Controversies In Cardiac Rehabilitation

This book contains the proceedings of a conference organized by the Klinik Hohenried at the Evangelische Akademie in Tutzing under the patronage of the International Society of Cardiology - Council on Rehabilitation - from Febr. 12-14, 1981. The purpose of the meeting on Current Problems in Cardiac Rehabili tation was to come closer to answering the questions posed in the fol lowing pages, and to make some opinions about cardiac rehabili tation less contoversial. To comment briefly on the interesting question of why opinions in the field of cardiac rehabilitation seem more controversial than in other fields of cardiology, we would like to propose the following explanation: 1. Lack of personal experience and lack of special training in cardiac rehabilitation are a major source of misunderstandings and differ ences of vocabulary between cardiologists engaged in clinical practice and in rehabilitation. 2. Emotional problems in accepting a new kind of partnership between coronary patients and their physicians and a "nihilistic attitude" towards therapy of behaviour play an important role in the scepti cism of cardiologists. 3. Fear of an expensive "overmedication" (I. Illich) is another argu ment concerning rehabilitation.

In this book the lectures of the first course of the International School of Cardiology at Ettore Majorana are presented. It is difficult to reflect in a publication of this kind the atmosphere and spirit of this postgraduate course. Moreover, the beautiful scenery of Erice and its surroundings, celebrated by ancient Greek poets, can never be described by the editors of this book. The purpo~e of this course was to deepen our knowledge accumulated todate on the subjects of non-invasive cardio circulatory assessment and the analysis of the comprehensive approach to cardiac rehabilitation. The clinical value of exercise testing, echo-cardiography, scintigraphy, systolic time intervals have been discussed, as well as the tasks of exercise training, surgery and drugs in the secondary prevention of coronary heart disease. The problems of arrhythmias and the prevention of sudden death have been touched on, as well as early m~bilization after myocardial infarction, the use of digoxin and beta blockers and finally, the controversies in cardiac rehabilitation.

Reviews the best therapies and surgical techniques available to provide quality care for the elderly cardiac patient and of those areas that require further research. The authors detail preventive therapies and the cardiovascular syndromes that disproportionately afflict the older individual, including arrhythmias (particularly atrial fibrillation), syncope, heart failure (particularly diastolic heart failure), and ischemic heart disease. They also delineate the surgical management of the heart patient with discussions of postoperative management and its complications and of specific surgical procedures such as coronary artery bypass grafting, valve surgery, pacemaker and defibibrillators, and surgical management of heart failure.

This book will consider several clinical and interventional topics for which there is uncertainty, continued debate and/or no consensus based on current guidelines. While there are numerous guidelines in cardiology, new and on-going trials that address new drugs treatments and procedures raise many unanswered questions. Furthermore, most practicing cardiologist taking care of the patients are likely unable to digest all of these studies or guidelines and necessarily correctly apply them to their patients. If one considers in the guidelines the frequent use of Level C (consensus), there are many areas or situations where no trial exists. Also, when applying the results of a trial to an individual patient, there can be uncertainty of how this patient should be managed based on the present body of evidence.

This book is a timely and thorough review of prevention, lifestyle counseling and rehabilitation for cardiologists and all physicians and other health professionals in cardiac rehabilitation teams. The Editors have gathered over 60 experts from all parts of the globe. Each highlights the role of cardiac rehabilitation and preventative cardiology from exercise testing and training, through nutrition, smoking cessation, behavioral and social support to adapted programs for newer groups with specific demands. The book emphasizes the organizational aspects of cardiac rehabilitation, including quality assurance and economic evaluation.

When I gave a presentation on return to work after heart valve replacement at the Tenth Congress of the German Society for Thoracic and Cardiovascular Surgery in 1981, I was surprised by the relatively low level of interest that cardiac surgeons seemed to have in this subject. This stimulated me to intensify my research in this area and to extend it to patients with coron ary heart disease. Obviously, physiological and mechanical aspects of medical treatment are of special interest to the surgeon. For the majority of cardiac surgical patients, that is those with coronary heart disease, the technical problems of the operative procedure have been solved to a great extent. Many studies have demonstrated that, aside from reduction of symptoms, aortocoronary bypass operation can lead to improvement of cardiac performance un der stress conditions. However in spite of the technical solutions to hemodynamic problems, it has become very clear that the reintegration of patients into their social sphere has not been accomplished to the extent that might be expected, as exempli fied by the relatively low rate of postoperative return to work.

Cardiac rehabilitation is coming into its own after controversy over its usefulness for either chronic heart disease or recently operated patients. This book evaluates the effects of rehabilitation and provides practical advice on its implementation.

First multi-year cumulation covers six years: 1965-70.