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Journal of Cardiopulmonary Rehabilitation & Prevention:
doi: 10.1097/01.HCR.0000434049.98919.c5
Association Annual Meetings

American Association of Cardiovascular and Pulmonary Rehabilitation 28th Annual Meeting: October 3–5, 2013, Nashville, TN

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RESEARCH COMMITTEE

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2:45 PM–3:45 PM

Thursday, October 3, 2013

Scientific Oral Presentations

Beginning Investigator Presentations

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HEMODYNAMIC RESPONSES TO COMBINED ENDURANCE AND RESISTANCE EXERCISES IN HYPERTENSIVES

Raphael M. Ritti Dias,1 Annelise L. Meneses,1 Cláudia L. Forjaz,2 Paulo F. Lima,1 Rafael M. Batista,1 Maria F. Monteiro3

Institutions: 1. School of Physical Education, University of Pernambuco, Recife, Pernambuco, Brazil. 2. School of Physical Education and Sports, University of São Paulo, São Paulo, São Paulo, Brazil. 3. Cardiology State Hospital of Pernambuco, University of Pernambuco, Recife, Pernambuco, Brazil.

Introduction: Usually aerobic and resistance exercises are performed within the same exercise session. The influence of exercise order on post-exercise blood pressure responses has been previously investigated in normotensives; no difference was found in the blood pressure changes following different exercise orders, however, it remains unclear whether similar responses would be observed in hypertensive subjects that are known to present altered cardiovascular control.

Purpose: To evaluate the effects of the order of endurance and resistance exercises performed in a single session on post-exercise blood pressure (BP) and hemodynamics in hypertensive women.

Design: This is a cross-over study

Methods: Nineteen hypertensive women participated in three experimental sessions: C = control session, E+R = endurance exercise (50-70% of heart rate [HR] reserve) followed by resistance exercise (50% of 1-RM), and R+E = resistance exercise followed by endurance exercise. Before and after each session, BP, peripheral vascular resistance (PVR), cardiac output (CO), stroke volume (SV) and HR were obtained in a supine position.

Results: Compared to pre-intervention values, BP increased after the C session (Systolic BP: +9 ± 2 mmHg, diastolic BP: +6 ± 2 mmHg and mean BP: + 7 ± 2 mmHg, P < .01) and did not change after the E+R and R+E sessions (P > .05). After the C session, PVR increased (+ .15 ± .04 mmHg.min/L, P = .01) and CO decreased (–.58 ± .28 L/min, P = .05); however, these values did not change after the E + R and R + E sessions (P > .05). SV did not change after the C session (P >.05) and decreased after the E + R (–14 ± 3 mL, P < .05) and R + E (–9 ± 4 mL, P < .05) sessions. HR decreased after the C session (–5 ± 1 bpm, P < .01) and increased after the E + R (+ 5 ± 1 bpm, P < .01) and R + E (+4 ± 1 bpm, P < .01) sessions. For all variables, there were no significant differences between the E + R and R+E sessions.

Conclusions: In hypertensive women, the order of endurance and resistance exercises did not influence post-exercise hemodynamics.

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THE IMPACT OF INPATIENT-PROVIDER DISCUSSIONS ON ENROLLMENT IN CARDIOVASCULAR REHABILITATION: SAY WHAT?

Sanam Pourhabib, BSc,1 Caroline Chessex, MD,2 Shannon Gravely, PhD,2 Tiziana Rivera, RN, MSc, GNC (C),3 Judy Murray, MScPT,3 Sherry L. Grace, PhD1, 2

Institutions: 1. York University, Toronto, ON, Canada. 2. University Health Network, Toronto, ON, Canada. 3. Mackenzie Health, Richmond Hill, ON, Canada.

Introduction: Globally, cardiovascular disease (CVD) is among the leading causes of morbidity. Secondary prevention programs such as cardiovascular rehabilitation (CR) have been designed to control and decrease the burden of CVD. Despite the evidence of benefit in multiple domains and clinical recommendations for referral, CR is significantly under-utilized. The most successful strategy to promote CR utilization is systematic referral with a patient-provider discussion.

Purpose: This study investigated the elements of the inpatient-provider CR discussion, to identify which aspects are related to patient enrollment.

Design: This was a prospective study of cardiovascular inpatients and their healthcare providers recruited from 3 hospitals (n = 2 academic) in Southern Ontario.

Methods: Upon consent, a digital audiorecorder was provided to record their subsequent interaction, about “secondary prevention”. All participants completed a self-report survey assessing sociodemographic characteristics, perceptions of CR and their clinical interaction. Discussions were anonymized and coded using the Roter Interaction Analysis System. Two months later, CR enrollment (yes/no) was extracted from CR charts and/or self-report. Bivariate analyses were used to examine which utterances were associated with CR enrollment.

Results: Of the 111 inpatients approached who were receiving care from one of the 28 consenting healthcare providers (n = 15; 53.6% nurses), 50 patients consented and completed the study (68.49% response rate; mean age = 65.1 ± 13.2; 14 [28%] female; percutaneous coronary intervention n = 23 [46.0%]). Overall, 35 (70.0%) participants were referred to CR, and 27 (54.0%) enrolled. Patient enrollment was unrelated to the type of referring provider, and the provision of a CR program pamphlet/motivational letter to patients. Enrollment in CR was significantly related to the healthcare provider reassurance and optimism (P = .045). Patient utterances significantly related to enrollment were reassurance and optimism (P = .035), asking questions related to lifestyle (P = .009), data-gathering regarding lifestyle/psychosocial issues (P = .017), and rapport-building/emotional statements (P = .038).

Conclusions: Elements of patient-provider communication are significantly related to patient enrollment in CR programs weeks later. While replication is warranted, these novel findings demonstrate the importance of CR promotion, and the power of interpersonal communication. Providers should be informed of these findings, and further tests are needed to assess whether providers can be trained to communicate in an enrollment-enhancing manner, such that patient enrollment rates are increased.

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EFFECTIVENESS OF HOSPITAL VERSUS HOME-BASED CARDIAC REHABILITATION ON LEFT VENTRICULAR EJECTION FRACTION IN POST-PTCA PATIENTS: A RANDOMIZED CONTROLLED TRIAL

Mohammad H. Haddadzadeh, PhD,1, 2 Arun G. Maiya PhD,2 R. Padmakumar, DM, DNB,2 Shirish S. Borkar, MCH, DNB,2 Vivek G. Raman, DM,2 Tom Devasia, DM,2 Bijan Shad, DM,3 Fardin Mirbolouk, DM,3 N. Sreekumaran Nair, PhD,4 Vasudev Guddattu, MSc4

Institutions: 1. Physical Therapy, Wheeling Jesuit University, Wheeling, WV, United States. 2. Physiotherapy, Manipal University, Manipal, Karnataka, India. 3. Cardiovascular Interventions, Golsar Hospital, Rasht, Guilan, Iran, Islamic Republic of. 4. Statistics, Manipal University, Manipal, Karnataka, India.

Introduction: During the past decade cardiac rehabilitation programs faced fundamental advances and alternative methods but there is still less body of evidence on effectiveness of Home-based Cardiac Rehabilitation programs particularly on clinical indices like left ventricular ejection fraction (LVEF).

Purpose: To find out the effectiveness of hospital versus home-based cardiac rehabilitation on LVEF following percutaneous transluminal coronary angioplasty (PTCA).

Design: This was a single blinded randomized controlled trial.

Methods: After approval from Ethical Committee of Kasturba Hospital under Manipal University; India, post-PTCA patients (age of 35 to 75 years old) with low and moderate risk (AACVPR classification-99) who gave written informed consent were included in the study. High risk patients and any contraindications to exercise testing and training were excluded. Recruited subjects were randomly allocated into 3 groups by using concealed envelope method; hospital-based CR (HsCR), home-based CR (HmCR) and control group. Hospital-based group (n = 35) underwent 12 weeks structured and supervised CR program 3 times per week. Home-based group (n = 35) underwent 12 weeks structured home-based CR program monitored every two weeks by phone and a supervision session every month. Control group (n = 35) were given the usual medical prescription by cardiologist without any CR program. LVEF was measured by echocardiography before and after 12 weeks and its changes compared with control group. Using intention to treat approach, between and within group analysis was done using one way ANOVA by keeping level of significance at P ≤ .05. SPSS v17 was used to analyze data.

Results: 105 (75 Male, 30 Female) post-PTCA patients with mean age of 56.1 ± 9.1 years old enrolled in the study. At baseline there was no significant difference between groups with respect to the main outcome. There was a significant increase in LVEF in HsCR (53.8 ± 7.4 to 65.1 ± 4.4) compared with control (56.8 ± 9.1 to 57.9 ± 8.8) group (P < .0001). There was no significant difference between HmCR (56.8 ± 8.5 to 61.1 ± 6.6) and control (P = .254) group. Post hoc analysis showed a significant difference between HsCR and HmCR in increasing LVEF. (P < 0001).

Conclusions: The present study showed 12 weeks structured hospital-based cardiac rehabilitation carried under supervision 3 times per week could significantly increase LVEF compared with Home-based CR in post-PTCA patients. Results also showed that however home-based CR could improve LVEF but it was not statistically significant. Thus, appropriate selection of patients according to their baseline clinical picture to enter either program could play an important role in overall patient prognosis.

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PARTICIPATION IN CARDIAC REHABILITATION PROGRAMS AMONG VETERANS

David W. Schopfer, MD,1 Steven Takemoto, PhD,1 Kelly Allsup, BS,2 Daniel E. Forman, MD,3, 4 Mary A. Whooley, MD1, 5

Institutions: 1. San Francisco VA Medical Center, San Francisco, CA, United States. 2. New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA, United States. 3. Division of Cardiovascular Medicine, VA Boston Healthcare System, Boston, MA, United States. 4. Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, United States. 5. Department of Medicine, Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States.

Introduction: Exercise-based cardiac rehabilitation (CR) programs are underutilized despite evidence they reduce morbidity and mortality in patients with ischemic heart disease (IHD). Although numerous barriers for both providers and patients exist, geographic distance has been highlighted as a major factor affecting utilization of CR programs, however, the extent to which Veteran participation is associated with availability of nearby Veterans Affairs (VA) CR programs is unknown.

Purpose: We sought to determine whether the presence of an on-site CR program was associated with greater utilization of CR in Veterans with IHD.

Design: Observational study of participation in on-site (VA) and off-site (non-VA) CR programs between 2008 and 2011.

Methods: We categorized VA medical centers based on the presence or absence of an on-site CR program. Eligible patients were defined as patients hospitalized for acute myocardial infarction (MI), percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at any VA facility between 2008 and 2011. We calculated the proportion of eligible patients who participated in CR using CPT codes for VA and/or non-VA (fee basis) care using VA administrative data. We then compared the proportion of eligible patients who participated in CR at facilities with vs. without onsite CR programs using t-test.

Results: Of the 123 VA facilities that provide inpatient cardiac care, 35 (28%) have on-site CR programs. Between 2008-2011, 20837 Veterans were hospitalized with acute MI, 25214 underwent PCI, and 10989 had CABG. The proportion of eligible patients participating in any (VA or non-VA) CR program ranged from 5.7% to 6.8%. The presence of an on-site CR program was associated with greater likelihood of participating (8.9% vs. 5.1%, P = .02).

Conclusions: Presence of an on-site CR program was associated with greater utilization of CR. However, the proportion of eligible patients who participated in CR was extremely low (< 10%) regardless of the presence or absence of an on-site program. These findings suggest that disseminating existing models of on-site CR programs may not substantially improve utilization of this evidence-based program. Alternative strategies must be evaluated to facilitate participation in CR.

10:45 AM–11:45 AM

Friday, October 4, 2013

Scientific Oral Presentations

Cardiac Rehabilitation–Physiology

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CARDIAC REHABILITATION ENHANCES GLUTATHIONE (GSH) ANTIOXIDANT SYSTEM IN SUBJECTS WITH ISCHEMIC HEART FAILURE (IHF), AND SUBJECTS WITH CORONARY ARTERY DISEASE (CAD)

Ahmed S. Elokda, PT, PhD, CLT_LANA1, 2

Institutions: 1. Physical Therapy for Internal Medicine Conditions, Cairo University, Cairo, Egypt. 2. Physical Therapy, NYIT, Old Westbury, NY, United States.

Introduction: A disturbance between the balance of free radical formation and the antioxidants is thought to be a key factor in the development of CAD and IHF. GSH is considered to be a critical participator of the cellular homeostasis and, anti-oxidant defense. Acute exercise was effective in inducing cellular oxidative stress (increased free radical formation, increased oxidized form (GSSG), decreased GSH, decreased GSH:GSSG ratios). Whether the cumulative effects of repetitive exercise are effective in producing protective adaptive changes (increased resistance) to oxidative stress is a question with significant clinical interest.

Purpose: The purpose of this study was to investigate the effects of 12 weeks of cardiac rehabilitation in the form of combined aerobic exercise training (AT) and resistance training (RT) on general adaptations to oxidative stress in subjects with IHF, and subjects with CAD.

Design: A mixed model repeated measures ANOVA design was used with Bonferonni adjusted t tests for preplanned comparisons.

Methods: A convenience sample of 20 subjects with IHF, and 20 subjects with CAD were randomly assigned to 2 groups: control (no exercise) and AT + RT. Intervention included AT 3 times per week at 40-70% HRR (15 min. warm up, 30 min. exercise, 15 min. cool down), and RT 2 times per week (acclimation method with 8-10 exercises involving upper and lower body). Venous blood sampling was taken at rest pre- and post-12 weeks of AT+RT. The GSH:GSSG-412 assay: Colorimetric determination of reduced and oxidized glutathione was used for venous assay analyses.

