Rehabilitation after myocardial infarction: the European experience

World Health Organization -L ~ Regional Office for Europe ~ ~ Copenhagen ~ ~ Public Health in Europe 24 Rehabilitation after myocardial infarction lllllllllll\111~1111 111111 11111 1111\\IIIIIIII .. 0002855 '-i" The European experience Edited by Veikko Kallio Director, Rehabilitation Research Centre of the Social Insurance Institute Turku, Finland and Elizabeth Cay Consultant. Rehabilitation Medicine Unit Astley Ainslie Hospital Edinburgh, United Kingdom ICP/CVD 005 ISBN 92 890 1160 2 © World Health Organization 1985 Publications of the World Health Organization enjoy copyright protection in ac- cordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation , in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0 , Denmark. The Regional Office welcomes such applications . 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PRINTED IN DENMARK ISSN 0300-4880 CONTENTS Page Editors' note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v11 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix I . Rehabilitation as part of comprehensive care H. Deno/in ......... ..... ............................... . 2. Cardiopulmonary function after myocardial infarction: effects of bed-rest, disease and training J. Widimsky & J.-P. Broustet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3. Exercise testing of cardiac patients S. Degre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4. Psychological factors in patients after myocardial infarction E. Cay, V.P. Zaitsev & S. Rudnicki . . . . . . . . . . . . . . . . . . . . . . . . . 33 5. Implications of social factors in cardiac rehabilitation S. Laaksovirta & V. Kallio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 6. Secondary prevention I. Orha, L.F. Nikolaeva & J. Velasco . . . . . . . . . . . . . . . . . . . . . . . . 73 7. Educational programmes after myocardial infarction W. Geissler, E. Cay & D. Dorossiev . . . . . . . . . . . . . . . . . . . . . . . . . 89 8. Organizatio n of rehabilitatio n services K. Konig, M. Bran & J. Salonen ............................ 103 9. Controlled studies on the effects of rehabilitation E. Cay , S. Degre, H. Deno/in, D. Dorossiev, £. Dowd, F. Endersz, D. Grafnetter, J. Hakkila, V. Kallio, G. Lamm, Z. Pisa, P. Szabo/cs & G. Wagner . . . . . . . . . . . . . . . . . . . . . . . . . . 111 10. Rehabilitation after myocardial infarction: where does current knowledge lead? Z. Pisa, H. Deno/in & G. Lamm . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Annex I. Social security in different countries involved in the WHO Study V. Kallio, S. Laaksovirta, B. Devetakov & V. Tormo Alfonso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 37 Annex 2. WHO study on the effects of rehabilitation and comprehensive secondary prevention after myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 V Editors' note The editors acknowledge the help of all those who took part in the study. They are in debt not only to those who wrote the individual chapters but to many others whose assistance was invaluable. The advice provided by the editorial board, consisting of Professor H . Denolin, Dr D. Dorossiev, Mr E. Dowd, Dr G. Lamm, Dr Z. Pisa and Professor G . Wagner, is also gratefully acknowledged. Thanks are also due to the Social Insurance Institution, Finland, which placed facilities in the Rehabilitation Research Centre, Turku at the disposal of the editors. The editors cannot express adequately the thanks that are due to the secretarial staff in the Rehabilitation Research Centre, Turku , and the Rehabilitation Medicine Unit of the Astley Ainslie Hospital , Edinburgh, without whose cheerful and devoted hard work this book could not have been produced. Veikko Kallio Elizabeth Cay Vil Preface There have been marked developments in the whole field of cardiology in the past thirty years. New methods of investigation have led to easier and more accurate diagnosis of congenital cardiac malformations and acquired disease. These new techniques can be invasive, such as cardiac catheterization, but, more recently, the cardiologist has been able to draw upon a wide variety of non-invasive diagnostic aids, mecanography, echocardiography, Holter moni- toring and radioisotopic investigation. The advent of antibiotics, diuretics, vasodilators, beta-blockers and calcium antagonists has changed medical management so that patients can now live more normal lives and prognosis in many cardiac diseases has been considerably modified. Surgery, now supple- mented by the extracorporeal heart-lung machine and improved artificial valves and pacemakers, has met with increasing success. Epidemiological studies have improved our knowledge of the natural history of cardiac disease and hypertension; risk factors have been recognized and their role documented, and, at the present time, large-scale preventive trials are in progress which hopefully will yield favourable results. Despite all this progress, and the recent moderate decrease in cardio- vascular mortality apparent in some countries, cardiac diseases still account for 40% of deaths and are one of the major causes of morbidity in most technically developed countries. The sheer size of the problem means that all possible measures to mitigate the consequences of chronic cardiac disease must be undertaken. For these reasons, the principles of rehabilitation, with their avowed aims to limit as much as possible the physical, psychological and social sequelae of locomotor, neurological and psychiatric disease, are now seen as being relevant in the treatment of patients with cardiac disease, particularly those suffering from the commonest cardiac