Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in women

and Exercise Training on Exercise Capacity, Coronary Risk Factors, Behavioral Characteristics, and Quality of Life in Women Carl J. Lavie,

MD, and Richard V. Milani,

Despite the known benefits of cardiac rehabilitation, limited data are available on the outcome of this treatment in women, and this secondary prevention strategy may be underutilized. To assess the gender differences in baseline exercise capacity, indexes of obesity, lipid profiles, behavior chamcteristics, and components of quality of life, as well as the improvements in these components after a secondary prevention program, we retrospectively reviewed data from 458 patients (83 women and 375 men) enrolled in a hase II cardiac rehabilitation and exercise program a t!e r a major cardisc event. At baseline (6 weeks after the cardiac event and before rehabilitation), exercise capacity (-9%, p = 0.08) and ratio of low-densi lipoprotein cholesterol/ high-density lipoprotein chot sterol (-14%, p ~0.01) were lower, but total cholesterol (+7%, p dI.Ol), highdensity lipoprotein cholesterol (+25%, p eO.OOOl), lowdensity lipoprotein cholesterol (+8%, p cO.Ol), and percent body fat (+ 15%, p kO.OOOl) were higher in women than in men with corona artery disease. In addition, with regard to quality of 7ife, women had lower scores for energy (p = 0.06), function (p cO.Ol), and total qual-

MD

ity of life (p eO.05) than men. After cardiac rehabilitation and exercise training, women had significant improvements in exercise capacity (+33%, p eO.OOOl) and percent body fat (-7%, p &OOl), which compared favorably with the improvements (+40% and -5%, respectively) seen in men, but impmvements in body mass index and Ii ids were not statistically significant. Althou h most be Ravioral traits and measures of quality of Iii!E!significantly improved in women, depression, hostility, and measures of mental health were not significantly reduced. However, improvements in all these risk factors, behavioral traits, and components of quality of life were statistically similar in men and women. Because women hove a lower exercise capacity, ener, function score, and total uality of lii score at basePy ine, these improvements aR, r cardiac rehabilitation may be of greater clinical benefit to women than to men. These data reaffirm that women should be routinely referred to and vigorously encouraged to participate in outpatient cardiac rehabilitation and exercise training after ma$r cardiac events. (Am J Cardiol 1995;75:34&343)

ardiac rehabilitation and exercise training have now beenshown to improve exercisecapacity,reduce varC ious coronary artery disease(CAD) risk factors, improve

the decline in CAD hasbeenconsiderably less in women than in men*’ and that CAD is the leading causeof morbidity and mortality in middle-aged and older women.‘* quality of life, reduce subsequenthospitalization costs, Therefore,, we reviewed data from 458 consecutive as well as reduce major CAD events, including fatal patients to assessand comparethe effectsof cardiac rehamyocardial infarction, sudden death, and all-cause mor- bilitation and exercise training in a group of 83 women tality.ld Despite these well-proven benefitsof outpatient compared with 375 men. cardiac rehabilitation and exercise training, limited data are available on the outcome of these treatments in METHODS women. In addition, recent data indicate that women, Patients: We reviewed data at baseline and after outespecially older women, are not referred to cardiac reha- patient phaseII cardiac rehabilitation and exercise probilitation programs as often as mcn?*6and it is general- grams in 458 consecutive patients (297 from Ochsner ly recognized that even when referred, women are not Medical Institutions and 161 from MassachusettsGenas vigorously encouraged to enter these programs.5 eral Hospital) who completed the program. Other than These data all support a possible gender bias in the higher levels of both low-density lipoprotein (LDL) choapproach to women with CAD,‘-lo despite the fact that lesterol (p ~0.05) and high-density lipoprotein (HDL) cholesterol (p ~0.05) in patients from Massachusetts General Hospital, the characteristics of patients from From the Department of Internal Medicine, Section of Cardiology, both institutions were statistically similar. A subgroup Ochsner Clinic and Alton Ochsner Medical Foundation, New of 83 women was compared with 375 men. All patients Orleans, Louisiana. Dr. Milarii was previous1 with the Department of Preventive Medicine, Cardiovascular HeathY Center, Massachuwere referred after a major ischemic CAD event. At setts General Hospital, Boston, Massachusetts. Manuscript received Ochsner, 25% of patients eligible for cardiac rehabilitaJune 16, 1994; revised manuscript received and accepted October tion and exercise training actually attend this program; 24, 1994. there are no significant gender differences (25% in men Address for reprints:.Carl J. iavie, MD, Ochsner Heart and Vasand 26% in women) in attendance at our institution. cular Institute, Section of Cardiology, 15 14 Jefferson Highway, New Orleans, Louisiana 7012 1 Patients taking lipid-lowering medications were exclud340