Results: Efficacy of the cardiac rehabilitation program was demonstrated by significant between group (exercise group versus control) comparisons. AT+RT showed significant pre-post-training increases in resting GSH and GSH:GSSG, and significant decreases in GSSG levels in subjects with IHF, as well as, subjects with CAD.

Conclusions: The current study represents the first longitudinal investigation involving the effects of cardiac rehabilitation on glutathione antioxidant system in subjects with IHF, and subjects with CAD. The significant findings of this study have positive potential clinical implications to individuals involved in cardiac and pulmonary rehabilitation.

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REMISSION OF RECENT ONSET TYPE 2 DIABETES MELLITUS WITH EXERCISE AND WEIGHT LOSS

Patrick D. Savage, MS,1 Annis Marney, MD,1 Kimberly Evans, RD,1 Philip Ades, MD1

Institution: 1. Cardiology, Fletcher Allen Healthcare, S. Burlington, VT, United States.

Introduction: The obesity epidemic has resulted in marked increases in rates of type 2 diabetes mellitus (T2DM). Exercise and weight loss are frequently recommended for individuals with newly diagnosed T2DM. However, there has been little study of whether an intensive lifestyle intervention, without medications, can result in T2DM remission.

Purpose: We examine the effectiveness of an intensive lifestyle intervention of exercise and behavioral weight loss counseling for individuals recently diagnosed with T2DM

Design: Prospective, non-randomized intervention trial.

Methods: Study eligibility required a recent (< 1 year) diagnosis of T2DM and not yet treated with medication. The study intervention comprised 6-months of exercise and behavioral weight loss counseling. Inclusion criteria required a hemoglobinA1c (HbA1c) between 6.5-8.0%, body mass index (BMI) between 25-40 kg/m2 and a waist circumference >88 and 102cm for men and women, respectively. Outcome measures included HbA1c, body composition with dual x-ray absorptiometry, fasting glucose and lipids, high sensitivity-c-reactive protein (hs-CRP), and peak aerobic capacity. All cardioprotective medications were held steady throughout the study. Statistical methods included paired t-tests and a P-value < .05 determined significance. Results are presented as mean + SD.

Results: Six individuals (4 males) enrolled and completed the study intervention. Mean age of study participants was 64.1 + 6.9 years and the duration since initial diagnosis of T2DM was 5.1+4.8 months. All of the study participants experienced remission of T2DM. Significant decreases were observed in HbA1c (6.9 + 2.3 vs 6.0 + 3.7%), body weight (107.4 + 11.5 vs 95.4 + 13.2kg), fat mass (41.2 + 13.6 vs 34.2 + 15.4kg), waist circumference (112 + 1.7 vs 105.4 +4cm) and BMI (35.3 + 4.2 vs 31.4 + 4.6kg/m2) (all, P < .05). Also, weight loss and exercise resulted in significant decreases in fasting glucose (140.6 + 20.4 vs 107.0 + 7.2mg/dL), total cholesterol (182.0 + 47.0 vs 166.6 + 49.1mg/dL), Total/HDL-cholesterol (4.8 + 1.7 vs 4.1 + 1.3) and hs-CRP (6.7 + 5.7 vs 5.4 + 5.7mg/L) (all, P < 0.05). Peak aerobic capacity was unchanged (22.1 + 4.5 vs 27.1 + 8.5 mL·kg−1·min−1, P = .19)

Conclusions: Exercise and behavioral weight loss counseling results in remission of T2DM as defined by HbA1c, significant weight loss, and improvements in fasting lipids and CRP levels. Further study is required to determine the sustainability of our results and whether delaying or avoiding pharmacological therapy for T2DM results in a postponement of medical complications associated with T2DM such as cardiovascular disease, cerebrovascular accident, retinopathy, and kidney failure.

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IMPACT OF CARDIAC SURGICAL INTERVENTION ON SUCCESSFUL WEIGHT LOSS OF OVERWEIGHT AND OBESE CARDIAC REHABILITATION PATIENTS

Michelle La Londe, MA,1 Lynn Shaffer, PhD,1 Jesse Hickerson, MBA,1 Gregory Lam, MD,1,2 Anne Albers, MD,1 Daniel Mudrick, MD, MPH,1,2 Richard J. Snow, DO, MPH,1, 4 Teresa Caulin-Glaser MD1, 3

Institutions: 1. McConnell Heart Health Center, Columbus, OH, United States. 2. Duke University Medical Center, Durham, NC, United States. 3. Women's Health Research, Yale University, New Haven, CT, United States. 4. College of Osteopathic Medicine, Ohio University, Athens, OH, United States.

Introduction: One goal of cardiac rehabilitation (CR) is to improve coronary heart disease (CHD) risk factors, including obesity. The effect of CHD intervention type, surgical vs. nonsurgical, prior to CR participation on likelihood of weight loss success is unclear.

Purpose: We assessed whether likelihood of successful weight loss among overweight and obese CR participants was associated with surgical vs. nonsurgical intervention for patients with CHD.

Design: Retrospective cohort study

Methods: This analysis included 2065 patients who participated in CR between 2004 and 2012. All individuals with a BMI ≥ 25 kg/m2 and program entry and exit anthropometrics, labs, stress tests, BDI-II scores, SF-36 scores and blood pressures were included.

Successful weight loss was defined as ≥ 0.42% of body weight loss per week (based on an extrapolation of NIH recommendations) or achievement of an exit BMI <25 kg/m2.

Chi-square analysis was used for frequency data and t-tests for continuous data to identify significant differences between patients with and without a surgical indication for CR. All statistically or clinically important variables were considered candidate variables for logistic regression modeling.

Multivariate logistic regression was performed modeling successful weight loss to determine if a surgical indication for CR was a significant factor in successful weight loss after adjustment for candidate variables identified with univariate analysis.

Results: Successful weight loss was achieved by 12% of surgical patients vs 19% of nonsurgical patients (P < .0001). Surgical intervention remained a significant negative factor in the achievement of successful weight loss in this cohort of CR participants after adjustment for differences in program compliance, changes in exercise capacity, entry body weight, age, diabetes status, and diet stage of change (OR = 0.52, 95% CI = 0.30,0.69). Patients with a surgical indication for CR are 48% as likely to achieve successful weight loss when compared to patients with a nonsurgical indication for CR. Diabetes, age, and program noncompliance were negative predictors of weight loss success. Diet stage of change indicating healthy diet changes prior to CR entry and greater increases in exercise capacity were positive predictors of successful weight loss.

Conclusions: Overweight and obese patients with surgical indications for CR may require a different approach to weight management than patients entering with a non-surgical indication for CR. Further investigation is warranted to determine what specific interventions will help patients with surgical indications to be more successful with weight loss in CR.

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IS THE EFFICACY OF EXTERNAL COUNTER PULSATION (ECP) ENHANCED WITH CONCOMITANT PHASE II CARDIAC REHABILITATION (CR)?

Patricia Lounsbury, RN, BSN, MEd,1 James K. Johnson, RKT, Med,1 Christina Clair, BS, MS,1 Ahmed S. Elokda, PT, PhD,1 Ellen Gordon, MD1

Institution: 1. CHAMPS, University of Iowa Health Care, Iowa City, IA, United States.

Introduction: ECP has been used to reduce and/or eliminate angina in patients with coronary artery disease (CAD) and to increase functional capacity.

Purpose: We sought to examine what effect, if any, undergoing CR concomitantly would have on functional capacity, measured by cardiopulmonary testing (CPX), after ECP and at followup. We also sought to examine the effect on depression, as assessed by the PHQ9.

Design: A retrospective analysis was conducted on all patients who have undergone ECP since the inception of the program in 2001. Patients who also underwent CR during ECP were compared with those who did not participate in CR. Patients underwent CPX and PHQ9 before starting ECP, on completion of ECP, and at 6 months (6m) followup.

Methods: Depression inventories (PHQ9), V02max, METs, and anaerobic threshold (AT) were measured at initiation and conclusion of 35 sessions of ECP and at 6 months (6m) followup. Matched pairs were analyzed for mean difference comparing t-tests.

Results: Patients who concomitantly underwent CR had significantly greater improvements in V02max (reported in METs) from 4.48 before and 5.85 after (n = 33) (P = < .0001); ECP alone (n = 47) with 4.77 before and 5.63 after ECP (P = .0002). These represent increases of 30.6% and 18% respectively. Anaerobic threshold was increased from 7.58 mL·kg−1·min−1 to 12.02 mL·kg−1·min−1 in those undergoing ECP with CR (an increase of 60.9%) and from 10.19 mL·kg−1·min−1 to 11.55 mL·kg−1·min−1 in patients undergoing ECP alone (a 13% increase).

For those patients who returned for 6m follow-up cardiopulmonary tests, those who participated in CR demonstrated a decrease from 5.5 METs to 4.9, a 10.9% decrease (n = 20) while ECP-only patients decreased from 5.98 to 5.41 METs (10.5%) (n = 29).

There were significant differences in PHQ9 tests with both groups. The ECP with CR group scored 8 prior to ECP and 4.18 after (P = .0006) (n = 28). The ECP alone group scored 4.64 on admission and 3.72 on discharge (P = .0221) (n = 36). On 6m followup, the ECP with CR group scored 3.13 after ECP and 4.63 at 6m (n = 16) (NS); while the ECP alone group scored 4.17 after ECP and 4.83 at 6m (NS).

Conclusions: ECP alone increases METs and anaerobic threshold. This increase is enhanced when ECP patients undergo CR concomitantly.

This study demonstrates that ECP is underutilized and greater participation should be encouraged especially with concomitant CR.

8:00 AM–9:30 AM

Saturday, October 5, 2013

Scientific Oral Presentations

Cardiac Rehabilitation–Programming

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KNOWLEDGE LEVEL OF CARDIOVASCULAR DISEASE RISK FACTORS IN ADULTS WHO HAVE PARTICIPATED IN A CARDIAC REHABILITATION PROGRAM

Pamela Bartlo, PT, DPT, CCS,1 Dawn M. Hayes, PT, PhD, GCS2

Institutions: 1. Physical Therapy, D'Youville College, Buffalo, NY, United States. 2. Oncology Support Services, Northside Hospital Cancer Institute, Atlanta, GA, United States.

Introduction: Cardiovascular disease (CVD) remains the most prevalent cause of death in the US. There has been a public agenda for education on the risk factors associated with CVD. Since the incidence of CVD remains high, it is important to assess whether adults are obtaining this knowledge and which educational methods may achieve that the best.

Purpose: The purpose of this study was to assess the knowledge level of CVD risk factors in adults that have participated in a phase II cardiac rehabilitation program and to examine if differences existed in the type of educational method used and the choices made by men compared with women.

Design: This study was a prospective analysis of relationships design using a survey to collect data about subjects' knowledge of CVD risk factors.

Methods: Subjects completed a 3 part survey that consisted of 11 questions using a 5 point Likert scale. The first part of the survey was for demographic information. The second part assessed the amount and type of previous education of risk factors that the subject had received. The third part focused on information regarding modifiable CVD risk factors. χ2 was calculated to examine differences in frequency of educational methods used, independent t-test used to note differences in survey total score between types of educational methods, and Pearson χ2 was used to determine differences in educational method used by gender.

Results: Overall, mean survey score for all subjects was 45.49/55 or 82.7% correct. The educational methods identified significantly more often, included cardiac rehab phase I (P = .003) and books/magazines (P < .001). The educational methods significantly used the least by this sample included family discussion, internet resources, radio, and community groups. No significant differences in survey total scores were noted between educational methods surveyed, gender, or ethnic groups. Gender differences were noted in three of the educational methods. Females were 2.0 times (P = .014) more likely to choose a television special program, 1.6 times (P = .042) more likely to choose family member experience, and 2.4 times (P = .045) more likely to choose medically-oriented websites as compared to males.

Conclusions: The overall knowledge of this study's subjects regarding CVD risk factors was good. While the educational methods used by participants did not affect survey total score, relevant differences were noted in educational methods chosen most and least often. Additionally, differences in choice of educational methods were noted between males and females. Participants involved in phase II cardiac rehab programs obtained risk factor education primarily in phase I and from books/magazines. This sample was least likely to use the internet or radio for information. Additionally, it appears gender needs to be considered when determining cardiac risk factor educational methodology.

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OUTCOMES OF CARDIAC REHABILITATION IN WOMEN AFTER MAJOR CARDIAC INTERVENTIONS

Vishal Mundra, MD,1 Gwen Moudry,2 Steven Henquinet, CM2

Institutions: 1. Internal Medicine, St John Medical Center, Tulsa, OK, United States. 2. Department of Cardiac and Pulmonary Rehabilitation, SJMC, Tulsa, OK, United States.

Introduction: Cardiac rehabilitation has been well proven to benefit patients after any cardiac interventions and with chronic heart failure. Most of the patient data base is centered on men and very little evidence exist for women in this regard. There are only a few studies and reviews about its benefit in women.

Purpose: We want to analyze benefits of cardiac rehabilitation amongst women and find any gender specific differences.

Design: Retrospective chart review.