disorder, ischaemic heart disease. To understand how this has come about let us consider the plight of the patient recovering from a heart attack in the early 1960s. There he lies, immobile in his bed some weeks after the onset of acute symptoms, with a nurse feeding him and tending to his every bodily function. But has he really lost the capacity to eat, sit up, move freely or possibly even to work? Completely unsure if this was the case, members of the medical profession used all their authority to impose immobility, believing that they were acting in the patient's best interests. What we now term, somewhat erroneously, "rehabilitation" is more IX a gradual reversal of our own overcautious tyranny, as our knowledge that many patients with myocardial infarction recover completely or are left with only slight disability. As restriction of the individual's mobility and physical activity was the obvious effect of early methods of treatment, rehabilitation initially was synonymous with physical training. It was only when it was demonstrated that it was relatively easy to restore muscular vigour and stamina quite soon after an infarction that other important facets of full recovery from an illness, such as psychological and social adjustment, received attention. There was growing awareness that the ability to perform well in the laboratory or gymnasium was not a realistic measure of a good outcome. The patient needed more than just the capacity to return to a normal life; his fears of doing so had to be dispelled and he had to be helped to bring this about. Thus rehabilitation became more complex, and not only correction of iatrogenic illness. Matters became more complicated by the late 1960s and early 1970s. With the idea of prevention gaining ground, rehabilitation aimed not only to restore premorbid abilities in all spheres of life but also to halt progression of the disease, prevent recurrence and prolong life. Secondary prevention was con- sidered an integral part of cardiac rehabilitation; the boundaries between the two became blurred, and over-enthusiastic claims of benefits gained, based more on ideas and attitudes than on well established facts, began to appear. It is easy now from the vantage point of the 1980s to criticize; we must remember that these dramatic changes were taking place within a mere ten years. Certainly by 1972 there was good pathophysio/ogica/ and clinical evidence to support this new approach to treating patients with myocardial infarction, but there was a lack of definitive fact based on large numbers of patients. It was against this background that the World Health Organization Regional Office for Europe invited members of the leading centres of cardiac rehabilitation in Europe to meet, with the aim of examining the feasibility of launching a large collaborative study to test whether or not systematic rehabilitation and secon- dary prevention reduced the recurrence of myocardial infarction and prolonged the patient's life. Lack of standardized measurements, very little knowledge of which psychological and social variables were relevant, inability to define satis- factorily a good outcome of rehabilitation, and restricted means dictated that it was not possible to carry out a strictly controlled, multicentre collaborative trial. It was decided that as many local studies as possible should be set up, based on a common protocol. It was hoped that as methods of assessment and measurement improved it might be feasible to combine some of the results. In the event, the problems and difficulties were even greater than foreseen; the interval between organizing the study and evaluating its results has been more than ten years! Nor has time stood still while this study has been in progress. Substantial changes in the theory and practice of cardiac rehabilitation have taken place in this decade. For these reasons, those involved felt that, coincidental with the publication of the results of the WHO study, a they should take the opportunity to a Dorossiev, D. Rehabilitation and comprehensive secondary prevention after acute myocar- dial infarction: report on a study. Copenhagen, WHO Regional Office for Europe, 1983 (EURO Reports and Studies, No. 84). X examine critically the present position of cardiac rehabilitation. Of necessity, the experience derived from the study and its results have played a major part in their thinking, but in the last ten years other factors and developments have also been important. This book, therefore, reflects the collective view of leading European experts in rehabilitation at the beginning of the 1980s. Its production is an amalgam of all their efforts, each one adding his or her share. This book is meant for cardiologists, physicians and general practitioners who are interested in cardiac rehabilitation. Although the salient features of the WHO study are adequately described, it is beyond the scope of the book to give a detailed account of it. (For that, the reader is referred to the report on the WHO study.) The authors have aimed to summarize what is known, what is assumed and what still has to be learned of the process of helping patients to lead a more normal life following an infarction. Whether or not they have succeeded in their aim will be determined by the amount and quality of new research which this book inspires. G. Lamm H . Denolin Z. Pisa XI 1 Rehabilitation as part of comprehensive care H. Deno/in The Development of Rehabilitation To understand the present role of rehabilitation in ischaemic heart disease, it is necessary to trace how it has developed over the last thirty years. The first steps For the first half of the twentieth century, there seemed