https://www.rima.org/web/medline_pdf/Am_J_Med_682.pdf

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials.

The objective of this review was to update Sobal and Stunkard’s exhaustive review of the literature on the relation between socioeconomic status (SES) and obesity (Psychol Bull 1989;105:260–75). Diverse research databases (including CINAHL, ERIC, MEDLINE, and Social Science Abstracts) were comprehensively searched during the years 1988–2004 inclusive, using ‘‘obesity,’’ ‘‘socioeconomic status,’’ and synonyms as search terms. A total of 333 published studies, representing 1,914 primarily cross-sectional associations, were included in the review. The overall pattern of results, for both men and women, was of an increasing proportion of positive associations and a decreasing proportion of negative associations as one moved from countries with high levels of socioeconomic development to countries with medium and low levels of development. Findings varied by SES indicator; for example, negative associations (lower SES associated with larger body size) for women in highly developed countries were most common with education and occupation, while positive associations for women in medium- and low-development countries were most common with income and material possessions. Patterns for women in higher- versus lower-development countries were generally less striking than those observed by Sobal and Stunkard; this finding is interpreted in light of trends related to globalization. Results underscore a view of obesity as a social phenomenon, for which appropriate action includes targeting both economic and sociocultural factors.

http://bvsper.paho.org/texcom/nutricion/29.pdf

Socioeconomic Status and Obesity

The Clinical Efficacy Assessment Subcommittee of the American College of Physicians–American Society of Internal Medicine acknowledges the scientific validity of this product as a background paper and as a review that captures the levels of evidence in the management of patients with chronic stable angina as of November 17, 2002





The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or a full revision is needed This process gives priority to areas in which major changes in text, and particularly recommendations, are merited on the basis of new understanding or evidence Minor changes in verbiage and references are discouraged

The ACC/AHA/American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Guidelines for the Management of Patients With Chronic Stable Angina, which were published in June 1999, have now been updated The full-text guideline incorporating the updated material is available on the Internet (wwwaccorg or wwwamericanheartorg) in both a track-changes version showing the changes in the 1999 guideline in strike-out (deleted text) and highlighting …

https://cdr.lib.unc.edu/downloads/bz60cz34d

ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)

Background
Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise‐based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

Objectives
To assess the clinical effectiveness and cost‐effectiveness of exercise‐based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health‐related quality of life (HRQoL) in people with CHD.

Search methods
We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

Selection criteria
We included randomised controlled trials (RCTs) of exercise‐based interventions with at least six months’ follow‐up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

Data collection and analysis
We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta‐analysis by duration of follow‐up: short‐term (6 to 12 months); medium‐term (> 12 to 36 months); and long‐term ( > 3 years), and used meta‐regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow‐up time point). 

Main results
This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post‐MI and post‐revascularisation patients, with a mean age ranging from 47 to 77 years.

In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty‐one of the included trials were performed in low‐ and middle‐income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow‐up time was 12 months (range 6 months to 19 years).

At short‐term follow‐up (6 to 12 months), exercise‐based CR likely results in a slight reduction in all‐cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all‐cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise‐based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow‐up. We are uncertain about the effects of exercise‐based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all‐cause hospitalisation, but not for all other outcomes.

At medium‐term follow‐up, although there may be little to no difference in all‐cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all‐cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials).

At long‐term follow‐up, although there may be little to no difference in all‐cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise‐based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials).

Meta‐regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow‐up length, publication year, CR setting, study location, sample size or risk of bias.

There was evidence that exercise‐based CR may slightly increase HRQoL across several subscales (SF‐36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow‐up; however, these may not be clinically important differences. The eight trial‐based economic evaluation studies showed exercise‐based CR to be a potentially cost‐effective use of resources in terms of gain in quality‐adjusted life years (QALYs).

Authors' conclusions
This updated Cochrane Review supports the conclusions of the previous version, that exercise‐based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all‐cause mortality, and a large reduction in all‐cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow‐up. Over longer‐term follow‐up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well‐designed, adequately‐reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer‐term follow‐up, and assess costs and cost‐effectiveness.

