Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction. Results of a randomized, controlled trial

and the need for CRF modification. Usual care involved counseling by a research nurse and referral “as appropriate.” Intensive case management included research nurses, dietitians and sessions tailored to stages of change using visits, mail and telephone and drug therapy as per NCEP guidelines. Results: 1009 patients qualified of whom 450 consented to randomization. This was a predominately well-educated, fit and low-risk group with average age of 42 years and 80% male. Mean BP was 120/80 mm Hg, LDL-C 128 mg/dL, HDL-C 54 mg/dL, and trigs 113 mg/dL. The mean 10-year FRS was less than 6%. Coronary calcium was present in 15% with a mean score of about 5⫾20. LDL-C decreased by about 8 mg/dL in the NCM and 4 mg/dL in usual care. The mean 1-year absolute change in 10-year FRS was ⫹0.30 in those who received calcium score vs. ⫹0.36 in those who did not. The mean change in 10-yr FRS was ⫺0.06 in those with ICM vs. ⫹0.74 for usual care, p⫽0.003. Improved or stabilized CV risk was found in 40%. After controlling for knowledge of CCS, motivation for change and several psychological variables, only the number of risk factors and receipt of intensive case management (ICM) were associated with improved or stabilized FRS. Conclusions: Using coronary calcium screening to motivate patients to make evidence-based changes in risk factors was not associated with improvement in modifiable cardiovascular risk at 1 year. Case management was superior to usual care in the management of risk factors. Perspective: This excellent study design was unfortunately conducted in a very young healthy cohort in whom the average 10-year FRS was only 6%, which is low risk and likely too low for them to get motivated. The results can’t be generalized. In a published uncontrolled study and in clinical practice the awareness of coronary calcium particularly when related to that expected by age enhances compliance. In fact, in this study, there was a trend to a smaller increase in FRS in those with coronary calcium who were given their score. MR

CR) post-myocardial infarction in middle-aged and elderly men and women living in Florence, Italy? Methods: 270 low-risk consenting post MI patients were referred 4 – 6 weeks post-MI; they were age and gender stratified in a factorial design into three groups (middleaged, 45– 65 years; older, 66 –75 years; and oldest, ⬎75 years). Hosp-CR consisted of 8 weeks of daily sessions, 24 (3/wk) sessions of endurance training with ECG telemetry and 16 (2/wk) 1-hr sessions of flexibility and stretching exercise. Home-CR began after 4 – 8 supervised instructional sessions in the CR unit. Home-CR had a similar exercise prescription, was provided a heart rate monitor, a bicycle ergometer, and a log and a physical therapist made q. 2 week home visits. Both groups received counseling regarding risk factors and were invited to a monthly support group. The no CR group received a single educational session. Improvement in total work capacity (TWC) and health-related quality of life (HRQL) were measured at 6 and 12 months. Results: 67% were men. Significantly more of the young group were smokers, married, hyperlipidemic and educated. 14.1% dropped out including 10 deaths, seven nonfatal CV events and 21 who refused to continue. Drop out was greater in Home-CR (16/90, p⫽0.04) than Hosp-CR and control (11/90 each) and was twofold greater in the oldest group. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in the middle-aged and older, and smaller in the oldest group. TWC reverted toward baseline by 12 months with Hosp-CR, but not with HomeCR. HRQL improved in middle-aged and older CR and control patients, but only with CR in the oldest group. Costs were lower for Home-CR than for Hosp-CR in part related to less frequent visits and rehospitalizations. Complications were similar across treatment and age groups. Conclusions: Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients. Perspective: The home-based cardiac rehabilitation program is very well designed and would benefit post-MI patients of all ages. Providing home exercise equipment with a method of monitoring compliance is a benefit worth testing. MR

Improved Exercise Tolerance and Quality of Life With Cardiac Rehabilitation of Older Patients After Myocardial Infarction. Results of a Randomized, Controlled Trial Marchionni N, Fattirolli F, Fumagalli S, et al. Circulation 2003; 107:2201– 6. Study Question: What is the relative value of hospital based (Hosp-CR) and home-based cardiac rehabilitation (Home-

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