to be no need to rehabilitate patients with ischaemic heart disease; the illness was relatively rare, it was confined to the elderly and there was no visible handicap following the acute attack. Return to work was thought to be ill advised and well nigh impossible after an infarction and any suggestion that this might occur aroused great anxiety in the patient himself, his family and his employers. There was little information on which cardiologists and indus- trial physicians could base sound opinions, and there were many social obstacles to resumption of an active life. These attitudes were reflected in the prescribed treatment of the acute phase of myocardial infarction . Prolonged bed-rest , lying flat for six weeks, was the strict rule based largely on pathological observations; this period of rest was necessary for "healing" of the scarred myocardium and to allow a collateral circulation to develop ( I). In I 944, Levine (2) first drew attention to the fact that prolonged bed-rest had certain unfavourable effects. He showed that the venous return, and consequently the level of cardiac work, was less when the patient was sitting rather than lying flat and that this position had certain psycho- logical advantages. By 1952, Levine & Lown (3) were able to demonstrate that sitting in a chair seven days after the onset of symptoms was safe for the patient and, indeed, had a beneficial effect on his recovery. This concept was, however, not readily accepted and the majority of physicians continued to treat patients with long periods of immobilization after an infarction, and to regard them as permanent invalids thereafter. Using residual capacity Hellerstein & Ford ( 4) date the modern concept of rehabilitation from the time that work classification units were first established. These were set up in 1940 in New York and some ten years later in Cleveland, and provided the first evidence that a sizeable number of patients could work perfectly safely after an infarction. It appeared that many patients were employable, pro- vided that a thorough evaluation of their cardiac function and the physical requirements of their job was first undertaken. Over the next few years, it became clear that the proportion of patients who could return to work was higher than expected and that their subsequent work record was good; they did not have a higher rate of absenteeism than their "healthy" contempor- aries and they were not involved in a greater number of accidents at work (5,6). A report published by the World Health Organization (WHO) in 1964 ( 7) underlined the growing interest in the rehabilitation of patients with cardiovascular diseases. It reminded the medical profession that these indi- viduals have the same rights as healthy people and those who are handi- capped for other reasons. They deserve the same rehabilitation measures to make their life in society as normal and satisfying as possible. Rehabilitation was defined as being an integral part of medical treatment , aiming to restore the patient as closely as possible to his previous physical, psychological and social functional level. Improving residual capacity The finding that patients who went back to work after their infarction did well led to the idea that it might be possible to improve an individual's physical capacity by formally designed training programmes. Though this seemed a startling innovation in the early I 960s this was not an entirely new idea. As early as 1802, Heberden (8) had reported the case of a patient with angina pectoris whose physical condition had improved after sawing wood for half an hour each day. The next few years saw the development of various types of exercise testing using a variety of cardiac and circulatory parameters to assess physical capacity, the first training programmes to improve function, and the building of specialist centres in various parts of Europe. In 1967, the WHO Regional Office for Europe convened the first seminar on cardiac rehabilitation, which met in Noordwijk aan Zee, Nether- lands, to review the current situation (9). On balance, the participants felt that little had been done in Europe to promote cardiac rehabilitation. While everyone was concerned at the increased incidence of ischaemic heart dis- ease, there seemed to be a complete absence of any rational policy to combat the social impact of the effects of the disease. It was difficult to study the problem properly because there was no common terminology, and wide- spread cultural differences existed. It did appear, however, that little use was made of rehabilitation in the field of cardiovascular disease throughout most of Europe. By drawing attention to the fact that outcome following myocardial infarction could be improved and that rehabilitation should be comprehensive, should start early and should be continued until recovery 2 was achieved, the Noordwijk seminar changed the existing state of affairs quite considerably. Several large-scale studies on the effects of training programmes and the influence of exercise on cardiac muscle and peripheral circulation were carried out. The work received impetus from the concomit- ant development of ergometry, tests of working capacity, methods of earlier and more accurate diagnosis of coronary insufficiency, and ambulatory monitoring using the Holter technique and telemetry. By the following year it was possible for a WHO working group, which met in Frei burg, Federal Republic of Germany, to reach agreement on the main elements of a training programme (JO). Rehabilitation today Though the WHO reports in 1964 ( 7) and 1967 (9) emphasized that rehabili- tation must be comprehensive, for many years only the