Methods: We collected data from patients enrolled in phase II cardiac rehabilitation program from 2010 to 2012 in a tertiary care hospital. A total of 201 patients were enrolled but data was analyzed for 120 patients out of which 80 were males and 35 were females. Complete demographic data was not available for 5 patients. They were enrolled in the program for 8-12 weeks after major cardiac interventions. We did not have any patients enrolled due to heart failure. Average age of patients was 66.61 years. The data was analyzed using SAS software and t-tests by a professional statistician.

Results: Various modifiable risk factors were studied in the analysis. At baseline there was no significant difference between women and men in age, BMI, systolic and diastolic BP, exercise volume, triglycerides, glucose and METs achieved. However, women and men had significant difference in weight (kg) (172.0 vs 199.2, P < .001), waist circumference (inches) (36.4 vs 38.9, P < .04), cholesterol (178.9 vs 153.4, P < .001), LDL (102.8 vs 89.1, P < .03), and HDL (46.9 vs 36.5, P < .001) respectively. There was significant improvement in women in METs achieved (4.2 vs 2.5, P < .000), exercise volume (207.0 vs 67.6, P < .000), diastolic bp (72.0 vs 67.6, P < .0004), total cholesterol (178.8 vs 157.5, P < .03), glucose (150.5 vs 118.0, P < .03), LDL (102.9 vs 86.0, P < .04) and Beck's depression score (8.3 vs 4.8, P < .04). No significant improvement was seen in weight (169.4 vs 171.8, P = 0.8), HDL (46.8 vs 44.6, P = .5), waist circumference (36.4 vs 35.9, P = .75) and BMI (29.7 vs 29.1, P = .7). Men had similar improvement except in Beck's depression score (5.8 vs 7.2, P = .2). Upon correlation analysis using Pearson correlation test, total cholesterol (r = 0.27, P < .04), LDL (r = 0.20, P < 0.04), HDL (r = 0.28, P < .04) had a positive correlation with female gender where as weight had a negative correlation (r = −0.34, P < .0002).

Conclusions: Women derived significant improvement with cardiac rehabilitation in all the parameters with even more improvement in depression scoring. We may conclude that women benefit equally or possibly more with cardiac rehabilitation and should have higher rate of referral to these programs.

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PREDICTORS OF CR UTILIZATION FOLLOWING A CORONARY INTERVENTION

Michelle La Londe, MA,1 Lynn Shaffer, PhD,1 Jesse Hickerson, MBA,1 Gregory Lam, MD,1,2 Anne Albers, MD,1,5 Daniel Mudrick, MC,1,2 Richard J. Snow, DO, MPH,1,3 Teresa Caulin-Glaser, MD1,4

Institutions: 1. McConnell Heart Health Center, Columbus, OH, United States. 2. Duke University Medical Center, Durham, NC, United States. 3. Ohio University College of Osteopathic Medicine, Athens, OH, United States. 4. Women's Health Research, Yale University, New Haven, CT, United States. 5. OhioHealth, Columbus, OH, United States.

Introduction: Estimates for utilization of cardiac rehabilitation (CR) services following a coronary intervention range from 21% to 40%. Underutilization persists despite the overwhelming evidence of the effectiveness of CR.

Purpose: The purpose of this investigation was to determine local CR utilization rates following cardiac intervention and to determine predictors of CR participation.

Design: Retrospective Cohort Design

Methods: 1780 patients discharged between 4/6/2010 and 10/31/2011 from a large, urban hospital following PCI, CABG, valve surgery or a combined CABG/valve procedure and who resided in the zip code defined core service area were included in this analysis. This hospital has an automated process for eligible patients resulting in 100% referral to CR. Patients who expired or who were discharged to hospice, a long term care facility, or a psychiatric hospital were excluded.

These patients were matched to a CR data repository to determine CR participation either prior to or after their coronary intervention.

Multivariate logistic regression modeled CR participation after coronary intervention using candidate variables identified via χ2 analysis for frequency data and t test for continuous variables.

Results: Utilization of CR services following coronary intervention was 34.3%; however, utilization varied by type of cardiac intervention (P < .0001). The utilization rate for CABG patients was 56.7% compared to 45.9% for CABG/valve patients, 44.4% for valve patients and 28.3% for PCI patients.

Logistic regression revealed payor, coronary intervention type, tobacco use, diabetes, and sleep apnea as significant predictors of CR participation. Patients with a commercial payor were 2.4 to 4.8 times more likely to participate in CR when compared to those with a government payor or self pay. Surgical intervention patients were 1.9 to 3.5 times more likely to participate in CR when compared to PCI patients.

Patients with tobacco abuse or diabetes were significantly less likely to participate in CR (44% and 26% less likely, respectively). Patients with sleep apnea were 1.8 times more likely to participate in CR. Gender and past CR participation were not significant in this model (P = .20 and P = .06, respectively).

Conclusions: Opportunities exist for improving utilization of CR. Unfortunately, underutilization is high among diabetics and smokers who could benefit greatly from a CR program using a disease management model. Our data suggest financial barriers may affect patient ability to participate in CR. Strategies to increase CR utilization may need to be tailored based on the type of coronary intervention.

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UTILIZATION OF A 12:00 WALK TEST TO PREDICT PEAK VO2 IN PHASE II CARDIAC REHABILITATION PATIENTS

Jayme L. Rock-Willoughby, DO,1 Debra Boardley, PhD, RD/LD,1 Dalynn T. Badenhop, PhD1

Institution: 1. Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, OH, United States.

Introduction: The gold standard in assessing functional capacity is the direct measurement of peak VO2. Peak VO2 also predicts prognosis in patients with coronary artery disease. Most cardiac rehabilitation (CR) programs do not have the capability to perform Cardiopulmonary Exercise Testing (CPXT).

Purpose: This study analyzes the use of a 12:00 Walk Test (12MWT) to assess functional capacity/peak VO2 in ambulatory Phase II CR patients.

Design: For this retrospective study, medical record data was extracted on patients admitted into phase II CR from March 2003 through July 2012.

Methods: Patients were included if they participated in a pre-CR 12MWT and CPXT as well as a post-CR 12MWT and CPXT. A total of 240 patients met these criteria. Age, sex, admission diagnosis, CV disease risk factors, medications, body mass index (BMI), musculoskeletal limitations, peripheral arterial disease (PAD), and pulmonary diagnoses were evaluated.

Frequencies were determined for categorical variables. For continuous variables, mean and standard deviation were calculated. Pearson correlations were determined to explore relationships between continuous variables.

Categorical variables were recoded to dichotomous variables. Stepwise linear regression was used to determine the factors that best predict peak VO2 upon admission to Phase II CR. To build the model, all continuous and dichotomous variables were entered. Models were determined by stepwise regression with forward selection. Variables included age, gender, BMI, admitting diagnosis, musculoskeletal limitations, pulmonary diagnoses, PAD, medications, pre- and post-CR 12:00 Walk Distance (12MWD), and pre- and post-CR peak VO2 measured from a CPXT.

Results: The mean age was 61 ± 11 years. The average BMI was 30 ± 5 kg/m2. The mean pre-CR 12MWD is 3128 ± 635 feet. The mean pre-CR CPXT peak VO2 was 20.7 ± 5.4 mL·kg−1·min−1. The mean post-CR 12MWD was 3586 ± 631 feet, and the mean post-CR CPXT peak VO2 was 22.4 ± 5.9 mL·kg−1·min−1. Pre-CR peak V02 was predicted by 12MWD, BMI, age, sex, diabetes, and percutaneous coronary intervention (PCI) (R2 = 0.57, P < .001). 12MWD accounted for 23% of the variance, while BMI accounted for 12%, age 8%, gender 6%, diabetes 3% and PCI 3%. Post-CR peak VO2 was predicted by 12MWD, BMI, sex, age, total cardiovascular risk factors, height, and PCI (R2 = 0.63, P < 0.01). 12MWD accounted for 24% of the variance, while BMI accounted for 10%, gender 12%, age 11%, total cardiovascular risk factors 5%, height 5%, and PCI 4%.

Conclusions: 12MWD is an excellent predictor of pre- and post-CR peak VO2. A 12MWT is an inexpensive, easy to administer test that may act as a substitute to CPXT to assess functional capacity and prognosis in Phase II CR patients.

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TEXT-MESSAGING PROGRAM IMPROVES OUTCOMES IN OUTPATIENT CARDIOVASCULAR REHABILITATION

Patricia Lounsbury, RN, BSN, Med,1 Ellen Gordon, MD,1 William Clarke, PhD,2 Ahmed S. Elokda, PT, PhD1

Institutions: 1. CHAMPS, University of Iowa Health Care, Iowa City, IA, United States. 2. Biostatistics, University of Iowa, Iowa City, IA, United States.

Introduction: Long-term adherence to risk factor modification life-style changes during and after outpatient (OP) cardiovascular rehabilitation (CR) is a nationwide problem.

Purpose: We sought to examine the effect that a text-messaging program had on number of sessions completed in OP CR as well as other outcomes. It is well documented that patients who complete more OP CR sessions do better than those who complete fewer. We sought to determine if a text-messaging program would help patients complete more sessions.

Design: A retrospective analysis was conducted on all patients enrolled in outpatient OP CR beginning in June 2011 through December 2012, comparing those who enrolled and those who refused to enroll in the text messaging program on admission.

Methods: All patients who started OP CR were invited to enroll in the text-messaging program (n = 237). The program required that participants have a cell phone with texting capabilities. Text messages were sent 5-7 times per week and consisted of heart-healthy tips, requests for weight, minutes of exercise, blood pressure (BP) and medication adherence. Participant responses were graphed and staff was notified of abnormal BP measurements and/or when a participant had not responded for several days. Any of the staff members could send a message to the whole group or an individual participant. The 2 groups were compared using matched pairs, comparison of means, and frequencies for the following: gender, age, diagnoses, days post event, presence of diabetes mellitus (DM), smoking status, number of sessions completed, whether program was completed, risk stratification, complications during exercise sessions, whether patient was indigent or not, functional capacity, PHQ9 depression inventory, SF36, and BMI.

Subjects were compared using χ2statistics, t-tests, and the Wilcoxon Rank Sum test.

Results: Comparing the w groups revealed no significant difference in gender with 26.92% of the T and 29.19% of the NT female (χ2 = 0.1019, P = .7496).

Significantly more T were from the young age category (< 70 years) than the older (> = 70) (χ2, 1 DF, Value 8.6526, P = .0033).

The T group completed more sessions (mean 20.94) than NT (mean 16.21) (P < .0546).

In the T group, 61.5% of patients completed the program whereas only 50% of NT completed. Of those completing OP CR, the T group completed significantly more sessions (31.4) than the NT (25.3) (P = .01).

Conclusions: Patients who participate in a text messaging program in OP CR attend more sessions and are more likely to complete OP CR than patients who do not participate in texting.

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THE VALUE OF DETECTING ASYMPTOMATIC SIGNS OF MYOCARDIAL ISCHEMIA IN OUTPATIENT CARDIAC REHABILITATION (CR)

Patricia Lounsbury, RN, BSN, Med,1 Jennifer M. Bunning, BA,1 William Clarke, PhD,2 Ahmed S. Elokda, PT, PhD,1 Ellen Gordon, MD1

Institutions: 1. CHAMPS, University of Iowa Health Care, Iowa City, IA, United States. 2. Biostatistics, University of Iowa, Iowa City, IA, United States.

Introduction: Silent electrocardiographic (ECG) ST changes predict future coronary events in patients who have ischemic heart disease. However, the value of identifying significant, asymptomatic ST segment depression during outpatient CR exercise in patients with coronary artery disease (CAD) has not been elucidated.

Purpose: The purpose of this study is to determine if diagnostic-quality ECG monitoring outpatients with CAD in CR is efficacious. AACVPR recommends that ECG monitoring need not be carried out on all patients, every session in outpatient CR. The frequency with which silent ischemia occurs in this setting has not been elucidated nor has the incidence of revision in medical management (RMM) as a result of the finding been sufficiently described for this population.

Design: A retrospective analysis of all CR outpatients since 2000 (n = 1,615) was performed to determine if ECG monitoring patients with CAD was useful in identifying asymptomatic ischemia that resulted in RMM.

Methods: Included in the analysis were patients with CAD (n = 1,191) (eliminated were those without CAD (n = 191), patients with ventricular assist devises (n = 9), heart transplant (n = 38)). Of the CAD patients, those with ST segments unable to interpret were excluded: patients with left ventricular hypertrophy (n = 71); patients on digitalis (n = 31); with left bundle branch block (n = 43); and those with ventricular pacemakers (n = 56). (some overlapping of diagnoses occurred).

Results: Of the patients in the data set, 25% (n = 293) displayed at least 1mm of asymptomatic ST segment depression 80 msec after the j-point in CM5 (a bipolar substitute for V5) during at least one session of CR. Of these patients, more than twice as many, 57%, had revisions in medical management (RMM) than the 24% of patients who did not show ischemia who had RMM (P < .0001). Of those patients with asymptomatic ischemia having a RMM, 84% were a direct result of CR detection and intervention.

Only 74 patients complained of chest discomfort but did not display ECG signs of ischemia. Of those, 65% had a diagnosis of PCI, 7% CABG, 32% MI, and 24% stable angina. Of these patients, reporting chest discomfort, 41% had RMM of which 70% were a direct result of reporting by CR.

Conclusions: This study demonstrates that 25% of patients with CAD show asymptomatic ECG signs suggestive of ischemia, most of whom undergo a RMM as a result of the finding.

Given the recent focus in medical management of coronary artery disease (CAD) (COURAGE Trial), CR may play a larger role in the optimization medical management of CAD.

