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Martin B.-J.,University of Calgary | Hauer T.,Cardiac Wellness Institute of Calgary | Arena R.,Cardiac Wellness Institute of Calgary | Galbraith P.D.,University of Calgary | And 7 more authors.
Circulation | Year: 2012

Background-Cardiac rehabilitation (CR) is an efficacious yet underused treatment for patients with coronary artery disease. The objective of this study was to determine the association between CR completion and mortality and resource use. Methods and Results-We conducted a prospective cohort study of 5886 subjects (20.8% female; mean age, 60.6 years) who had undergone angiography and were referred for CR in Calgary, AB, Canada, between 1996 and 2009. Outcomes of interest included freedom from emergency room visits, hospitalization, and survival in CR completers versus noncompleters, adjusted for clinical covariates, treatment strategy, and coronary anatomy. Hazard ratios for events for CR completers versus noncompleters were also constructed. A propensity model was used to match completers to noncompleters on baseline characteristics, and each outcome was compared between propensity-matched groups. Of the subjects referred for CR, 2900 (49.3%) completed the program, and an additional 554 subjects started but did not complete CR. CR completion was associated with a lower risk of death, with an adjusted hazard ratio of 0.59 (95% confidence interval, 0.49-0.70). CR completion was also associated with a decreased risk of all-cause hospitalization (adjusted hazard ratio, 0.77; 95% confidence interval, 0.71-0.84) and cardiac hospitalization (adjusted hazard ratio, 0.68; 95% confidence interval, 0.55-0.83) but not with emergency room visits. Propensity-matched analysis demonstrated a persistent association between CR completion and reduced mortality. Conclusions-Among those coronary artery disease patients referred, CR completion is associated with improved survival and decreased hospitalization. There is a need to explore reasons for nonattendance and to test interventions to improve attendance after referral. © 2012 American Heart Association, Inc.


Campbell T.S.,University of Calgary | Stevenson A.,University of Calgary | Arena R.,University of New Mexico | Hauer T.,Cardiac Wellness Institute of Calgary | And 6 more authors.
Journal of Cardiopulmonary Rehabilitation and Prevention | Year: 2012

Purpose: Research describing whether stress management can improve clinical outcomes for patients in cardiac rehabilitation (CR) has yielded equivocal findings. Methods: The present investigation retrospectively examined the incremental impact of exercise and stress management (n = 188), relative to exercise only (n = 1389), on psychosocial and physical health outcomes following a 12-week CR program. Results: Participation in stress management and exercise was associated with greater reductions in waist circumference and systolic blood pressure, relative to exercise alone, for patients with baseline clinical elevations on these measures. The stress management group had more depressive symptoms (as measured by the Hospital Anxiety and Depression Scale; t[1] = 3.81, P < .001) and lower physical quality of life (as measured by the 12-Item Short Form Health Survey Physical Component; t[1] = 3.00, P = .003) than the exercise-only group at baseline, but there were no differences between the groups at 12 weeks in terms of depressive symptoms (t[1] = 1.74, P = .082) or physical quality of life (t[1] = 1.56, P = .120). CONCLUSION: These findings suggest that stress management may offer additional benefits in selected patients over and above exercise in CR. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Clark A.M.,University of Alberta | King-Shier K.M.,University of Calgary | Thompson D.R.,Australian Catholic University | Spaling M.A.,University of Alberta | And 6 more authors.
American Heart Journal | Year: 2012

Background: Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood. Methods: A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995. Results: Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile. Conclusions: Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms. © 2012 Mosby, Inc.


Aggarwal S.,Cardiac Wellness Institute of Calgary | Aggarwal S.,University of Calgary | Aggarwal S.,Libin Cardiovascular Institute of Alberta | Arena R.,Cardiac Wellness Institute of Calgary | And 10 more authors.
Journal of Cardiopulmonary Rehabilitation and Prevention | Year: 2012