physical aspects received attention, an attitude which still persists today. Physicians recog- nized clinically that psychological factors were important but these tended to be neglected, largely because there were difficulties in communication between cardiologists and psychologists. The problems were obvious from the report of a WHO working group which met in Warsaw ( / 1) and they are still not completely resolved. As a result, psychological rehabilitation has lagged behind physical rehabilitation. The social aspects of rehabilitation have been studied by various centres. There is now a large body of infor- mation on the effects of invalidity on patient and family, employment after an infarction , the physical demands of differing occupations, and the cost of rehabilitation. There is much still to do. Many of these problems are unsuitable for a multicentre trial, particula rly if patients of different nationalities are involved; the financial impact of the disease depends mainly o n a country' s social legislation. As yet, other problems have not been completely solved; there is not enough information on the energy costs of many kinds of job and leisure activity to allow the clinician to give an accurate estimation of the level of activity that is safe for his patient. Over the years there has , however, been slow but appreciable progress towards acceptance of the general principles of comprehensive rehabilitation as declared in 1964 and defined three years later in Noordwijk. Recently , the concept of secondary prevention has been added. The known risk factors for the development of ischaemic heart disease can st ill exert an effect after myocardia l infarction, though their influence on sub- seq uent mortality and morbidity is not necessarily the same as before the first major attack. Correction of at least some of these risk factors has been shown to improve the patient's prognosis. Treatment with beta-blockers and platelet antagonists may also play an important part in primary and secondary prevention but conclusive results are awaited. In this field of research, Europe has made a major contribution. The advent of coronary bypass surgery has had considerable impact on the management of patients with myocardial ischaemia and may have modified their prognosis. Rehabilitation needs remain the same; the general principles of comprehensive rehabilitation are as applicable to the patient after operation as they are to the patient after infarction. 3 Implementing Rehabilitation The current definition of rehabilitation is generally accepted although, in practice, physical training constitutes the major part of any rehabilitation programme and the psychological and preventive aspects are relatively or indeed completely ignored. The patients It can be said that, after an infarction regardless of its severity, all patients can derive some benefit from adequate physical, psychological and social help and advice on secondary preventive measures while they are receiving medical treatment or awaiting the decision to operate. The level of activity in any rehabilitation programme depends on an accurate assessment of cardiac function , but even in those patients with serious arrhythmias , persistent angina or cardiac insufficiency, it is possible to give some help, particularly to enable them to adjust successfully to a somewhat limited existence. Today, the general principles underlying a comprehensive rehabilitation programme are not restricted to the patient after myocardial infarction; they are the same for those with angina or for those who have recently undergone coronary bypass surgery. Patients with other forms of chronic cardiac disease, congenital or acquired , and with arterial hypertension can also benefit. Phases of illness The course of a myocardial infarction can be divided into phases. The acute phase. This begins with the onset of symptoms and ends when the patient is discharged from hospital. The convalescent phase. This lasts some 4-8 weeks, depending on the severity of illness, and ends when the patient's clinical state approximates as closely as possible to the premorbid level. The maintenance phase. By now the patient is rehabilitated and is encouraged to persevere with secondary preventive measures begun during the acute phase. If problems arise during this time, another period of active intervention may be necessary. Some individuals like to continue with a programme designed to maintain the acquired situation . ' The amount of physical activity that may be undertaken varies with the phase of illness. During the acute phase, light activities are appropriate followed by a progressively more active training programme, until the patient is as fit as possible. Thereafter, some individuals like to continue training with the aim of maintaining fitness at the level attained by the end of the convalescent phase. At each phase, psychological and social problems will be assessed and treated and secondary preventive measures begun or repeated. Regular evaluation is important in order that treatment can be changed as necessary . Any rehabilitation programme must be adapted to the individual and the stage of disease. Examples of programmes given in the 4 literature are not to be taken as rigid and unchangeable but should be used as models on which to base treatment. Similarly, the duration of each phase varies from patient to patient. In recent years the time spent in hospital has become appreciably less, patients have been allowed out of bed earlier, and physical reconditioning has been speeded up, so that now the stage has been reached that exercise tests are being carried out before the patient leaves