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TABLE I Baseline Characteristics

in 1 week of the end of the program. In addition, the prevalence of patients who were continuing to smoke as well as those with a personal history of hypertension and diabetesmellitus was assessedby questionnaire. Obesity was defined as body massindex 227.8 kg/m2 for men and 227.3 kg/m2 for women, as previously described.16 Before entering the program, patients underwent symptom-limited exercise testing, usually with a standard Bruce treadmill protocol, although about one third used an alternative treadmill protocol or an upright bicycle ergometric protocol. After the outpatient cardiac rehabilitation and exercisetraining program, eachpatient underwent a protocol similar to the exerciseassessmentbefore the program. Exercise capacity was then assessedin estimated metabolic equivalents using standardmethods.” In a subgroup of 151Ochsner patients (120 men and 31 women), components of behavior and quality of life were quantitated by validated instruments using questionnaires obtained at entry and completion of the program.18~19The Kellner questionnaire assessesseveral behavioral characteristics (anxiety, depression, somatization, and hostility), and a lower scoreindicates a more favorable behavioral trait.18 The MOS 36-item shortform health survey (SF-36) was used to assessquality of life and severalof its components(mental health, energy, general health, pain, function, and well-being), with higher scoresindicating a more favorable quality of life trait. l9 Statistical methods: Results are expressedas mean f SD. Baseline characteristics of men and women were compared by nonpaired t tests and chi-square analysis. Baseline and postrehabilitation data were compared in each group by paired t tests, and the changes in data between groups were analyzed with a 2-factor (pre/post and gender)repeated-measuresanalysis of variance with repeatedmeasuresin 1 factor (pre/post). Factorspredicting improvementsin CAD risk factors (e.g., body massindex, percent body fat, exercisecapacity, and lipids) were assessedby univariate and multivariate analyseswith Stat-View II software(AbacusConcepts, Berkeley, California) on a Macintosh II computer system(Apple, Cupertino, California), as describedelse-

of the Study Population

(n = 458) Women Age (years) Currently smoking (%) Systemic hypertension (%) Diabetes mellitus (%) Exercise capacity (estimated metabolic equivalents) Body mass index (kg/mz) Body fat (“‘%) Obesity (%) Total cholesterol (mg/dl) Triglycerides (mg/dl) High-density lipoprotein cholesterol (mg/dl) tow-density lipoprotein cholesterol (mg/dl) tow-density lipoprotein cholesterol/high-density lipoprotein cholesterol

(n = 83)

Men (n = 375)

63 2 lO* 20

61 f 10 15

68t 30t 6.1 f 2.6*

A6 20 6.7 k 2.8

26.5 z 5.0 28 f 7T

27.1

k 3.8

154+59 A7 * 14z

24 r 6 35 202 * 39 169 z~96 38 r 10

142 c 35t

131 *37

217

487 + 4lt

3.02 e 1.127

3.48 f 1.26

*p = 0.08 compared with men; tp co.01 compared with men; rp ~0.0001 compared with men.