INTRODUCTION: Despite its numerous other benefits, cardiac rehabilitation (CR) has not consistently proven to be an effective, although much needed, intervention for weight loss in the cardiovascular disease (CVD) population. Comparatively, the LEARN (Lifestyle, Exercise, Attitudes, Relationships, Nutrition) program appears to be an effective intervention for weight loss. The purpose of the present investigation was to compare changes in body weight in a CVD cohort consecutively participating in traditional CR and the LEARN program. METHODS: Forty-four patients diagnosed with CVD (22 men/22 women) participated in a 12-week multidisciplinary CR program. All patients successfully completed the LEARN program following CR. Body mass index (BMI) and body weight were recorded immediately prior to and following both CR and LEARN. RESULTS: The peak metabolic equivalents were significantly higher following CR (7.3 ± 1.6 vs 8.5 ±1.6, P < .001), while body weight (203.5 ± 32.6 vs 201.8 ± 32.5 lbs, P > .10) and BMI (32.1 ±4.0 vs 31.8 ±3.9 kg/m, P > .05) were unchanged. All subjects then successfully completed the LEARN program, participating in an average of 10 sessions. There was a significant reduction in body weight (203.3 ± 30.7 vs 190.1 ± 30.4 lbs, P < .001) and BMI (32.0 ± 3.9 vs 29.5 ±3.8 kg/m, P < .001) following the LEARN program. DISCUSSION: Our results support the independent value of the LEARN program in eliciting weight loss for CR patients. Clinicians delivering CR services should consider integrating a focused weight loss program, such as LEARN, into their usual CR programs. © 2012 Lippincott Williams & Wilkins, Inc.


Clark A.M.,University of Alberta | King-Shier K.M.,University of Calgary | Duncan A.,University of Alberta | Spaling M.,University of Alberta | And 4 more authors.
European Journal of Preventive Cardiology | Year: 2013

Background: Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood. Design: We performed a systematic review using qualitative meta-synthesis. Methods: A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995. Results: A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an overreliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging. Conclusions: The greatest increases in patient referral to programs could be achieved by allowing referral from nonphysicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs. © 2012 The European Society of Cardiology.


von Ranson K.M.,University of Calgary | Stevenson A.S.,University of Calgary | Cannon C.K.,Cardiac Wellness Institute of Calgary | Shah W.,Hypertension and Cholesterol Center
Eating Behaviors | Year: 2010

Objective: Two quasi-experimental pilot studies examined eating pathology, eating self-efficacy, shame, guilt, and pride in adults with chronic illness before and after participating in brief cognitive-behavioral psychoeducational groups addressing eating concerns. Method: In Study 1, 60 adults completed assessments before and after a series of two groups; in Study 2, 21 adults also completed an assessment five weeks prior to the first group to identify time-related changes in symptoms. Results: Study 1 participants improved across domains, whereas Study 2 analyses also examining time-related changes showed improvements in eating self-efficacy, shame, guilt, and pride, but not in eating pathology. Discussion: Psychoeducational groups may help improve symptoms including eating pathology, eating self-efficacy, shame, guilt, and pride among chronically-ill adults with eating concerns. © 2009 Elsevier Ltd.


Martin B.-J.,University of Calgary | Martin B.-J.,Cardiac Wellness Institute of Calgary | Arena R.,Cardiac Wellness Institute of Calgary | Arena R.,University of Illinois at Chicago | And 9 more authors.
Mayo Clinic Proceedings | Year: 2013

Objective: To assess the association between cardiorespiratory fitness (CRF) and outcomes in a cardiac rehabilitation (CR) cohort. Patients and Methods: We conducted a retrospective study of 5641 patients (4282 men [76%] and 1359 women [24%]; mean ± SD age, 60.0±10.3 years) with coronary artery disease who participated in CR between July 1, 1996, and February 28, 2009. Based on peak metabolic equivalents (METs), patients were classified as low fitness (LFit) (<5 METs), moderate fitness (5-8 METs), or high fitness (>8 METs). Results: Baseline fitness predicted long-term mortality: relative to the LFit group, patients with moderate fitness had an adjusted hazard ratio of 0.54 (95%CI, 0.42-0.69), and those with high fitness a hazard ratio of 0.32 (95%CI, 0.24-0.44). Improvement in CRF at 12 weeks was associated with decreased overall mortality, with a 13%point reduction with each MET increase (P<.001) and a 30%point reduction in those who started with LFit. At 1 year, each MET increase in CRF was associated with a 25%point reduction in overall mortality in the whole group (P<.001). Conclusion: In this study of contemporary CR patients, higher baseline fitness predicted lower mortality. The novel finding was that improvement in fitness during a CR program and improvements that persisted at 1 year were also associated with decreased mortality, most strongly in patients who start with LFit. © 2013 Mayo Foundation for Medical Education and Research.