hospital. The psychological benefit to the patient of these new methods of treatment , now becoming widely accepted as standard practice, has been considerable (12). As soon as the patient can lead a more or less normal life, convalescence is over and he can return to work free of limitations and unjustified con- straints. Should unforeseen physical and psychological problems arise at this time, it may be necessary to dispel these with a few weeks of intensive treatment. A maintenance programme is required only if the individual's physical activity at work or during leisure is not enough to allow him to keep fit. Putting rehabilitation into practice Rehabilitation begins with the onset of symptoms and, in principle, the general practitioner is the best person to continue rehabilitation measures once his patient has been discharged from hospital. In practice, this is often not feasible; with increasing knowledge there is now awareness of the complexity of many rehabilitation problems, and the general practitioner may not have the time or equipment to carry out a suitable programme. As a result, specialized rehabilitation centres have been developed. The organiz- ation of these centres varies considerably. They may be run as day centres, where patients can attend for a few weeks to take part in supervised training, or as evaluation centres to monitor the patient's progress in order to supply the general practitioner with adequate advice on graduated physical activity. Throughout Europe there are many different schools of thought on the best way to organize cardiac rehabilitation at each phase of illness. During the acute phase, the majority of patients are treated initially in intensive care units and the rehabilitation programme begins in the coronary care unit. On the other hand, in some districts the policy is to keep some patients at home during the acute illness, so that the early programme must be adapted to this situation (13) . It is at the next stage, convalescence, that the organization of rehabilitation services differs most. In some countries, all patients are transferred from the acute hospital to a specialized rehabilitation centre, where they spend some weeks. There are many arguments in favour of this type of institutionalized rehabilitation; the patient is removed for a time from family and social problems, training programmes can be rigorously supervised, education on dietary habits and correction of risk factors is more intense, and there is more time for specialized psychological help. The cost of this type of rehabilitation is, of course, considerable. Other countries have favoured less formal rehabilitation programmes. During convalesc- ence the patient returns to the hospital or clinic where he was treated during the acute phase for an outpatient training programme. Those who 5 advocate this kind of rehabilitation feel that it provides a supportive setting in which the patient can more easily pick up the threads of normal family and social life again. This helps him psychologically and such treatment is relatively inexpensive. Mixed systems are also found, where selected patients are admitted to rehabilitation centres while others attend as outpatients. Within a single country or district wide variations occur, with well established rehabilitation services in some towns and few or none in others. At its simplest, rehabilitation can be relatively unorganized, with a physical training programme for the patient to carry out at home being prescribed on the basis of a single exercise test and little or no check on progress thereafter. Though the principle of rehabilitation is accepted throughout Europe and the advantages of a unified global approach are, in theory at least, recognized, there is little or no agreement on many aspects. There are differing opinions as to how long patients should remain in hospital during the acute phase, when cardiac function should be evaluated, what methods should be used for psychological assessment and, particularly, how treat- ment during the maintenance phase should be organized. This is most likely the result of different traditions in many European countries, the lack of a well defined plan of rehabilitation and the absence of declared national or international health policies. The Future There remain many unsolved problems in rehabilitating patients after myocardial infarction, not the least being the best way to organize re- habilitation services. More research is needed on many aspects of rehabili- tation: the length of hospital stay, the physical training programme that offers the most efficient way of improving the patient's cardiac function, standardized methods to assess and treat the psychological repercussions of the disease , more accurate determination of when it is safe for the patient to resume work, and further knowledge of the principles of secondary preven- tion and how best to teach these to the patients. In spite of this, rehabilitation has become an integral part of treatment of the patient with myocardial infarction, offering him and his family a better quality of life. Even if coronary heart disease becomes less common, as appears to be happening in a few countries, and medical and surgical treatment becomes more sophisticated, the major part of the burden of care of those with ischaemic heart disease will remain the treatment of the physical , psychological and social sequelae of myocardial infarction. Further research in rehabilitation, both on a theoretical and practical level, will enhance the concept of the value of treating the individual as a whole. It will also bring considerable benefit to clinicians engaged in this field; they can learn much about other related specialties, physiology, psy- chology, industrial medicine and sociology. 