ed from the study. Other medications that have affected lipids in some studies (e.g., estrogens, B-adrenergic blockers, diuretics, a-adrenergic blockers, and calcium antagonists) were at stable doses for 24 weeks before study entry, and doses of these medications were not altered during the study period in the patients included in the study. Protocol and data collection: Patients were referred to and participated in an outpatient phase II cardiac rehabilitation and exercise program, which usually lasted approximately 12 weeks and consisted of 36 educational and exercisesessions.In general, the exerciseand educational components of the programs were similar at both institutions, and the protocols have been described in detail elsewhere.3,13-15 Height, weight, body mass index, percent body fat (sum of the skin fold method), age, gender, fasting plasma lipids, and exercise capacity (estimated metabolic equivalents) were assessedat baseline (4 to 8 weeks after the major CAD event [average6 weeks]) and again withTABLE II Improvements Artery

in Coronary

Risk Factors After Cardiac

Rehabilitation

and Exercise

Training

in Women

and Men With

Coronary

Disease Women Before Rehabilitation

Body mass index (kg/m’J) Body fat (%) Exercise capacity (estimated metabolic equivalents) Total cholesterol (mg/dl) Triglycerides (mg/dl) High-density lipoprotein cholesterol (w/4 tow-density

lipoprotein

(mddll tow-density lipoprotein cholesterol/high-density lipoprotein cholesterol

cholesterol

(n = 83)

After Rehabilitation

Men (n = 375)

% A

p Value

Before Rehabilitation

After Rehabilitation

% A

p Value

-1.1 -5 +A0

<0.0001 <0.0001 <0.0001

co.0 1

26.5 + 5.0 28 f 7 6.1 t 2.6

26.2 * A.9 26 f 6 8.1 f 3.3

-1.1 -7 +33

0.1 1
<0.0001

24 + 6 6.7 e 2.8

217 * 41 154 + 59 47Yc 14

213 f 41 147 + 93 48+ 13

-2 -5 +3

0.62 0.20 0.35

202 2 39 169 k96 38-c 10

199 ir36 155 + 113 39 2 11

-1.5 -8 +5

<0.0001

142 sz 35

136+35

-A

0.44

131 +37

129 e 31

-1.5

0.12

3.0 * 1.1

2.8 k 1.0

-7

0.51

3.5 ct: 1.3

3.3 f 1.1

-6


27.1

t 3.8

26.8 t 3.6 23 + 6 9.4 * 3.3

O.OA

% A = percent change.

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and HDL cholesterol (p
of Exercise Hemodynamics Before and After Cardiac Rehabilitation and Exercise Training in Women and Men With Coronary Artery Disease [mean f: SD]

TABLE IV Effects of Cardiac Artery

Rehabilitation

and Exercise

Training

Women

and Quality

of life in Women

*A reduction +An increase

% A = percent

After Rehabilitation

4+5 3*4 6*4 3*4

3*4 3*5 524 2+4

24 f 5

24 2 5

14*4 21 +4

16 +4

8*2 33 i: 7 45 i: 8 99*17

in unit score demonstrates in unit score demonstrates change.

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(n = 31)

Before Rehabilitation Behavioral characteristics* Anxiety Depression Somatization Hostility Quality-of-life componentst Mental health Energy General health Pain Function Well-being Total quality of life

342

on Behavior

and Men With

Coronary

Disease

JOURNAL

%A

p Value

-30

0.05 0.24 0.03 0.40

4+5 325 6+4 3*4

324 2+4 423 3k4'

0.29

24 f 4

25 f 4

15 *4

18 *4

+14

22 f 4 8*2 37 i 8 47 i: 8

23 f 5 10 + 2 42 2 6 52 k 8

+8 +21 +16 +12

<0.0001

+12

<0.0001

-15

-21 -16

23 f 4 lo*

Men (n = 120) Before Rehabilitation

1

39 f 7 50 f 9 112 * 17

+3 +18 +12

co.01
+16 +19

<0.0001

+lO


+14

co.ooo1

an improvement on improvement

in behavior trait. in quality of life component.