Recommendations for ECG monitoring during CR should include, rather than exclude, those low risk, asymptomatic patients with CAD and recommendations not to monitor unless patients have symptoms would, therefore, not be recommended.

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Poster#: S101EFFECTS OF A MAXIMAL GRADED EXERCISE TEST ON GLUTATHIONE (GSH) AS A MARKER OF ACUTE OXIDATIVE STRESS IN SUBJECTS WITH COPD

Ahmed Elokda, PT, PhD, CLT_LANA1

Institution: 1. Physical Therapy, Cairo University, Cairo, Egypt.

Current Track: Pulmonary

Introduction: Strenuous exercise in animal studies has been shown to cause acute oxidative stress due to the generation of oxygen-centered free radicals reflected in lower levels of glutathione (GSH) which is one of the body's most important antioxidants, higher levels of glutathione disulfide (GSSG), and a drop in GSH:GSSG ratios, the maintenance of which is crucial for a variety of cell functions. Human studies on this topic are limited, and in subjects with COPD are lacking.

Purpose: The purpose of this study was to verify the validity of using an incremental continuous ramp protocol as a model to induce acute oxidative stress in subjects with COPD.

Design: A 2 factor mixed model repeated measures ANOVA was used for data analysis.

Methods: Twenty subjects with mild stable COPD as per the Global Initiative for Obstructive Lung Disease (GOLD) guidelines (10 males, and 10 females; age = 62.1 ± 4 y, weight = 81.4 ± 7 kg, and height = 171.9 ± 12 cm, max Vo2 = 14.2 mL·kg−1·min−1) were used as a sample of convenience. Venous blood samples for GSH, and GSSG were collected directly before, and immediately after post-max GXT.

Results: Anaerobic threshold was attained in all the 20 patients. The dominant symptom at peak exercise was dyspnoea (n = 14), leg fatigue (n = 4), and significant oxygen desaturation (n = 2). As an acute response to maximal exercise, the GSH levels dropped significantly from a resting baseline value of 820 uM to an immediate post max GXT value of 632 uM. The GSSG levels significantly increased from 3.6 uM to 4.8 uM. The GSH:GSSG ratio levels significantly dropped from baseline 227.8 to 131.7 postexercise.

Conclusions: The current data indicated that in subjects with mild stable COPD an incremental continuous ramp protocol is a valid model for inducing acute oxidative stress. The potential for using this model in assessing oxidative stress responses to cardiac and pulmonary rehabilitation is of clinical interest with a need for further investigation.

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Poster#: S102INFECTION PREVENTION STRATEGIES IN CARDIAC REHABILITATION PROGRAMS

Wendy Bjerke, PhD, PAPHS,1 Suzanne Standish, MS, RD, RN,2 Anthony Pastore1

Institutions: 1. Exercise Science and Nutrition, Sacred Heart University, Fairfield, CT, United States. 2. Cardiac Rehabilitation, Bridgeport Hospital, Bridgeport, CT, United States.

Current Track: Prevention/Wellness

Introduction: Nosocomial infections result in 25 thousand deaths each year. Researchers argue that one third of these deaths are preventable via behaviors such as frequent hand washing in in-patient settings but little research is being conducted in outpatient settings such as cardiac rehabilitation. Cardiac rehabilitation centers are also potential sites for infections or exposure to infectious illnesses such as influenza, pneumonia, or upper respiratory tract infections and patients and staff could potentially benefit from similar prevention strategies.

Purpose: To examine the effectiveness of nosocomial infection prevention strategies in a cardiac rehabilitation setting given the frequency of patient visits and relative increased vulnerability of heart patients to infectious illnesses and diseases.

Design: Observations of the frequency of hand washing among cardiac rehabilitation patients pre and post four nosocomial infection prevention strategies including 1) Provision of nosocomial infection education and signs, 2) “Bioderm” demonstration, 3) Nosocomial infection prevention video, and 4) Provision of hand sanitizer samples. Washing hands prior to exercise frequency (washing in) was observed as well as washing hands prior to leaving the cardiac rehabilitation center (washing out).

Methods: Frequency of washing in and washing out among all patients were recorded at baseline and after each of the 4 interventions. Mean frequencies of washing in and washing out were compared among a mean of 32-39 cardiac rehabilitation patient visits over 12 weeks using descriptive statistics and t-tests to determine if changes were significant pre and post intervention strategies.

Results: At baseline, an average of less than one patient washed in or out during an outpatient cardiac rehab visit. Post intervention 1, 2, 3, and 4, the mean frequency of washing in and out was 10 (P = .037) and 10 (NS), 12 (NS) and 10 (NS), 11 (P = .01) and 10 (P = .05), and 9 (P = .00) and 8 (P = .03), respectively.

Conclusions: Significant changes in frequency of washing in and out were observed including a potential cumulative effect of the interventions. Researchers examining nosocomial infection prevention have primarily focused on in patient settings. Outpatient settings are also potential sites for increased risk of infections given the fact that many outpatient personnel work also in inpatient settings. Additional relevant considerations include infections that can be introduced to the outpatient setting by visiting cardiac rehabilitation patients and the fact that many cardiac rehabilitation patients have multiple comorbidities and compromised immune system function after their acute cardiac events.

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Poster#: S103SPECIFICITY OF THE SIT-AND-REACH TEST IN THE DETERMINATION OF HAMSTRING FLEXIBILITY

Donald Shaw, PT, PhD, D.Min,1 Alyssa Bosak, BS,1 Joseph Faia, BS,1 Courtney Moore, BS,1 Matthew Spilsbury, BS1

Institutions: 1. Physical Therapy Program, Midwestern University, Glendale, AZ, United States.

Current Track: Prevention/Wellness

Introduction: The Sit-and-Reach Test (SRT) is often used as a measure of hamstring flexibility. However, a variety of musculoskeletal variables may contribute to the actual SRT score.

Purpose: The purpose of this study was to determine if a hamstring-specific muscle length test is comparable to the SRT in the determination of hamstring flexibility.

Design: This was a quasi-experimental correlational study.

Methods: Forty-three Midwestern University physical therapy students (23 males, 20 females) with a mean age of 25.8 ± 2.3 years participated in the study. Following acquisition of informed consent, subjects performed a 5 repetition toe touch warm-up. Hamstring length was then determined using the 90-90 method measuring degrees from full knee extension; lumbar flexion ROM was determined using a double inclinometer. Subjects performed 3 SRT trials seated against a wall to block the pelvis (reducing excessive posterior rotation) and with arms fully extended. Measurements in cm were obtained from the tip of a subject's middle finger at both the beginning of and end of motion. A second hamstring length and lumbar ROM measurement was taken following the last SRT.

Results: Hamstring length, lumbar flexion ROM, and SRT scores were compared using Pearson product-moment correlations. A moderate inverse relationship was found between posttest hamstring length and raw SRT scores (r = −.67) as well as between post-test hamstring length and SRT scores adjusted for hand starting position (r = −0.59). A weak positive correlation was found between lumbar flexion ROM and adjusted (r = 0.18) and raw (r = 0.05) SRT scores. Paired t-tests were run between pre- and post- SRT hamstring length measures as well as lumbar flexion ROM. Changes in both mean hamstring length (–1.56 degrees) and lumbar flexion ROM (1.98 degrees) were significant (α = .05).

Conclusions: Results indicate hamstring length has a greater relationship to SRT scores than lumbar flexion ROM, however, both clearly contribute to SRT performance. Also, raw SRT scores (ie, those not adjusted for individual starting points) revealed even stronger relationships to hamstring length. Blocking excessive pelvic posterior rotation limited some subjects scores Although anecdotal only, upper extremity length and scapulothoracic/cervicothoracic, and SIJ mobility appear related to SRT performance. Last, the SRT correlates positively with hamstring length and can be used as a relative measure of hamstring flexibility. However, one should be aware that the SRT is more than a measurement of hamstring flexibility; other musculoskeletal factors clearly intervene to inflate scores when hamstrings are tight.

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Poster#: S104TEST-RETEST RELIABILITY AND CORRELATION BETWEEN CARDIOPULMONARY FITNESS AND FUNCTIONAL ABILITIES IN STROKE PATIENTS

Sungju Jee, MD1

Institution: 1. Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, Korea, Republic of.

Current Track: Prevention/Wellness

Introduction: Many studies reported that maximal exercise test have high test-retest reliability for cardiovascular disease patients. However, it is still unclear whether the reliability of maximal exercise test for stroke patients is high.

Purpose: To assess the reliability and relationship between maximal treadmill test and functional abilities in hemiplegic stroke patients.

Design: Reliability Evaluation Study

Methods: The comfortable treadmill speed was determined in a practice session for 3 minutes. Maximal exercise test was performed with their comfortable treadmill speed and increased the 2% grade every 2 minutes. Retest was done after 2-3 days by using the same methods. Test-retest reliability was calculated by comparing tests done twice and the correlation between the results of K-MBI, BBS, TUG, 10m walking test and peak VO2 was also evaluated by measuring intraclass correlation coefficient and spearman correlation.

Results: All 15 patients completed the maximal exercise test and the test was stopped by their ask. In realibility measurement, very high test-retest reliability was found in VO2 (ICC = 0.95) and high in respiratory exchange ratio (RER) (ICC = 0.83). Peak heart rate and systolic blood pressure showed more lower test-retest reliability (ICC = 0.643, 0.606). There were no significant correlations between peak VO2 and results of K-MBI, BBS, TUG, 10m walking test with Spearman correlation.

Conclusions: The test-retest reliability of peak VO2 and RER were high in maximal exercise test performed for stroke patients. These results suggest that maximal exercise test could be the useful screening test for assess the cardiovascular fitness in stroke patients.

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Poster#: S105HEART WELLNESS PROGRAMME—A COMMUNITY BASED CARDIAC REHABILITATION AND PRIMARY PREVENTION PROGRAMME TO REDUCE CARDIOVASCULAR DISEASE IN A MULTIETHIC SOCIETY

Yu Heng Kwan, BSc (Pharm) (Hons),1 Kheng Yong Ong, BSc (Pharm) (Hons),1 Hung Yong Tay, BHSc (Physiotherapy),2 Joanne Y. Chang, PharmD, BCPS1

Institutions: 1. Department of Pharmacy, National University of Singapore, Singapore, Singapore. 2. Health Wellness Centre, Singapore Heart Foundation, Singapore, Singapore.

Current Track: Prevention/Wellness

Introduction: Community-based exercise programmes have been shown to be effective in the Western world. However, there is a dearth of literature on its effectiveness in Asia.

Purpose: In this study, we aim to find out the effectiveness of the Health Wellness Programme (HWP) in Singapore. The Singapore HWP provides community cardiac rehabilitation (CR) and primary prevention (PP) services.

Design: A retrospective cross-sectional study.

Methods: Subjects who had completed a 1-year wellness programme from 2010 to 2011 were included and those with incomplete 1-year data were excluded. Socio-demographic, anthropometric, clinical and laboratory data were recorded. Changes between the baseline and final measurements were analyzed using paired t-test. Differences between changes of CR and PP subjects were explored using student's t-test.

Results: A total of 207 patients with complete data were analyzed. Improvements were seen in diastolic blood pressure (DBP) (Δ: −1.6 mmHg, P < .01), body fat percentage (Δ: −0.8%, P < .01), distance walked (Δ: 10.7 m, P < .01), total cholesterol (TC) (Δ: −0.2 mmol/L, P < .01) and low-density lipoprotein (LDL) (Δ: −0.3 mmol/L, P < .01). CR subjects saw improvements in body fat percentage (Δ: −1.4%, P < .01), distance walked (Δ: 9.7 m, P < .01), TC (Δ: −0.2 mmol/L, P = .03), LDL (Δ: −0.2 mmol/L, p = 0.03) and triglyceride (Δ: −0.2 mmol/L, P < .01). PP patients experienced improvements in DBP (Δ: −2.8 mmHg, P < .01), distance walked (Δ: 11.4 m, P < .01) and LDL (Δ: −0.5 mmol/L, P < .01).

Conclusions: The low to moderate intensity HWP seems to be effective in the multi-ethnic community setting. More research is needed to confirm its effectiveness and examine its cost-effectiveness in a prospective controlled trial.

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Poster#: S106APOLIPOPROTEIN PROFILES IN SUBJECTS WITH AND WITHOUT PERIPHERAL ARTERY DISEASE

Polly Montgomery, MS,1 Petar Alaupovic, PhD,1 Donald E. Parker, PhD,1 Ashley Roof, BSN,1 Ana Casanegra, MD,1 Andrew Gardner, PhD1

Institution: 1. University of Oklahoma, Oklahoma City, OK, United States.

Current Track: Cardiac

Introduction: Peripheral artery disease (PAD) is prevalent in more than 12% of the US population 65 years of age and older, and is associated with elevated rates of mortality and morbidity. The plasma apolipoprotein profiles of PAD subjects has not been previously compared to control subjects.

Purpose: We compared plasma apolipoprotein profiles in 39 subjects with PAD and intermittent claudication and in 70 control subjects. Furthermore, we compared the plasma apolipoprotein profiles of subjects with PAD either treated (n = 21) or untreated (n = 18) with statin medications.

Design: The design of the study is cross-sectional.

Methods: Subjects were assessed on plasma apolipoproteins, medical history, physical examination, ankle/brachial index, and exercise performance using a treadmill test. The means of measurement variables were compared between the 2 groups using independent t-tests. Pearson correlation coefficients were computed as the measure of associations of clinical characteristics and apolipoprotein measures in subjects with peripheral artery disease. Two-tailed statistical significance was defined as P < .05.