6 References 1. Blumgart, H.L. Anatomy and functional importance of intercoronary arterial anastomoses. Circulation, 20: 812-815 (1959). 2. Levine, S.A. Some harmful effects of recumbency in the treatment of heart disease. Journal of the American Medical Association, 126: 80 ( 1944). 3. Levine, S.A. & Lown, B. "Armchair" treatment of acute coronary thrombosis. Journal of the American Medical Association, 148: 1365- 1369 (1952). 4. Hellerstein, H.K. & Ford, A.B. Rehabilitation of the cardiac patient. Journal of the American Medical Association, 164: 225-231 ( 1957). 5. Clark, R.J. & Altman, G.E. Cardiac rehabilitation for work. Modern concepts of cardiovascular disease, 29: 577-580 ( 1960). 6. Franco, S.C. The cardiac can work. In: The heart in industry. Conference of the New York Heart Association. New York, I 953, p. 8. 7. WHO Technical Report Series, No. 270, 1964 (Rehabilitation of patients with cardiovascular diseases: report of a WHO Expert Committee). 8. Heberden, W. Commentaries on the history and cure of diseases. London, T. Payne, 1802. 9. Rehabilitation of patients with cardiovascular diseases: report on a Seminar. Copenhagen, WHO Regional Office for Europe, I 969 (docu- ment EURO 0381). 10. A programme for the physical rehabilitation of patients with acute myocardial infarction: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1968 (document EURO 5030(1)). 11. Psychological aspects of the rehabilitation of cardiovascular patients: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1970 (document EURO 5030(2)). 12. Wenger, N.K. Early ambulation after myocardial infarction: rationale, program components and results. In: Wenger, N .K . & Heller- stein, H .K., ed. Rehabilitation of the coronary patient. New York, John Wiley & Sons , 1978. 13. Coronary care outside big centres: report on a Working Group. Copen- hagen, WHO Regional Office for Europe, 1975 {document EURO 8204(6)). 7 2 Cardiopulmonary function after myocardial infarction: effects of bed-rest, disease and training J. Widimsky & J.-P. Broustet Physical Capacity Deconditioning Immobilization after a myocardial infarction increases the risk of acute thromboembolic complications and results in a number of unfavourable side effects. According to Saltin et al. (/), after twenty days of inactivity maximum aerobic power and muscular strength decrease by 25-50% , heart rate increases for work of medium intensity and stroke volume decreases by 30% . After two weeks disorders of orthostatic regulation are obvious and total blood volume falls. Significant metabolic disturbances occur after restriction of physical activity. Within two days there is a rise in the excretion of nitrogen, sulfur and calcium due to increased catabolism of bone and muscle. Negative nitrogen balance occurs after the fifth day. This can be prevented by a low level of activity, for example by passive movements in bed. Long-term immobility has unfavourable psychological effects, too. Patients become frustrated and if this is unrelieved there is a tendency for depressive symptoms to develop. It was 25 years ago that Levine & Lown challenged the dogma of prolonged immobilization for patients with acute myocardial infarction by proposing "armchair treatment" . Up to then, patients were kept in bed for six weeks or longer in the belief that the myocardial scar was not firm until that time, and partly as a result of the curious observation that rupture of the myocardium was more common in mental hospital patients because they were mentally deranged, restless and would not stay in bed. Duration of immobilization The time spent in hospi tal following infarction has become progressively shorter, and now, for patients with uncomplicated infarction, mobilization frequently starts on the third and fourth day, with discharge home after about 8-10 days. The impact of early mobilization on long-term mortality 9 and morbidity has been studied by groups of cardiologists (2-5). It has been found that the occurrence of cardiac aneurysm is low, about 3%, and is the same whether the patient is mobilized early or late. According to Adgey (6), early discharge does not lead to early readmission or death. Angiographic follow-up studies, however, analysing the incidence of cardiac aneurysm after early mobilization and exercise have so far been made only in very few patients, but their results suggest that early mobilization might increase the occurrence of aneurysm. Some British authors (7) recommend hospitaliz- ation for only 7-10 days, according to the extent and severity of myocardial infarction, though some centres in various countries have examined experi- mentally the effect of shortening the duration of hospital stay even more, particularly in young patients. ~uch drastic shortening of hospitalization can become routine practice only after critical evaluation of results from larger prospective randomized studies, which have yet to be undertaken. Physical capacity at the end of hospitalization Once the condition of the patient becomes stable there is an early improve- ment in the relationship between myocardial oxygen supply and demand, and a later improvement in functional capacity which is associated with increased stroke volume and cardiac output. At about the time of discharge, 50% of patients are unable to reach a heart rate of 130 beats/min without being limited by cardiac symptoms. Subsequently most patients following a recent myocardial infarction have significantly reduced functional capacity of the cardiovascular system, as measured by peak workload and estimated oxygen uptake during