Stone J.A.,Cardiac Wellness Institute of Calgary | Stone J.A.,University of Calgary | Hauer T.,Cardiac Wellness Institute of Calgary | Haykowsky M.,University of Alberta | And 2 more authors.
Heart Failure Clinics | Year: 2015

Contemporary pharmacologic therapies have greatly improved outcomes in patients with heart failure (HF). Exercise therapy also has become increasingly recognized and utilized over the last decade. Patients with HF undergo significant central and peripheral deconditioning. Aerobic and resistance training in this patient population may improve quality of life, muscular strength, aerobic capacity, and potentially longevity. Those HF patients who are able to remain adherent to exercise training programs may improve their self-monitoring skills with respect to progressive volume overload, as well as their capacity for independent living, thereby reducing the likelihood of rehospitalization. © 2015 Elsevier Inc.


Armstrong M.J.,University of Calgary | Martin B.-J.,University of Calgary | Martin B.-J.,Cardiac Wellness Institute of Calgary | Arena R.,Cardiac Wellness Institute of Calgary | And 8 more authors.
Medicine and Science in Sports and Exercise | Year: 2014

PURPOSE: Diabetes increases mortality after myocardial infarction, but participation in cardiac rehabilitation (CR) reduces this risk. Our objectives were to examine whether attendance at CR and changes in cardiorespiratory fitness differed according to diabetic status and sex. METHODS: Retrospective cohort study of patients referred for CR in Calgary between 1996 and 2010. Cardiorespiratory fitness in metabolic equivalents (METs) was estimated by maximal exercise testing at baseline, at the end of the 12-wk CR program, and 1-yr after CR. RESULTS: Among 7036 nondiabetic and 1546 diabetic patients who started, 84.9% of nondiabetic versus 79.5% of diabetic patients completed CR (P < 0.0001). The difference between diabetic and nondiabetic patients was greater in women (81.7% vs 72.1%, P < 0.0001) than that in men (86.0% vs 82.5%, P = 0.004). Patients without diabetes were more likely to return for the 1-yr assessment (53.7% vs 42.7%, P < 0.0001), and nondiabetic women were more likely than diabetic women to attend the 1-yr follow-up (44.3% vs 31.7%, P < 0.0001). Change in cardiorespiratory fitness from baseline to 12 wk was +1.0 METs in nondiabetic men, +0.9 METS in diabetic men, +0.9 METs in nondiabetic women, and +0.7 METs in diabetic women (within-group change; P = 0.0009). Changes in cardiorespiratory fitness at 1 yr compared with baseline were +0.9, +0.6, +0.9, and +0.5 METS, respectively (within-group change, P = 0.0001). CONCLUSIONS: Patients with diabetes, especially females, were less likely than patients without diabetes to complete CR and attend follow-up. Among patients who attended 1-yr follow-up, changes in cardiorespiratory fitness were not as well maintained in diabetic patients as in nondiabetic patients. Identifying barriers and targeting CR adherence interventions to patients with diabetes may help improve outcomes. © 2014 by the American college of Sports Medicine.


PubMed | Cardiac Wellness Institute of Calgary
Type: Journal Article | Journal: Obesity (Silver Spring, Md.) | Year: 2012

Cardiac rehabilitation (CR) produces a host of health benefits related to modifiable cardiovascular risk factors. The purpose of the present investigation was to determine the influence of body weight, assessed through BMI, on acute and long-term improvements in aerobic capacity following completion of CR. Three thousand nine hundred and ninety seven subjects with coronary artery disease (CAD) participated in a 12-week multidisciplinary CR program. Subjects underwent an exercise test to determine peak estimated metabolic equivalents (eMETs) and BMI assessment at baseline, immediately following CR completion and at 1-year follow-up. Normal weight subjects at 1-year follow-up demonstrated the greatest improvement in aerobic fitness and best retention of those gains (gain in peak METs: 0.95 1.1, P < 0.001). Although the improvement was significant (P < 0.001), subjects who were initially classified as obese had the lowest aerobic capacity and poorest retention in CR fitness gains at 1-year follow-up (gain in peak eMETs: 0.69 1.2). Subjects initially classified as overweight by BMI had a peak eMET improvement that was also significantly better (P < 0.05) than obese subjects at 1-year follow-up (gain in peak eMETs: 0.82 1.1). Significant fitness gains, one of the primary beneficial outcomes of CR, can be obtained by all subjects irrespective of BMI classification. However, obese patients have poorer baseline fitness and are more likely to give back fitness gains in the long term. Obese CAD patients may therefore benefit from additional interventions to enhance the positive adaptations facilitated by CR.

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