You have been asked to help with the development and review of local CR services. As part of the programme the patients should receive a range of baseline measurements to help inform their goals and subsequently to assess them for change post-rehabilitation.
Which one of the following is not a baseline measurement recommended by the Department of Health?
Although NICE guidelines for secondary prevention following myocardial infarction and chronic heart failure recommend the assessment of left cardiac function using echocardiography, this is not an assessment against which to assess change post-CR. These measures include:
You are working on a general cardiology ward, looking after a 55-year-old man who presented with an NSTEMI. The patient lectures on physiology at the local university and asks you about targets he should aim to achieve given his recent diagnosis.
Which one of the following would not be appropriate?
Following an ACS, patients should be counselled to set realistic individualized goals. However, recommended targets include:
The NSF CHD has set the goal that 1 year after discharge, at least 50% of people should be non-smokers, exercise regularly, and have a BMI <30 kg/m2
You are looking after a 75-year-old man who has been newly diagnosed with chronic heart failure.
As part of a referral to the CR services, which one of the following should not be considered?
The core components of CR are the same for patients with chronic heart failure as for patients following an ACS. These include lifestyle measures (e.g. smoking, diet, and exercise/ functional capacity), risk factor management (BP, lipid and blood sugar control), cardioprotective drugs and devices, and psychosocial wellbeing. These core components are underpinned by education and long-term management strategies. In patients with chronic heart failure, it is also particularly important to assess fluid status and manage this appropriately with diuretics.
You are working on a cardiology ward in a district general hospital and have been asked to teach the medical students about cardiac rehabilitation. A particularly keen student asks about the physiological mechanisms for the cardiac benefits of exercise.
Which one of the following statements is incorrect?
There is increased expression of NO synthase.
Exercise training has several neurohormonal effects. Changes in the autonomic nervous system reduce the resting sympathicoadrenergic tone, and modifications within the renin–angiotensin– aldosterone system result in reduced plasma renin activity. On a microvascular level there is improved endothelium-dependent vasodilation, with increased expression and activity of endothelial NO synthase, as well as increased angiogenesis and collateralization. In patients with heart failure, as well as the benefits of exercise training listed in the question, studies have shown a reduction in circulating levels of angiotensin II, aldosterone, and atrial natriuretic peptide. These patients also benefit from better respiratory function and improved skeletal muscle metabolism and function.
You are working on a cardiology ward in a district general hospital and have been asked to teach the medical students about cardiac rehabilitation. One of the students asks if there is an evidence base to support the role of CR.
Which one of the following is the correct response?
A Cochrane review of exercise training (Jolliffe et al. 2001, updated in 2009) demonstrated that exercise-only cardiac rehabilitation and comprehensive CR reduced all-cause mortality by 27% and 13%, respectively, and cardiac death by 31% and 26%, respectively, for patients with previous MI, revascularization, or angina. There was no effect on non-fatal MI alone and there was no apparent additional benefit from comprehensive CR. The population studied included predominantly younger low-risk male patients. A Cochrane review of studies of exercised-based CR in patients with mild to moderate heart failure (Davies et al. 2010) demonstrated a 28% reduction in heart-failure-related hospital admissions and an improvement in patients’ quality of life, although no significant reduction in all-cause mortality was shown.
Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Failure 2010; 12: 706–15.
Jolliffe J, Rees K, Taylor RRS, Thompson DR, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev, 2001; (1): CD001800.
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