a progressive exercise test (8). The rate-pressure product is closely correlated with myocardial oxygen uptake and coronary blood flow in normal subjects and provides a reproducible estimate of the threshold of ischaemia in patients with angina pectoris. However, it dis- regards two major determinants of myocardial oxygen demand, contractile state and ventricular volume. In a series of patients tested by Ibsen et al. (9), at three weeks fatigue was the endpoint in 50%. The median maximal workload was 400 (kp, m)/min (65 watts) with a peak heart rate of 129. Angina occurred in only 11 %, but ST-segment displacement ofat least 1 mm was present in 63% of patients without bundle-branch block or left ventricu- la r hypertrophy. The prognostic significance of the electrocardiographic manifestations of exercise-induced ischaemia during the early phase of recovery is now apparent (JO, 11). Physical capacity after six weeks The lower incidence of exercise-induced ischaemia at six weeks may reflect improved myocardial oxygen supply or a decrease in myocardial oxygen demand. The degree of physical impairment suffered by the patients can range from none to severe. Improvement in the first six weeks in the threshold of myocardial ischaemia as measured clinically and by ECG may be associated with a favourable myocardial oxygen supply/demand ratio. Sanne (12) and Kentala (13) have published data on unselected patient populations studied at uniform intervals after infarction. In Sanne's series, the mean maximal oxygen uptake in 212 male patients three months after infarction was 21 .3 ml/(kg, min) compared with 30.4 in a control group of the same age, i.e. 70% of expected; 55% of the male patients had a physical performance capacity within normal limits. At the beginning of an exercise programme, patients with myocardial infarction have reduced values for cardiac output and stroke volume com- pared with healthy middle-aged men. Only those with a relatively high work capacity have cardiac output and stroke volumes within the normal range. The primary mechanism for reduction of cardiac output in response to exercise is reduction in stroke volume. With more advanced disease and exertional chest pain, restricted chronotropic capacity (reduction in maxi- mal heart rate) and inability to increase systemic arterial pressun:s are additional limiting factors (14). Both cardiac output and stroke volume remain unchanged during the first three months after infarction but improve significantly in the next three months. Haemodynamic Changes Left ventricular function Patients with coronary heart disease often have abnormally raised left ventricular pulmonary end-diastolic pressure, reflecting left ventricular failure. The increase in left ventricular end-diastolic pressure is transmitted to the pulmonary capillary bed, pulmonary compliance is dramatically reduced and as a result exercise-induced dyspnoea is common. The depressed functional state of the left ventricle owing to ischaemia and loss of muscle mass is most likely to be a major factor in this , but extracardiac mechanisms, particularly those affecting ventricular filling pressures, may also be important, particularly after a period of bed-rest and restricted physical activity. In 75% of patients, studied 3-5 months after an acute myocardial infarction, Widimsky & Stolz (I 5) found that there was an increase in left ventricular end-diastolic pressure during exercise in most cases, but that this was observed at rest in a few instances. After digitaliza- tion 88% improved in that they had evidence of a decrease of left ventricular filling pressure, measured directly at rest and during exercise, and an improved relationship between the stroke work index and left ventricular filling pressure . It is not known whether or not digitalis influences myocar- dial compliance, and its effect on left ventricular filling pressure may be due to improvement in myocardial function. In the patients in whom left ven- tricular filling pressure was not influenced by digitalis, it can be assumed that the dominant pathophysiological change is abnormal myocardial com- pliance. The prognostic significance of these findings is not yet known, but it may be concluded that a large proportion of patients after myocardial infarction have latent signs of cardiac insufficiency during rehabilitation . Treatment with digitalis may be of benefit to these patients. Because coronary blood flow is inadequate, the ventricle is unable to function as an efficient pump: there is a loss in contractility, which may be transitory (exercise-induced ischaemia) or permanent (myocardial fibrosis after infarction). Pump failure is not, however, the sole cause of reduced 11 exercise capacity, and other complications may be present to stop the patient's activity before pump failure appears. Changes in systemic blood pressure If exercise-induced ischaemia or post-infarction myocardial fibrosis involves a large ventricular area, patients are unable to increase or to sustain an initial rise in systolic blood pressure. In patients without an infarct, this may be an indicator of stenosis of the left main coronary artery and is generally associated with deep ST-segment depression on the ECG. In those with a history of infarction, the necrotic area is usually shown in many of the anterior leads and severe dyskinesia or aneurysm must be suspected. Physiological Basis of a Training Programme The effect of myocardial ischaemia on response to exercise Before starting his patient on an exercise programme, the cardiologist must assess him thoroughly and carefully and weigh up the possible risks and benefits. His judgement will be sounder if based on knowledge of exercise physiology and, in particular, the effect that ischaemia of the myocardium has on the body's response to exercise. This can be summarized as follows. I. There is reflex compensatory vasodilatation of the coronary bed. 2. Metabolic changes take place which increase the excretion oflactate and potassium from ischaemic cells into the coronary sinus. Ventricular excitability is increased. 