specific patient perceptions of barriers to CR.


Poster #: S126




Pedro T. Recalde, MS, MBA, MHA


Primary Institution: St. Luke's Episcopal Hospital


Classification: Cardiac


Introduction: Most cardiac rehabilitation programs operate under the 36 session maximum limit. Limiting the number of sessions based on risk stratification has gained popularity; however pre-assigning a number of sessions ignores the specific needs of the individual patient.


Purpose: To present an alternative method of defining cardiac rehabilitation discharge criteria utilizing the S.M.A.R.T. acronym (Specific, Measurable, Achievable, Relevant, and Time bound). Emphasis on a patient selected goal for activities of daily living and asymptomatic ventilatory threshold as a marker for exercise tolerance within the selected MET range is the corner stone of this method.


Design: Common discharge criteria include undergoing stress testing without demonstrating significant ischemia or dysrhythmia after completion of six minutes of a Bruce protocol, or equivalent, achieving a stable level of exercise tolerance (7 METS). This single definition for exit criteria does not reflect the needs of our patients with varying entry diagnosis and ages ranging from 18 to 87 years of age.


Methods: The goal setting survey was adapted from the table of Metabolic Equivalents of Activities as printed from ACSM. The 5 point functional assessment identifying ventilatory threshold and "goal setting" survey complete the entry patient assessment. This information is used to guide exercise intensity and progression individualized for each patient with an objective goal to work towards. A sample of the tool and full explanation of the alternative definition to "functional capacity" will be provided.


Results: We have a tool to guide exercise prescription and to guide answers to questions regarding the purpose of cardiac rehabilitation.


Conclusions: In line with the S.M.A.R.T. acronym, the combined "Goal Setting" survey and functional assessment allow for the patient care team to set specific goals, which are measurable within the clinic, achievable via consistent participation, realistic to the patients expected activities of daily living, and bound within the time constraints set forth by insurance guidelines.