/pdf/exercise-based-cardiac-rehabilitation-for-coronary-heart-ctqt9teiud.pdf

Exercise-based cardiac rehabilitation for coronary heart disease

Considerable knowledge has accumulated in recent decades concerning the significance of physical activity in the treatment of a number of diseases, including diseases that do not primarily manifest as disorders of the locomotive apparatus. In this review we present the evidence for prescribing exercise therapy in the treatment of metabolic syndrome-related disorders (insulin resistance, type 2 diabetes, dyslipidemia, hypertension, obesity), heart and pulmonary diseases (chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication), muscle, bone and joint diseases (osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, chronic fatigue syndrome) and cancer, depression, asthma and type 1 diabetes. For each disease, we review the effect of exercise therapy on disease pathogenesis, on symptoms specific to the diagnosis, on physical fitness or strength and on quality of life. The possible mechanisms of action are briefly examined and the principles for prescribing exercise therapy are discussed, focusing on the type and amount of exercise and possible contraindications.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0838.2006.00520.x

Evidence for prescribing exercise as therapy in chronic disease.

This paper reports our experience with the use of an improved self-administered questionnaire for assessing quality of life (QOL) after acute myocardial infarction. The modified questionnaire significantly increased the proportion of patients able to answer all questions from 84%–92%. The additional questions in the improved questionnaire increased the total variance explained by the Emotional, Physical and Social QOL factors from 65.8%–66.5%. Internal consistency and construct validity were assessed and found to be high. Overall, we have found that this improved questionnaire is easy to administer and that it possesses desirable properties of validity and reliability.

An improved questionnaire for assessing quality of life after acute myocardial infarction

A self-administered quality-of-life questionnaire after acute myocardial infarction

The hypothesis that 6 months after acute myocardial infarction, adoption of secondary prevention activities would be higher, quality of life better, and blood cholesterol lower in patients randomly allocated to a mail-out intervention program than in those receiving usual care was tested. Patients were aged < 70 years, admitted to hospitals in and around Newcastle, Australia with a suspected heart attack and discharged alive from the hospital. Cluster randomization, based on the patient's family practitioner, was used to allocate consenting patients to an intervention or usual care group. A low-cost mail-out program was designed to help patients reduce dietary fat, obtain regular exercise by walking and (for smokers only) to quit smoking. Supplementary telephone contact was also used. In addition, a letter was sent to the family doctor regarding the benefit of aspirin and beta blockers for secondary prevention. Of eligible patients, 71% participated, and 79% of the 213 intervention subjects and 87% of the 237 usual care ones returned a 6-month follow-up questionnaire. Self-reported fat intake was significantly lower, an "emotional" score obtained from a quality-of-life questionnaire was significantly higher in the intervention than in the usual care group, and "physical" and "social" scores for quality of life were slightly higher. Blood cholesterol level and other variables were not different between the groups at 6 months. Simple low-cost programs providing support and advice on lifestyle change may be beneficial, particularly in improving patients' perceived quality of life.

Secondary prevention after acute myocardial infarction.

Socio-economic status and risk factors for cardiovascular disease: a multicentre collaborative study in the international clinical epidemiology network (inclen)

The seasonal pattern in hip fracture rates and its relationship to weather variables was studied using hospital admission data for New South Wales. There was a consistent seasonal pattern for hip fracture, with a trough in the summer and a peak in the winter, for the six years for which data were available: 1981, 1983, 1986, 1988, 1989 and 1990. The seasonal trends for all years were statistically significant (P<0.01) in men and in women, and in people who were 75 years and over. The relationship between the monthly admission rates for hip fracture in Sydney and such weather variables as mean daily minimum temperature, mean cloud cover, number of days with strong wind, number of days of fog, number of days of mist and number of days with 0.1 mm or more rainfall in a month were studied by Poisson regression. The mean daily minimum temperature for each month was the single weather variable independently and consistently associated with the monthly rates of hip fracture in both younger and older people. For the first time, a seasonal pattern for hip fracture and its close association with monthly temperature in Australia has been demonstrated.

Lisa Valenti

Papers

An improved questionnaire for assessing quality of life after acute myocardial infarction

A self-administered quality-of-life questionnaire after acute myocardial infarction

Secondary prevention after acute myocardial infarction.

Socio-economic status and risk factors for cardiovascular disease: a multicentre collaborative study in the international clinical epidemiology network (inclen)

The seasonality of hip fracture and its relationship with weather conditions in New South Wales.