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f

16

After Rehabilitation

%A

-31 -30 -40 -14

118+

15

+6

p Value

0.03
1

0.32

DISCUSSION Cardiac rehabilitation and exercisetraining in women has received very little attention in the medical literature, possibly due to a relatively small number of women enrolled in these programs. Although the major trials demonstrating reductions in cardiac morbidity and mortality have mainly included men, both sexes seem to exhibit similar improvements in various CAD risk factors, suggestingthat this treatment is extremely valuable regardless of gender. The marked 33% improvement in exercise capacity after cardiac rehabilitation and exercise training in women is in exact agreement with the functional improvement recently reported by Cannistra et a120and is statistically similar to the improvement noted in men. This improvement in functional capacity for women has previously been documented in other studies of cardiac rehabilitation.21-23Becausewomen began the cardiac rehabilitation program with a lower functional capacity as shown by our data and other studies,20,21the clinical benefit may actually be greater for women than for men who already have a very good exercise capacity. Like Cannistra et aJ20 we also did not demonstratesignificant improvement in lipid profiles or in a major index of obesity (body massindex), although we did demonstratesignificant reduction in percent body fat in women after cardiac rehabilitation and exercise training. The lack of a significant improvement in body mass index in women may be particularly important, since obesity is more common in women with CAD, as demonstratedin our study and elsewhere,20and recent data have demonstratedthat obesity is strongly and independently related to CAD events in women.24,25 In general, after cardiac rehabilitation and exercise training, behavioral characteristics and nearly all components of quality of life improved to a similar degree in women and men. However, at baseline, women not only had significantly lower exercise capacity but also scoredlower than men with regard to validated measures of energy, function, and overall quality of life. Therefore, as with improvement in exercise capacity, the improvement in various components of quality of life may be of greater clinical benefit to women than to men. Symptomsof depressionand hostility may affectprognosis after major cardiac events.26*27 Disappointingly, neither depression nor hostility indexes were significantly reduced in women after the rehabilitation program. Severallimitations should be emphasized:The potential for selection and referral bias may have beenpresent; the study was retrospective and nonrandomizedand was of relatively short duration; and the study was performed at large academicmedical centers. Formal stressmonitoring and intervention were not included. Neither plasma glucose nor insulin sensitivity was routinely monitored. Exercise capacity was estimatedand not precisely assessedby expired gas exchange.In addition, baseline lipid values were obtained, on average,6 weeks after a major cardiac event, so it is possiblethat lipid values may not have completely returned to the precardiacevent levels in all patients. Finally, as we discussedelsewhere,nJ4 a control group was not included. Despite these limitations, our data indicate that women and men with CAD differ regarding baseline risk