Results: The PAD group had higher apoB (P = .003), triglycerides (P < .001), and glucose (P < .001), and lower HDL-cholesterol (P = .010) than the controls. Forty percent of the PAD group had an abnormal value of apoB (>95 mg/dL) compared to only 13% of the control group (P < .001). The PAD group taking statins had lower values for apoB (P = .014), total cholesterol (P = .036), LDL-cholesterol (P = .022), LDL-cholesterol/HDL-cholesterol ratio (P = .050), and non-HDL-cholesterol (P = .013) than the untreated PAD group.

Conclusions: Subjects with PAD have higher levels of apoB than controls, and subjects on statin medications have a more favorable risk profile, characterized by lower apoB, total cholesterol, LDL-C, and non-HDL-C concentrations. Statin therapy may be efficacious for improving apolipoprotein profiles in subjects with PAD and intermittent claudication.

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Poster#: S107COMPARISON OF OUTCOMES RELATED TO DIETARY FAT INTAKE AND EXERCISE COMPLIANCE IN PHASE II CARDIAC REHABILITATION

Teresa M. Corbisiero, RN-BC, MBA,1 Nathan J. Boehlke, MS,1 Cynthia A. Oster, PhD, MBA, APRN, CNS-BC, ANP,2 Mary S. Meyers, MS, EMT-P3

Institutions: 1. Cardiac Rehabilitation, Porter Adventist Hospital/Centura Health, Denver, CO, United States. 2. Professional Development and Critical Care Services, Porter Adventist Hospital/Centura Health, Denver, CO, United States. 3. QA/QI Research EMS, Porter/Littleton/Parker Adventist Hospitals, Denver, CO, United States.

Current Track: Cardiac

Introduction: Cardiovascular disease (CVD) is a leading cause of death. Healthy lifestyle changes reduce morbidity and mortality. Cardiovascular rehabilitation (CR) professionals assist patients in acquiring motivation to change behaviors. Motivational interviewing and coaching can increase adherence to healthy behaviors.

Purpose: The study aimed to compare pre/post Dietary Fat Screener (DFS) scores and exercise compliance among Phase II CR patients.

Design: A retrospective comparative design compared 307 Phase II CR program participants completing ≥ 12 sessions between January 2008 and October 2012 at a hospital-based CR program.

Methods: The DFS (target ≤ 7), previous month eating habits before cardiac event survey, was administered during initial CR session and two CR sessions before program discharge. DFS scores were compared among participants exercising and not exercising to American College of Sports Medicine guidelines (Ex2G). Medical record review collected DFS scores, Ex2G, gender, and age. The t-test determined statistical significance. Binary logistic regression used age and gender to predict Ex2G.

Results: 224 males (mean = 64.9 years) and 83 females (mean = 66.8 years) participated. 213 were Ex2G at discharge and 68 were not. Mean pre and post DFS scores significantly decreased for Ex2G (pre = 16.5, post = 9.5; t = 13.4, P < 0.001) and not Ex2G (pre = 17.8, post = 13.4; t = −5.3, P < .001) groups. Mean post DFS scores were significantly lower (t test = 4.25, P < .001) with significantly larger mean score change among those Ex2G.

Females Ex2G significantly decreased mean pre and post DFS scores (pre = 13.8, post = 9.7; t = −6.7, p < 0.00). Mean post scores were significantly lower (t = 2.8, P = .002) for Ex2G (post = 9.7) versus not Ex2G (post = 13.5) Males significantly decreased mean DFS scores whether Ex2G (pre = 17.3, post = 9.5; t = 12.32, P < .001) or not Ex2G (pre = 19.0, post = 13.3; t = −5.63, P < .001). Mean post scores were significantly lower (t = 3.4, P = .001) for Ex2G (post = 9.5) versus not Ex2G (post = 13.3).

Odds of Ex2G decreased 4% with every 1 year age increase (P = .001).

Conclusions: All patients significantly decreased DFS scores with participants Ex2G achieving lower scores. Age is a superior predictor of Ex2G than gender. Adherence to healthy behaviors is low during and after CR despite known benefits. Understanding factors influencing exercise and dietary compliance is crucial to developing effective interventions. Addressing ambivalence about lifestyle changes is a major focus when coaching and motivating CR patients to Ex2G.

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Poster#: S108CARDIAC REHABILITATION DECREASES URINARY 8-EPI-PROSTAGLANDIN-F2 IN SUBJECTS WITH HEART FAILURE (HF)

Ahmed S. Elokda, PT, PhD, CLT_LANA1, 2

Institutions: 1. Physical Therapy, Cairo University, Cairo, Egypt. 2. Physical Therapy, New York Institute of Technology (NYIT), Old Westbury, NY, United States.

Current Track: Cardiac

Introduction: An increasing body of evidence suggests that oxidative stress mediated by reactive oxygen species has a role in the pathogenesis of cardiovascular diseases, including atherosclerosis, ischaemia/reperfusion injury, hypertension, and heart failure (HF). Isoprostanes are prostaglandin-like compounds that are produced by peroxidation of lipoproteins. 8-epi-prostaglandin-F2 has been shown to play a potent role in atherosclerosis and HF. 8-epi-prostaglandin-F2 was shown to be a specific, chemically stable, quantitative marker of oxidative stress in vivo. Increased urinary excretion or plasma concentrations of 8-epi-prostaglandin-F2 have been observed in subjects with HF. Whether exercise training could decrease 8-epi-rostaglandin-F2 in subjects with stable HF is a question of clinical interest.

Purpose: The purpose of this study was to investigate the effects of 12 weeks of cardiac rehabilitation in the form of combined aerobic exercise training (AT) and resistance training (RT) on a novel marker of oxidative stress, urinary 8-epi-prostaglandin-F2 in subjects with HF.

Design: A mixed model repeated measures ANOVA design was used with Bonferonni adjusted t tests for pre-planned comparisons.

Methods: A convenience sample of 12 subjects with HF were randomly assigned to 2 groups: control group (no exercise) and exercise training group (AT+RT). Intervention included AT 3 times per week at 40-70% HRR (15 min. warm up, 30 min. exercise, 15 min. cool down), and RT 2 times per week (acclimation method with 8-10 exercises involving upper and lower body). Urinary sampling was taken at rest pre and post 12 weeks for the control and AT+RT. The BIOXYTECH® Urinary 8-epi-rostaglandin-F2 Assay, a competitive enzyme-linked immunoassay (ELISA), had been used for determining levels of 8-epi-rostaglandin-F2 in urine samples.

Results: Efficacy of the cardiac rehabilitation program was demonstrated by significant between group (exercise group versus control) comparisons. AT+RT showed significant decreases in pre-post-12 weeks of exercise training for urinary 8-epi-prostaglandin-F2 in subjects with HF.

Conclusions: The current preliminary study represents the first longitudinal investigation involving the effects of Cardiac Rehabilitation on urinary 8-epi-prostaglandin-F2 in subjects with HF. The significant findings of this study might have positive potential clinical implications to individuals involved in cardiac and pulmonary rehabilitation.

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Poster#: S109PHYSICAL FITNESS MODERATES THE RELATIONSHIP BETWEEN DEPRESSIVE SYMPTOMS AND STIMULATED IL-6 IN PATIENTS ENROLLED IN CARDIAC REHABILITATION

Joel Hughes, PhD,1, 2 Tracy Hammonds, MA,1 Tejasvi Pasupneti, MPH,6 Elizabeth Casey, PhD,4 Therese Keary, PhD,5 Thomas Alexander, PhD,3 Donna Waechter, PhD,2 James Rosneck, PhD2

Institutions: 1. Psychology, Kent State University, Kent, OH, United States. 2. Center for Cardiopulmonary Research, Summa Health System, AKron, OH, United States. 3. Molecular Pathology Research Laboratory, Summa Health System, Akron, OH, United States. 4. Department of Social Sciences, Onondaga Community College, Syracuse, NY, United States. 5. Department of Psychology, John Carroll University, University Heights, OH, United States. 6. Northeastern Ohio Medical University, Rootstown, OH, United States.

Current Track: Cardiac

Introduction: Depression is implicated in cardiovascular disease morbidity and mortality, and has also been associated with altered inflammatory processes. Fitness may modify the relationship between depression and pro-inflammatory cytokines, by either attenuating inflammatory responses or by reducing inflammation-induced depression symptoms.

Purpose: We examined the relationship between depression and stimulated IL-6. It was hypothesized that greater physical fitness would be associated with a weaker relationship between depressive symptomology and pro-inflammatory immune reactivity.

Design: This was a cross-sectional cohort study consisting of individuals at entry to phase-II cardiac rehab (CR).

Methods: During the first week of CR, 96 participants completed venous blood draws, exercise stress testing, and the Beck Depression Inventory (BDI). METS was estimated from stress testing. IL-6 levels were measured using a multiplex bead array (Luminex, Austin, TX) and Bio-Rad reagents (Hercules, CA) after in-vitro lipopolysaccharide (LPS) challenge.

Results: Regression results found no main effects for BDI (B = .01, P = .97) or METS (B = .11, P = .59) in predicting stimulated IL-6. However, BDI interacted with METS to predict stimulated IL-6 (B = −.40, P = .05). Specifically, depression was not related to stimulated IL-6 in patients with high levels of physical fitness (METs > 8). Among those with poorer physical fitness (METs ≤ 8), patients with less depression (BDI < 10) had lower IL-6 (M = 9.89, SD = 1.96) than those with greater depression (BDI ≥ 10) (M = 11.00, SD = .73), t(45) = −2.031, P < .05.

Conclusions: Physical fitness was shown to moderate the relationship between depressive symptomology and stimulated IL-6. The direction of this relationship is not known; fitness may protect against depression induced pro-inflammatory responses, or alternatively inflammation-induced depression symptoms. Given the focus of CR on improving physical fitness, the ability of CR to favorably alter the relationship between depression and pro-inflammatory cytokines should be explored.

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Poster#: S110CARDIAC REHABILITATION LEADS TO IMPROVEMENTS IN FUNCTIONAL ABILITIES

Brenda Youngs, RN,2 Michael Puthoff, PT, PhD1

Institutions: 1. Physical Therapy Department, St. Ambrose University, Davenport, IA, United States. 2. Cardiac Rehabilitation, Genesis Health Systems, Davenport, IA, United States.

Current Track: Cardiac

Introduction: While evidence exists that cardiac rehabilitation (CR) leads to improvements in endurance, strength and mortality, there is limited evidence if CR increases functional abilities in participants.

Purpose: To examine if completing a CR program leads to improvements in functional abilities, demonstrated through changes in gait speed and five times sit to stand (5 STS) test.

Design: This study utilized a 1-group pretest-posttest design.

Methods: Gait speed and 5 STS were assessed at the start and end of CR and paired t-tests were used to detect changes.

Results: Data on 72 participants who completed 20 or more sessions were included in analysis. There was no overall significant improvement in gait speed (P = 0.083) while participants demonstrated a significant improvement in 5 STS (P < .001). When examining the 27 individuals who began cardiac rehabilitation with a gait speed less than 1.0 m/s, these individuals demonstrated a significant improvement in their gait speed (P = .001). For the 21 participants with a 5 STS performance greater than 15 seconds, there was a significant change in their performance (P < .001).

Conclusions: Results of this study indicate that CR leads to improvements in functional abilities, especially when patients enter rehabilitation with activity limitations. Future studies should determine whether further gains can be achieved through different dosages of exercises.

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Poster#: S111THE PREVALENCE OF ACTIVITY LIMITATIONS IN PATIENTS ENTERING CARDIAC REHABILITATION

Michael Puthoff, PT, PhD,1 Brenda Youngs, RN2

Institutions: 1. Physical Therapy Department, St. Ambrose University, Davenport, IA, United States. 2. Cardiac Rehabilitation, Genesis Health Systems, Davenport, IA, United States.

Current Track: Cardiac

Introduction: Patients entering a phase II cardiac rehabilitation program are typically over the age of 60, present with extensive past medical histories and are recovering from a recent medical event. All these factors may increase their risk for activity limitations. However the prevalence of activity limitations in individuals enrolling in cardiac rehabilitation has not been thoroughly examined.

Purpose: To examine the prevalence of individuals entering cardiac rehabilitation with low performance in gait speed and the five times sit to stand (5 STS) test.

Design: This study utilized a descriptive design format.

Methods: Individuals entering a phase II cardiac rehabilitation were recruited to participate in the study. Gait speed over four meters and the time needed to complete 5 STS without the use of arms were measured. Means and standard deviations on demographic data, gait speed and 5 STS were calculated. Correlation analysis was also conducted.

Results: Data was collected on 107 participants with an average age of 64.5 (10.7) years, 80 men and 27 women. Average gait speed was 1.02 (0.27) m/s and the average time to complete 5 STS was 13.7 (4.6) seconds. Of the 107 participants, 41 (38.3%) demonstrated a gait speed less than 1.0 m/s and 30 (28%) required greater than 15 seconds or could not stand from a chair five times indicating an activity limitation and a risk for falls. Age was significantly correlated to gait speed (r = −0.254), but not 5 STS time (r = 0.184).

Conclusions: A portion of patients entering cardiac rehabilitation present with activity limitations. These activity limitations could affect patient recovery and indicate risk for future adverse events. Efforts should be taken to identify these patients and provide interventions to help improve their functional abilities.