factors, but both showed similar improvements in exercise capacity, percent body fat, body mass index, lipid profiles, behavioral characteristics, and quality of life after outpatient cardiac rehabilitation and exercisetraining. These data support the idea that women should be routinely referred to and vigorously encouragedto pursue cardiac rehabilitation and exercise training after major cardiac events. Greater emphasis on improving lipids, particularly reducing elevated LDL cholesterol levels, and reducing indexes of depression and hostility is needed to further enhance secondary prevention of CAD in women. 1. O’Connor GT, Baring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr, Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234-244. 2. Squires RW, Gau GT, Miller TD, Allison TG, Lavie CJ. Cardiovascular rehabilitation: status, 1990. Mayo Chin Proc 1990;65:731-755. 3. Lavie CJ, Milani RV: Littmao AB. Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly. J Am CON Cardiol 1993:22:678&683. 4. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation paxticip&on predicts lower rehospitalization costs. Am Heart J 1992;123:916-921. 5. Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients a&d 262 years. Am J Cardiol 1992;69:1422-1425. 6. Ades PA, Waldmann ML, McCann W, Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med 1992;152: 1033-1035. 7. Healy B. The Yentyl syndrome. N Engl J Med 1991;325:274275. 8. Wenger NK. Gender, coronary artery disease, and coronary bypass surgery. Ann Intern Med 1990;112:557-558. 9. Bickell NA, Pieper KS, Lee KL, Mark DB, Glower DD, Pryor DB, Califf RM. Referral patterns for coronary artery disease treatment: gender bias or good clinical iudrrement? Ann Intern Med 1992:116:791-797. 10.~Laikey WK. Gender differences &the management of coronary artery disease: bias or good clinical judgement? Ann Intern Med 1992;116:869-870. 11. Eaker ED, Packard B, Thorn TJ. Epidemiology and risk factors for coronary heart disease in women. Cardiovasc Clin 1989;19:129-145. 12. Wahl P, Walden C, Knopp R, Hoover J, Wallace R, H&s G, Ritind B. Effect of estrogen/progestin potency on lipid/lipoprotein cholesterol. N Engl J Med 1983:308:X62-867. 13. Lavie CJ, Milani RV. Factors predicting improvements in lipids following cardiac rehabilitation and exercise training. Arch Zntern Med 1993;153:982-988. 14. Lavie CJ, Milani RV. Patients with high baseline exercise capacity benefit from cardiac rehabilitation and exercise training programs. Am Heart J 1994;128: 1105-1109. 15. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training on low-density lipoprotein cholesterol in patients with hypertriglyceridemia and coronary artety disease. Am .I Cardiol 1994;74: 1192-l 195. 16. Colditz GA. Economic costs of obesity. Am J Clin Nutr 1992;55(suppl 2): 503s-507s. 17. Bardsley WT, Mavkin HT. Exercise testing. In: Brandenburg RD, Fuster V, Giuliani ER, McGoon DC, eds. Cardiology Fundamentals and Practice. Chicago: Year Book Medical, 1987:3691102. 18. Kellner R. A symptom questionnaire. J C/in Psychiatry 1987;48:268-274. 19. Ware JE Jr, Sherboume CD. The MOS 36.item short-form health survey (SF36) I. Conceptual framework and item selection. Med Care 1992;30:473483. 20. Cannistra LB, Balady GJ, O’Malley CJ, Weiner DA, Ryan TJ. Comparison of the clinical profile and outcome of women and men in cardiac rehabilitation. Am J Cardiol 1992;69:1274-1279. 21. O’Callaghan WG, Teo KK, O’Riordan J, Webb H, Dolphin T, Horgan JH. Comparative response of male and female patients with coronary artery disease to exercise rehabilitation. Eur Heart J 1984;5:649-65 1. 22. Oldridge NB, LaSalle D, Jones NL. Exercise rehabilitation of female patients with coronau heart disease. Am Heart J 1980:100:755-757. 23. DeBusk RF, Houston N, Haskell W, Fry G, Parker M. Exercise training soon after myocardial infarction. Am J Cardiol 1979;44:1223-1229. 24. Manson JE, Colditz GA, Stampfer MJ, Willett WC, Rosner B, Monson RR, Speizer FE, Hennekens CH. A prospective study of obesity and risk of coronary heart disease in women. N En@ J Med 1990;322:882-889. 25. Hubert HB, Feinleib M, McNamara PM. Cast& WP. Obesitv, as an indeDen1 ~~~ dent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67:968-977. 26. Milani RV, L&man AB, Lavie CJ. Depressive symptoms predict functional improvement following cardiac rehabilitation and exe&e pro&am J Cardiopul Rehabil 1993;13:40&411. 27. Milani RV, Littman AB, Lavie CJ. Psychological adaptation to cardiovascular disease. In: Messerli FH, ed. Cardiovascular Diseases in the Elderly, 3rd ed. Norwell, MA: Kluwer Academic, 1993:401-412.

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