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Poster#: S112HEALTH LITERACY IS ASSOCIATED WITH KNOWLEDGE OF HEART FAILURE SELF-MANAGEMENT

Kate A. Guerini, Med,2 Michael Fulcher, BA,2 Emily Gathright, MA,1 Joel Hughes, PhD,1, 2 Ellen Grady, BS, MNO,4 Rachel Grdina, BS,4 Anton Vehovic, BSN,4 Joseph Redle, MD,2 Richard A. Josephson, MD,3 John Gunstad, PhD,4 Mary A. Dolansky, PhD4

Institutions: 1. Psychology, Kent State University, Kent, OH, United States. 2. Center for Cardiopulmonary Research, Summa Health System, Akron, OH, United States. 3. Harrington Heart & Vascular Institute, University Hospitals Health System, Cleveland, OH, United States. 4. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States.

Current Track: Cardiac

Introduction: Health literacy is important to consider for patient education. We recently reported that health literacy predicted knowledge of cardiac disease as well as gains in knowledge in outpatient cardiac rehabilitation (CR). Furthermore, high quality programming appeared to largely overcome deficits in health literacy, as patients achieved high levels of knowledge. For patients with heart failure (HF), health literacy may be associated with knowledge of disease self-management.

Purpose: Health literacy and knowledge of self-management were examined in patients with HF. Greater health literacy was expected to predict HF self-management knowledge.

Design: This is an observational, cross-sectional study.

Methods: Participants were 298 predominantly Caucasian (73.5%) English-speaking HF patients (63.4% male) aged 50-85 years (M = 68.7, SD = 9.5). Most participants (77%) had completed some college. A composite health literacy score was created from the Medical Term Recognition Test (METER) and the Rapid Estimate of Adult Literacy in Medicine (REALM). Measures of HF self-management were the Dutch Heart Failure Knowledge Scale (Dutch) and a Heart Failure Knowledge Questionnaire (HFKQ) created for this study. The HFKQ is a 5-item free-response interview covering 5 essential concepts in heart failure self-management (e.g., how often should you weigh yourself?). Hierarchical linear regression was used for analyses.

Results: According to the METER, health literacy levels were functional for 76%, marginal for 19%, and low for 4% of the sample. Knowledge of HF self-management averaged less than 60% correct on the HFKQ. Controlling for education and minority status, health literacy positively predicted HF knowledge scores on the Dutch, beta = .27, t(297) = 4.51, P < .001, and the HFKQ, beta = .16, t(297) = 2.49, P < .05. Health literacy explained unique variance in Dutch scores, ΔR = 6, F(3,294) = 11.17, P < .001, and in HFK scores, ΔR = 4, F(3, 294) = 3.66, P < .05.

Conclusions: Adequate knowledge of self-management is critical for successful treatment of HF. Health literacy may influence knowledge levels, which could help to explain why health literacy was recently reported to predict mortality in HF. Future research should examine whether high quality education can overcome deficits in health literacy and achieve uniformly high levels of knowledge of key HF self-management concepts. Many patients in CR have HF, and CR may be an appropriate venue for HF self-management education.

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Poster#: S113OUTCOMES OF CARDIAC REHABILITATION ON VARIOUS MODIFIABLE RISK FACTORS

Vishal Mundra, MD,1 Gwen Moudry,2 Steven Henquinet, CM2

Institutions: 1. Internal Medicine, St John Medical Center, Tulsa, OK, United States. 2. Department of Internal Medicine, St. John Medical Center, Tulsa, OK, United States.

Current Track: Cardiac

Introduction: The term ‘cardiac rehabilitation' refers to coordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. Cardiac rehabilitation include baseline patient assessments, nutritional counseling, aggressive risk factor management, psychosocial and vocational counseling, and physical activity counseling and exercise training, in addition to the appropriate use of cardio-protective drugs that have evidence-based efficacy for secondary prevention.

Purpose: Here we report data from a single center about outcomes on various modifiable risk factors. We intend to use this data to obatin more referrals to our rehabilitation program.

Design: This was a retrospective chart review of all the patients enrolled in cardiac rehabilitation program in a tertiary care hospital between 2010 to 2012 after various cardiac interventions (PCI, CABG and valve surgery).

Methods: These patients were enrolled in phase II rehabilitation program from 8-12 weeks. A total of 201 patients were enrolled but only 120 patients were studied out of which 80 were males and 35 were females. Demographics were not available rest of the patients. Average age of patients was 66.61 years. The data was analyzed using SAS software and t-tests by a professional statistician.

Results: We compared various modifiable risk factors at the time of enrollment and after successful completion of rehab program. We found successful intervention in terms of following modifiable risk factors – BMI (P < .001), total cholesterol (P < .001), LDL (P < .001), diastolic BP (P < .001), METs (P < .001), Beck's depression scoring (P < .004), systolic BP (P < .04), glucose (P < .002), waist circumference (P < .002), weight change (P < .002) and triglyceride levels (P < .0006). However, no significant improvement was seen in tobacco cessation (P < .29) and HDL (P < .54). We further analyzed their correlation with age and found that Beck's depression scoring (r = 0.25, P < .007) increases with age where as exercise volume (r = −0.19, P < .05) and METs (r = −0.52, P < .001) decrease with age. In addition, patients with COPD (P < .03), CKD (P < .02) and baseline depression (P < .0002) tend to have higher depression score.

Conclusions: Our outcomes support extensive benefits provided by a dedicated cardiac rehab program in patients with cardiac interventions or events. In spite of these outcomes and well proven benefits unfortunately, cardiac rehabilitation programs remain underused in the US, with an estimated participation rate of only 10% to 20% of the >2 million eligible patients per year. We intend to use these results to obtain more referrals especially from heart failure patients in our area. In addition special attention should be paid to some subgroups that have higher depression score as it is an independent predictor of long term outcomes including mortality.

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Poster#: S114BENEFITS OF CARDIAC REHABILITATION IN PATIENTS WITH DIABETES MELLITUS

Vishal Mundra, MD,1 Gwen Moudry,2 Steven Henquinet, CM2

Institutions: 1. Internal Medicine, St John Medical Center, Tulsa, OK, United States. 2. Department of Cardiac and Pulmonary Rehabilitation, SJMC, Tulsa, OK, United States.

Current Track: Cardiac

Introduction: Diabetes mellitus (DM) is a major risk factor for coronary artery disease. DM was the seventh leading cause of death in 2006. The number of patients is expected to double by 2050.

Purpose: Since many patients have coexisting cardiovascular disease and DM, we wanted to study the benefit of cardiac rehabilitation in this subset and check if they needed any specific interventions.

Design: Retrospective chart review

Methods: Patients enrolled in phase II cardiac rehabilitation program in a major tertiary care hospital were included from 2010 to 2012. Total of 120 patients were studies out of which 85 were men and 30 were women. Data was not available for 5 patients. There were 40 patients with diabetes. Average age of patients was 66.61 years. The data was analyzed using SAS software and t-tests.

Results: As expected, significant benefits were seen in all parameters in the entire group between initiation and completion of the program which included BMI, Beck's depression score, waist circumference, lipid panel, blood pressure, and METs. Upon further analysis of patients with DM, we found patients had significant improvement in METs (4.0 vs 2.4, P < .000), exercise volume (200.1 vs 47.7, P < .00) and diastolic bp (65.9 vs 71.5, P < .001) similar to nondiabetics. On the contrary, patients with DM did not derive significant benefit in terms of LDL (85.4 vs 80.7, P = .56), total cholesterol (157.1 vs 152.7, P = .65), and Beck's depression score (5.8 vs 7.7, P = .33) as compared to nondiabetics. No significant improvement was seen in weight, HDL, waist circumference, BMI, systolic BP, glucose levels and tobacco smoking in both groups separately. On Pearson's correlation analysis, we found initial triglycerides (r = 0.22, P < 0.01), weight (r = 0.2, P = .02), BMI (r = 0.23, P = .01) and waist circumference (r = 0.24, P < .01) were positively correlated with DM whereas LDL (r = 0.19, P = .04) had a negative correlation. At the completion of program, exercise volume (r = −0.21, P < .03) and diastolic blood pressure (r = −0.18, P < .04) had negative correlation where as weight (r = 0.2, P = .02) had a positive correlation with DM. Linear regression analysis using ANOVA test showed that upon initial presentation, 59% of variation in triglyceride levels (P < .05) and 40% variation in waist circumference (P < .02) can be explained on the basis of diabetes. About 36% of variation in waist circumference (P < .04) can be explained on the basis of diabetes at the time of completion of the program. Total cholesterol was significantly higher in patients with DM (P < .02).

Conclusions: Patient with diabetes greatly benefit from cardiac rehabilitation program. These patients tend to adverse risk profile including weight, BMI, waist circumference and lipid panel. We should identify diabetic patients in the program and provide them with a more focused attention, intensive rehabilitation and additional measures as they derived less benefit in terms of cholesterol and Beck's depression scoring with standard protocol.

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Poster#: S115OUTCOMES OF CARDIAC REHABILITATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Vishal Mundra, MD,1 Gwen Moudry,2 Steven Henquinet, CM2

Institutions: 1. Internal Medicine, St John Medical Center, Tulsa, OK, United States. 2. Department of Cardiac and Pulmonary Rehabilitation, SJMC, Tulsa, OK, United States.

Current Track: Cardiac

Introduction: Cardiac rehabilitation has been well proven to be beneficial in patients after major cardiac events or interventions. On the other hand, chronic kidney disease (CKD) has been also a well-known risk factor for coronary artery disease. The benefits of cardiac rehabilitation have not been well studied in this subgroup of patients.

Purpose: We want to analyze if the patients with CKD derive equal benefit as the others. Also, we want to study if they need some specific interventions to improve their outcome.

Design: Retrospective chart review

Methods: We collected data for all the patients enrolled in phase II cardiac rehabilitation program in a tertiary care hospital from 2010 to 2012. A total of 201 patients were enrolled but data was analyzed for 120 patients out of which 80 were males and 35 were females. Complete demographic data was not available for rest of the patients. 21 patients had documented CKD stage III-V. Out of these 12 were men and 9 were women. The data were analyzed using SAS software and t-tests.

Results: Significant improvement were seen in almost all the parameters namely weight, BMI, Beck depression score, systolic and diastolic BP, waist circumference total cholesterol, LDL, and METs achieved at the completion of program as a whole. On further analysis, CKD patients derived significant benefit only in waist circumference (36.1 vs 37.1, P = .02), diastolic bp (66.1 vs 70.95, P = .02), METs (3.0 vs 2.1, P < .000) and exercise volume (202 vs 10.5, P < .000). There were nonsignificant improvements in the rest of the parameters. Using Pearson' correlation coefficient, at the end of program, CKD had positive correlation with Beck's depression score (r = 0.21, P < .02), triglycerides (r = 0.31, P < .002) and systolic bp (r = 0.19, P < .04). Presence of CKD was associated with lower METs, both at baseline (r = −0.30, P < 0.1) and at the end of the program (r = −0.32, P < .0006). On linear regression analysis, 1.6% of variation in smoking could be explained on the basis of CKD (P = .04).

Conclusions: CKD was associated with lower METs achieved at both points in time. These patients also had adverse systolic BP and triglycerides with higher Beck's depressions score. We could not demonstrate statistical significance in many of the parameters probably due to small sample size. Another, contributing factor may be that they need more concerted approach to derive same benefits. We need a larger study in this high risk group to answer these questions.

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Poster#: S116EFFECTIVENESS OF EARLY EXERCISE-BASED CARDIAC REHABILITATION ON LEFT VENTRICULAR EJECTION FRACTION IN POST-CABG PATIENTS: A RANDOMIZED CONTROLLED TRIAL

Mohammad H. Haddadzadeh, PhD,1,3 Arun G. Maiya, PhD,2 Bijan Shad, MD,3 Fardin Mirbolouk, MD,3 R. Padmakumar, DM,2 Shirish S. Borkar, DM,2 Tom Devasia,2 Vivek G. Raman, DM,2 N. Sreekumaran Nair, PhD,4 Vasudev Guddattu, MSc4

Institutions: 1. Physical Therapy, Wheeling Jesuit University, Wheeling, WV, United States. 2. Physiotherapy, Manipal University, Manipal, Karnataka, India. 3. Cardiovascular Interventions, Golsar Hospital, Rasht, Guilan, Iran, Islamic Republic of. 4. Statistics, Manipal University, Manipal, Karnataka, India.

Current Track: Cardiac

Introduction: Despite 30 years of conception of exercise training as an integral part of cardiac rehabilitation programs, there is paucity of studies on its effectiveness on clinical outcomes like left ventricular ejection fraction (LVEF).

Purpose: To determine the effectiveness of early exercise based cardiac rehabilitation on left ventricular ejection fraction in post-CABG patients.

Design: This was a single blinded randomized controlled trial.

Methods: Study was approved by the ethical committee of Golsar Hospital; Rasht, Iran. Post-CABG patients (within one month of hospital discharge) with age group of 35 to 75 years old who gave written informed consent were recruited. Exclusion criteria were high risk group (AACVPR-1999 guidelines) patients and contraindications to exercise testing and training. Recruited subjects were randomized either into exercise-based CR (CR) or control group by concealed envelope method. CR group (n = 15) underwent 12 weeks structured Exercise-based CR program (ACSM-2005 guidelines) under supervision of physical therapist in hospital 3 times per week. Control group (n = 15) only received the usual cardiac care without any exercise training. Main outcome; LVEF was measured by echocardiography before and after 12 weeks and its changes compared with control group. Using intention to treat approach, between and within group analysis was done using one way ANOVA by keeping level of significance at P ≤ .05. SPSS v17 was used to analyze the data.

Results: 30 post-CABG patients (mean age 60.2 ± 9.4 years) within 1 month postdischarge enrolled in the study. At baseline there was no significant difference between groups with respect to the main outcome. Results showed a significant increase in LVEF in CR (48.1 ± 5.2 to 60.1 ± 3.9) group compared with control (47.9 ± 7.4 to 48.6 ± 7.4) group. (P < .0001)

Conclusions: The present study showed an early (within one month post discharge) 12 weeks structured exercise-based cardiac rehabilitation carried 3 times per week under supervision of physical therapist in hospital could significantly improve LVEF in post-CABG patients.

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Poster#: S117TYPE OF SPORT INDEPENDENTLY PREDICTS ECHOCARDIOGRAPHIC FINDINGS IN NCAA DIVISION I COLLEGE ATHLETES

Max Weiss, BS,1 Danny Eapen, MD,1 Emir Veledar, PhD,1 Jonathan Kim, MD,1 Niels Engberding, MD,1 Patrick BeDell,1 Michael Huey, MD,1 B. Robinson Williams, MD,1 Stamatios Lerakis, MD,1 Laurence Sperling, MD1

Institution: 1. Emory University School of Medicine, Atlanta, GA, United States.

Current Track: Cardiac

Introduction: Cardiac structural adaptation in athletes is influenced by many factors including gender, body surface area (BSA), and race. The influence of type of sport (endurance vs. strength) on specific echocardiographic parameters has not been fully studied in NCAA Division I athletes.

Purpose: We hypothesized interventricular septal thickness during diastole (IVSd), left ventricular posterior wall thickness during diastole (LVPWT), and left ventricular end diastolic internal dimension (LVIDd) would be associated with type of sport.

Design: We performed a cross-sectional analysis of preseason screening echocardiograms from a large database of NCAA Division I athletes.

Methods: 1301 NCAA Division I athletes (age: 19 ± 1.3 years, 59% Male, 28% African American) from 3 universities had preseason screening echocardiograms performed from 2007-2012. 16 varsity sports were represented. Echocardiographic images were read and interpreted by board certified cardiologists. Multivariate regression models adjusting for age, gender, BSA, race and type of sport were performed. A particular sport's association with echocardiographic findings was analyzed in relation to the other sports.

Results: In a multivariate linear regression, IVSd was independently predicted by BSA (P < .0000001), race (P < .006), gender (P < .0001), and type of sport. LVPWT was independently predicted by BSA (P < .0000001), race (P < .0009), gender (Pp < .026), and type of sport. LVIDd was independently predicted by BSA (P < .0000001), race (p < .000002), gender (P < .0000001), age (P < .01) and type of sport. The greatest predictors of IVSd were distance running (1.32 mm impact, P < .0002) and track sprinting (0.73 mm impact, P < .05). The greatest predictors of LVPWT were distance running (1.32 mm impact, P < .0002) and baseball (0.63 mm impact, P < .006). The greatest predictors of LVIDd were swimming (4.76 mm impact, P < .01) and rowing (2.98 mm impact, P < .02).

Conclusions: In NCAA Division I athletes, several sports were independent predictors of IVSd, LVPWT, and LVIDd. Distance running was the greatest predictor of IVSd and LVPWT. Swimming was the greatest predictor of LVIDd. Mechanisms underlying these findings and clinical correlation require further study.

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Poster#: S118MEASUREMENT OF FARMERS' HEART RATES DURING HIGH-INTENSITY WORK TASKS TO AID IN DEVELOPMENT OF OCCUPATION-SPECIFIC CARDIAC REHABILITATION TRAINING

Pasquale C. Carbone, BS,1 Jenny Adams, PhD,2 Yahya A. Daoud, PhDc,4 Shannon Jordan, MS,3 Kathleen Kennedy, MS,2 Anne Lawrence, RN,2 Rebecca Rogers, MS,3 Justin Karcher, MS3

Institutions: 1. Strength and Conditioning, Baylor Health Care System, Dallas, TX, United States. 2. Cardiac Rehabilitation, Baylor Heart and Vascular Hospital, Dallas, TX, United States. 3. Kinesiology, Texas Womans' University, Denton, TX, United States. 4. Health Care Research, Baylor Health Care System, Dallas, TX, United States.

Current Track: Cardiac

Introduction: The American College of Sports Medicine recommends the use of occupation-specific exercises when preparing cardiac patients to return to manual labor jobs such as farming, whereas the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recommends exercise intensity that produces a heart rate of 110 to 150 bpm. When an individual's heart rate during typical job-related activities consistently exceeds 150 bpm, there is a need for a cardiac rehabilitation exercise training regimen that is specific to the muscle groups used and the energy systems taxed during that kind of work.

Purpose: To measure the heart rates of healthy farmers during job-related activities, with the intent of developing occupation-specific exercise training for cardiac rehabilitation of farmers.

Design: In a prospective, nonrandomized study of 31 farmers (25 men and 6 women), aged 18 to 57 years, heart rate monitors were worn by the participants as they performed a series of farming tasks.

Methods: Each participant wore work attire (boots, jeans, and shirt) as well as a heart rate monitor. Heart rates were recorded while the participants dug a fence post hole for 3 minutes, filled eight seed hoppers, loaded 10 hay bales, and shoveled grain. Peak heart rates were then compared to the 150-bpm recommendation from the AACVPR using a one-sided t test.

Results: The peak heart rate means ± SD were 167.6 ± 18.6, 174.4 ± 19.0, 166.8 ± 21.3, and 159.1 ± 22.6, respectively, for the 4 farming tasks: digging a fence post hole, filling eight seed hoppers, loading 10 hay bales, and shoveling grain. The 4 peak heart rate means were significantly higher than the 150-bpm recommendation, with P-values of < .0001, < .0001, .0002, and .0234, respectively.

Conclusions: During the high-intensity farming activities, the participants' heart rate means were significantly higher than the exercise heart rate recommended by the AACVPR. Cardiac rehabilitation that would adequately prepare a farmer to return to work after a cardiac event would require an exercise prescription that would elicit a similar cardiovascular response by using the muscle groups and energy systems specific to farming.

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Poster#: S119EARLY CARDIAC REHABILITATION ENROLLMENT IS ASSOCIATED WITH HIGH PARTICIPATION RATES BUT DOES NOT AFFECT THE TOTAL NUMBER OF SESSIONS ATTENDED

Kent J. Dudycha, BS,1 Shawn Leth, BS,1 Quinn R. Pack, MD,1 Randal J. Thomas, MD,1 Ray Squires, PhD1

Institution: 1. Mayo Clinic, Rochester, MN, United States.

Current Track: Cardiac

Introduction: Early enrollment in cardiac rehabilitation (CR) has recently been shown to increase initial patient participation rates, but it is unknown if early enrollment affects full program participation and completion.

Purpose: We hypothesized that early CR enrollment would favorably increase the total number of CR sessions attended, particularly among employed patients.

Design: Historical cohort.

Methods: We included all patients who enrolled in Mayo Clinic CR between May 2009 and January 2012. Follow-up occurred through May 2012. We correlated the time interval between hospital discharge and CR enrollment to the total number of CR sessions attended. Correlation coefficients were calculated and logistic regression used to test an interaction with employment status.

Results: We evaluated 1,048 sequential phase II CR patients. The median time [IQ range] to CR enrollment was 10 [7 to 15] days with 90% of patient enrolling by day 27. Patients attended a median of 15 [6 to 29] sessions. However, early enrollment was not associated with the total number of CR sessions (r = 0.001, P = .93) or program completion (r = 0.001, P = .77). Employed patients enrolled earlier when compared to retired patients at 9 [6 to 13] days vs at 11 [8 to 16] days, P < .001, respectively. However, total CR sessions were lower among employed patients vs. retired patients at 14 [5 to 26] and 18 [6 to 34] sessions, respectively. In logistic regression analysis, an early enrollment made no differential effect on total sessions among employed patients (P = .19.) During this same period, enrollment rates into our program among eligible hospitalized patients averaged 64.7%, well above national averages.

Conclusions: Early enrollment in CR does not appear to improve total number of CR sessions attended nor the rate of CR program completion. While early enrollment has been shown in other studies to improve patient enrollment in CR, other factors, including employment status, appear to have more of an impact on CR session attendance and program completion.

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Poster#: S120USE OF A MANUAL MUSCLE-TESTING DYNAMOMETER TO ASSESS STRENGTH OUTCOMES AFTER RESISTANCE TRAINING IN A CARDIAC REHABILITATION SETTING

Jenny Adams, PhD,1 Yahya A. Daoud, Phdc,3 Rafic Berbarie, MD2

Institutions: 1. Cardiac Rehabilitation, Baylor Hamilton Heart and Vascular Hospital, Dallas, TX, United States. 2. Internal Medicine, Baylor Hamilton Heart and Vascular Hospital, Dallas, TX, United States. 3. Health Care Research, Baylor Health Care System, Dallas, TX, United States.

Current Track: Cardiac

Introduction: Pre- and postrehabilitation testing of cardiovascular endurance is traditionally done for the purpose of reporting functional outcomes, but pre- and post-rehabilitation strength testing is not usually done because the benchmark tests—the 1 repetition maximum (1-RM) bench press and squat—can be difficult to administer and require considerable time, equipment, and staff involvement. The use of a manual muscle-testing dynamometer has the potential of being a straightforward yet effective way of capturing strength outcomes data in a cardiac rehabilitation setting.

Purpose: To capture outcomes data by measuring the muscular strength of patients before and after participation in resistance training program during cardiac rehabilitation.

Design: In a prospective pilot study involving 5 cardiac rehabilitation patients (3 women and 2 men), muscular strength was measured with a manual dynamometer before and after completion of a 70% 1-RM resistance training program so that the values could be compared.

Methods: During the patients' first session of cardiac rehabilitation, an exercise physiologist used a manual muscle-testing dynamometer to obtain pre-training strength measurements on selected muscle groups. Patients with post-surgical pain were allowed to decline specific tests. The measurements were repeated after the patients participated in a 70% 1-RM resistance training program during 18 sessions of cardiac rehabilitation. To evaluate the overall increase in muscular strength, a linear mixed model (LMM) was utilized; the outcome was the increase in muscular strength (difference between the measurements at the beginning and end of the training).

Results: The overall mean increase in muscular strength from the beginning of the resistance training program was 17.1 lbs, with a standard deviation of 10.2. The LMM showed that the increase was significant, with a P-value of .013.

Conclusions: Use of a manual muscle-testing dynamometer before and after resistance training enabled staff members to effectively quantify the patients' improved strength, thereby capturing outcomes data and demonstrating the program's positive results. Further study in a larger population is recommended to confirm the utility of this type of testing.

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Poster#: S121FACTORS INFLUENCING A PATIENT'S DECISION FOR PARTICIPATION OR COMPLETION OF CARDIAC REHABILITATION

Jong-Young Lee, MD1

Institution: 1. Asan medical center, Seoul, Korea, Republic of.

Current Track: Cardiac

Introduction: Despite its documented evidences, cardiac rehabilitation (CR) is still not well implemented in current clinical practice, especially in Korea.

Purpose: To identify potential barriers to participation will improve accessibility to CR.

Design: We made a detailed questionnaire for why not participation or completion of CR program.

Methods: Between July 2011 and December 2012, we have recommended multidisciplinary CR program for the eligible patients who received percutaneous coronary intervention in Asan medical Center.

Results: Among 1,576 patients who were recommended for the eligible CR program, total 925 (59%) patients have agreed in participation of CR. We recommended the initial program type A (24∼36 sessions during 12 weeks), type B (12∼24 sessions) and type C (4∼8 sessions), respectively, according to the patient's individual circumstances. For the investigation etiology of refusal or not completing, patients were asked to fill out a questionnaire. Key reasons for not attending CR were 1) physical barriers, such as lack of transport and distance to the CR center 2) financial cost, 3) personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR and 4) deficient recommendation by health providers. Among clinical variables, older age, women, non-ST-segment elevation myocardial infarction, and the presence of other comorbidities were associated with decreased odds of cardiac rehabilitation. On the other hand, a physician recommendation was identified as the single most important factor in participation. Of those who agreed in participation, 625 (67.5%) patients have completed the recommended program. The completion rate were significantly higher in type A (76%), compared with type B (62%) or type C (68%) (P < .001). The main 3 reasons for not completing an initiated CR program were patients' belief they could handle their own problems, other concomitant illness and difficulty of frequent session attendance.

Conclusions: Our data showed the importance of raising awareness of benefits of CR to both patients and health providers, especially. And several issues include system-level and patient-level barriers, which are potentially modifiable. Future research and effort would best be directed at investigating and improving strategies to overcome these barriers.

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Poster#: S122RATE PRESSURE PRODUCT DURING AN EXERCISE STRESS TEST IN DEPRESSED VS. NONDEPRESSED CARDIAC PATIENTS

Vicki H. Doe, PhD,1,2 Brandon S. Pollock, MS,1 Joel Hughes, PhD,1,3 Ellen L. Glickman, PhD, Donna Waechter, PhD,3 James Rosneck, BSN, MS3

Institutions: 1. Kent State University, Kent, OH, United States. 2. Haywood Doe Consulting Co., LLC, Niles, OH, United States. 3. Center for Cardiopulmonary Research, SUMMA Health Systems, Akron, OH, United States.

Current Track: Cardiac

Introduction: An exercise-based cardiac rehabilitation program improves myocardial oxygen demand, as estimated by the rate-pressure product (RPP); and cardiorespiratory fitness. Dysregulation of the autonomic nervous system (ANS) may elicit a different response in depressed cardiac patients.

Purpose: This study examined whether RPP would improve among depressed (DEP) cardiac patients enrolled in a phase II cardiac rehabilitation (CR) program.

Design: This study compared depressed (DEP) to nondepressed (NON) cardiac patients who took both an entry/exit ramped-protocol treadmill graded exercise test (GXT) and underwent 25 sessions of a 12-week CR exercise training program.

Methods: Participants included (DEP-N = 10; BDI-13 or above) and (NON-N = 8; BDI-6 or below). Depressive symptoms were measured pre and post intervention using the Beck Depression Inventory (BDI) and structured diagnostic interview. Functional capacity (FC) was assessed pre-and post-intervention at 50%, 75% and 100% exercise intensities of the GXT. A repeated measures ANOVA was conducted to compare DEP and NON groups on measures of FC [total duration of GXT, METS, and RPP (HR x systolic BP)] at 50%, 75%, and 100% exercise intensity levels of GXT peak.

Results: After CR exercise training program, mean max MET scores significantly improved for both groups, DEP (M = 5.6 ± 2.2 to M = 9.5 ± 3.1), P = .001; NON (M = 6.2 ± 1.7 to M = 11.8 ± 2.1), P = .001. Mean max RPP improved for both DEP and NON groups, however, mean max RPP improved significantly for NON compared to DEP; NON (M = 16287.0 ± 3362.9 to M = 24264 ± 4481.0), P = .001; DEP (M = 17651.0 ± 4194.1 to M = 19762.2 ± 4236.8), P = .001. Both DEP and NON groups total max GXT min significantly improved, DEP (M = 6.3 ± 2.3 to M = 9.0 ± 2.0), P = .001; NON (M = 7.1 ± 1.6 to 9.5 ± 1.0), P = .001.

Conclusions: After a CR exercise training program, both depressed and nondepressed cardiac patients experienced an increase in FC and an improved maximal exercise tolerance that may be attributed to a RPP closer to the normal range of ≥25,000 or higher during exercise. These cardiorespiratory improvements may motivate depressed cardiac patients to continue to participate in an exercise program even after participating in a CR exercise program.

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Poster#: S123MULTI-CENTER STUDY OF RISK FACTOR STATUS ON COMPLETION OF A CONTEMPORARY PHASE 2 CARDIAC REHABILITATION PROGRAM: TEMPORAL TRENDS

Neil Gordon, MD,1 Richard Salmon, DDS,1 Kevin Reid, MA,1 Brenda Wright, PhD,1 George Faircloth, MHA,1 Kim Allen, RD,1 John Thiel, MA,1 Tom Savona, MA,1 Julie Blakely, BS,1 Terri Gordon, MPH1

Institution: 1. INTERVENT International, Savannah, GA, United States.

Current Track: Cardiac

Introduction: No comprehensive data are available on temporal trends in the percentage of participants who are not at recommended cardiovascular disease risk factor goal levels on completion of a contemporary phase 2 cardiac rehabilitation (CR) program and, therefore, in need of additional intervention.

Purpose: The purpose of this study was to determine whether improvements have occurred in recent years in the control of multiple risk factors in patients exiting CR.

Design: In this multicenter study, we compared the percentage of participants not at goal for select risk factors on exit from CR during 2000-2004 versus 2005-2009.

Methods: Subjects were 12,984 consecutive patients who enrolled in a phase 2 CR program at 35 centers in the US between 2000 and 2009 and subsequently completed an exit evaluation on program completion (2000-2004: n = 5,468; age = 64+/–11 years; 2005-2009: n = 7,516; age = 65+/–11 years). Statistical significance of differences between groups was analyzed using chi-square tests and statistical significance was established at p < 0.05.

Results: Percentages of patients with risk factors not at goal levels on CR completion were as follows (p values are for 2000-2004 versus 2005-2009): 1. Cigarette smoking (goal = no smoking): 2000-2004, 4.1% not at goal; 2005-2009, 4.7% not at goal; NS; 2. Systolic BP (goal < 120 mm Hg): 2000-2004, 54.5% not at goal; 2005-2009, 50.9% not at goal; P < .001; 3. Diastolic BP (goal < 80 mm Hg): 2000-2004, 21.4% not at goal; 2005-2009, 17.3% not at goal; P < .001; 4. LDL cholesterol (goal < 100 mg/dl): 2000-2004, 29.7% not at goal; 2005-2009, 20.5% not at goal; P < .001; 5. HDL cholesterol (goal >39 mg/dl): 2000-2004, 38.6% not at goal; 2005-2009, 43.5% not at goal; P < .001; 6. Triglycerides (goal < 150 mg/dl): 2000-2004, 35.3% not at goal; 2005-2009, 28.2% not at goal; P < .001; 7. Body mass index (goal < 25 kg/m2): 2000-2004, 76.9% not at goal; 2005-2009, 79.0% not at goal; P < .01; 8. Fasting glucose (goal < 100 mg/dl): 2000-2004, 57.5% not at goal; 2005-2009, 54.8% not at goal; NS; and 9. Sedentary lifestyle (goal >149 min/wk): 2000-2004, 51.1% not at goal; 2005-2009, 37.4% not at goal; P < .001.

Conclusions: These data indicate that while the control of many risk factors has improved significantly over time, the control of some risk factors (namely, HDL cholesterol and body mass index) has worsened. The data further demonstrate that multiple risk factors are often inadequately controlled on exit from contemporary phase 2 CR programs and serve to emphasize the need for ongoing intervention.

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Poster#: S124EFFECTS OF EXERCISE TRAINING VERSUS ATTENTION ON PLASMA B-TYPE NATRIURETIC PEPTIDE, 6-MINUTE WALK TEST AND QUALITY OF LIFE IN INDIVIDUALS WITH HEART FAILURE

Joseph F. Norman, PhD, PT,1 Bunny J. Pozehl, PhD, APRN-NP,2,3 Kathleen A. Duncan, PhD, RN,2 Melody A. Hertzog, PhD,2 Steven K. Krueger, MD3

Institutions: 1. Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha, NE, United States. 2. College of Nursing, University of Nebraska Medical Center, Lincoln, NE, United States. 3. Bryan-LGH Heart Institute, Lincoln, NE, United States.

Current Track: Cardiac

Introduction: Comparisons of Exercise Groups (EX) to Attention Control Groups (AT-C) have been conducted in various patient populations but to our knowledge have not been reported in individuals with heart failure (HF).

Purpose: The purpose of this study was to compare EX with AT-C to more specifically assess the impact of exercise training on individuals with HF.

Design: An experimental design was utilized for comparisons.

Methods: Forty-two individuals with HF were randomized to AT-C or EX that met with the same frequency and format of investigator interaction. Baseline, 12 and 24-week measurements of B-type naturetic peptide (BNP), 6-minute walk test (6-MWT), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were obtained. Comparisons of group baseline measures were performed by χ2 and t-test analyses. Change over time was assessed by repeated-measures ANOVA.

Results: Forty subjects completed the 24 weeks of the study and were used in the analyses. Two subjects were lost to follow up. BNP tended to increase in the AT-C while remaining stable in the EX over time. A clinically significant increase in 6-MWT was demonstrated by the EX (55 m) but not the AT-C (32 m). The EX achieved a clinically significant change on the KCCQ at 12 weeks (+8), with further improvement by 24 weeks (+11), compared to baseline, while the AT-C demonstrated a clinically significant change only at 24 weeks (+5).

Conclusions: Attention alone was inadequate to positively impact BNP levels or 6-MWT distances, but did have a positive impact on quality of life after 24 weeks. Although exercise offers enhanced benefits, individuals with HF unable to participate in an exercise program may still gain quality of life benefits from participation in a peer-support group that discusses topics pertinent to HF.

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Poster#: S125PERIPHERAL ARTERY DISEASE WORSENS OUTCOMES FOR PATIENTS IN CARDIAC REHABILITATION

Marty Tam, MD,1,2 Richard Sukeena, MS,1 Chen H. Chow, MD,1,2 Chris T. Longenecker, MD,1,2 Marianne Vest, RN,1 Sri Krishnan Madan-Mohan, MD,1,2 Teresa L. Carman, MD,1,2 Sahil Parikh, MD,1,2 Richard A. Josephson, MS, MD1,2

Institutions: 1. University Hospitals Case Medical Center, Harrington Heart and Vascular Institute, Cleveland, OH, United States. 2. Case Western Reserve University, Cleveland, OH, United States.

Current Track: Cardiac

Introduction: Exercise-based cardiac rehabilitation (CR) is proven to benefit patients with cardiovascular disease, and the benefits correlate with the exercise performance achieved. Many patients in CR exercise at levels less than optimal, without obvious cardiac limitations. Peripheral artery disease (PAD) risk factors are also very common in the CR patients.

Purpose: We hypothesized that occult lower extremity PAD in this population may be a determinant of diminished exercise capacity and reduced benefit obtained from CR.

Design: This is a prospective, cross-sectional study.

Methods: In this study of 108 consecutive subjects enrolled in phase II CR, we describe the prevalence of PAD, the utility of externally validated screening questionnaires, and the potential impact on improvement in CR. Independent sample t-tests were used to compare group outcomes.

Results: Abnormal ABIs were observed in 22% of those studied, of which 15% had a low ABI (< 0.90) and 7% had a high ABI (>1.40). Eighteen subjects were referred for diagnoses other than coronary disease or myocardial infarction; of these, 3 had an abnormal ABI. The Edinburgh Claudication Questionnaire was specific but not sensitive for PAD (sensitivity 4.3%, specificity 94.0%, NPV 78.4%, PPV 16.7%). The Walking Impairment Questionnaire did not differentiate patients with or without PAD with regard to walking distance (68.7 vs. 68.3, P = .96), speed (51.9 vs. 45.6, P = .29) or symptoms (90.9 vs. 85.5, P = .11). A modified Gardner protocol (2 mph, 0% grade, max = 10') was of limited sensitivity to detect PAD (sensitivity 13.0%, specificity 93.9%, NPV 79.8%, PPV 33.3%). Importantly, of the 73 subjects that completed CR, exercise improvement was greater (+2.46 vs. +1.65 METS, P = .038) in those with normal ABI (n = 57) vs. those with abnormal ABI (n = 16).

Conclusions: PAD is common in patients in phase II CR and often goes undetected. Externally validated screening tools also seem to be insensitive in this particular population. For these patients in CR, lower extremity PAD does not appear to impair low level activity but significantly impacts exercise improvement, preventing patients from getting the full benefit of their exercise prescriptions.

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Poster#: S126THE EFFECT OF OBSTRUCTIVE SLEEP APNEA ON CARDIAC REHABILITATION OUTCOMES

Adrian Aron, PhD,1 Julia Castleberry, DPT,1 Brandon Briggs, MSc,2 Joseph L. Austin, MD,2 Donald Zedalis, MD3

Institutions: 1. Physical Therapy, Radford University, Roanoke, VA, United States. 2. Cardiac Rehabilitation, Carilion Health System, Roanoke, VA, United States. 3. Sleep Disorders Network of Southwest Virginia, Christiansburg, VA, United States.

Current Track: Cardiac

Introduction: Obstructive sleep apnea (OSA) is a complex disorder frequently observed in patients with cardiovascular disease. Clinical features include daytime hypersomnolence, chronic fatigue, poor attention, impaired cognition, and diminished exercise capacity.

Purpose: The purpose of this study was to evaluate cardiac rehabilitation (CR) outcomes in patients diagnosed with OSA compared with controls.

Design: Repeated measures study of 2 groups of patients tested before and after CR

Methods: We tested 74 consecutive patients enrolled in a Phase II outpatient CR clinic. All patients underwent 1 night of screening using a portable in-home apnea detection unit (Apnea Link Plus). The CR staff was blinded to the diagnostic result. Tests and measurements were performed at the start of the program and on the last visit. Patients were engaged in standardized scheduled rehabilitation sessions and guidelines for clinical care were administered by the CR nurses and clinical exercise physiologists following the current recommendations set by AACVPR. For data analysis, the patients were divided into 2 groups according to their OSA screening: severe OSA and no OSA.

Results: Groups were similar in age (mean ± SD, 65.5 ± 8.1 vs. 61.3 ± 12.5 years, OSA and control respectively) and sessions attended (24.3 ± 7.9 vs. 25.0 ± 7.7, OSA and control respectively). Following CR, abdominal circumference and BMI decreased in both groups (P = .005 and P = .03, respectively), while improvements in 6 minutes walk test scores (P = .0001), time spent performing aerobic activities (P = .0001), and average MET level were recorded (P = .0001). There were no significant differences between pre and post-CR measurements of hip circumference, handgrip strength, and quality of life questionnaire results. Overall, changes in CR outcome measurements were not statistically different between patients with OSA and controls. Pearson correlation did not show a significant association between presence of OSA and any of the patient characteristics or performance measures (P levels between 0.4 − 0.9).

Conclusions: Our study showed that OSA patients can improve their CR outcomes similar to that of normal patients. The lack of OSA influence may be a function of our small sample size or the unknown time of untreated OSA seen in our sample.

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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