3. There is dyskinesia of the left ventricle to some degree. 4. There are haemodynamic and functional changes: decreased cardiac output due to reduction in stroke volume; possible fall in blood pressure; if angina is present, ST-segment depression is present on the ECG and, occasionally, ventricular premature beats; after a small infarction , the commonest limiting symptom is dyspnoea; after a large infarction with dyskinesia, malignant arrhythmias are frequent and limit exercise and are a major risk factor in performing it. Feasibility and results of physical training The training programme should be set up in such a way that the patient himself is anxious to continue active participation in it. He needs instruction from both physician and physiotherapist. His motor ability should be tested and he should be made aware of the frequency of training that is necessary for it to be effective. The individual's physical limitations should be known from his heart rate, electrocardiographic changes, blood pressure and symptoms. 12 Contraindications to training A training programme is contraindicated in patients with unstable angina, arrhythmias which increase during exercise, in second- or third-degree atrioventricular block, with uncontrolled hypertension and cardiac insuf- ficiency. Hellerstein & Franklin (16), on the basis of angiographic findings, recommend that subjects with main coronary vessel stenosis of more than 80% should not be trained. Patients with unstable metabolic diseases should not be involved. The possible limitations of associated disease should be considered, such as mobility problems and psychological state. General effects of training It is not yet known why physical activity should exert a favourable effect on patients after infarction. It is due, undoubtedly, to a complex set of factors involving many biological systems. While knowledge in this area is incom- plete, increased physical activity may have the following beneficial effects: increased efficiency of central and peripheral haemodynamics; metabolic changes at cellular and subcellular levels; increased tolerance to stress; change in lifestyle; influence on blood coagulation and fibrinolytic activity; decrease in the tendency to develop arrhythmias; increase in high-density lipoprotein cholesterol, fall in plasma triglycerides; possible development of a collateral circulation . Influence of physical capacity Sanne (12) followed up for a year I I 2 unselected Gothenburg patients aged 57 years or less who took part in an exercise programme. Aerobic power increased by an average of 17%. In a subgroup who had angina pectoris it increased by as much as 100%. Energy requirements during submaximal exercise decreased. The performance of a control group exam- ined over the same length of time did not change. Almost half of the patients defaulted from the programme. Of those performing regular exercise, 41 % had various temporary orthopaedic troubles . Kentala (13) followed up a similar group from Helsinki. His patients were older; those up to the age of 65 years were included. Age was the main reason why the programme was applicable only in about 20% of the group. In those training regularly, the physical working capacity increased by 56%, compared with a 26% rise in the others. The performance level reached depended on starting performance, size of infarct and its seriousness. The number of orthopaedic complications was very low. Unlike Sanne's patients, the performance in Kentala's group was 50% less after a year than that of a control sample of the population of the same age. The two patient groups differed in starting performance, age and method of training. A rehabilitation programme of sufficient intensity, starting 21/ 2 - 3 months after infarction, with training for half an hour three times a week 13 and lasting 1 ½-3 months has a pos1t1ve effect on submaximal cardio- respiratory and metabolic behaviour, as well as on maximal working ca- pacity. At submaximal loads, heart rate, systolic arterial blood pressure and left ventricular work decrease, and there is a reduction in anaerobic metab- olism which is reflected in decreased lactic acid concentration in arterial blood. Maximal working capacity may increase by more than 30%. This enables patients to perform the same submaximal exercise with minor myocardial oxygen demand. A 6-12% decrease of submaximal heart rate is classically observed after a 6- to 8-week physical training programme. Similarly, a 15% mean decrease of pressure-rate product has been reported. These favourable influences of exercise may well disappear within 2-4 weeks of finishing the programme if the patient does not maintain a reasonable level of ordinary physical activity. Effects on the myocardium and collateral circulation Physical exercise leads to a decrease in the energy needs of the myocar- dium at standard submaximal loads. A significant lowering of the pressure-rate product after a period of physical exercise constitutes the likeliest physiological reason for the symptomatic improvement which occurs in patients with ischaemic heart disease after training. Kentala described a significant decrease in heart rate at a given submaximal workload in patients who had had an infarction 2-5 months previously, which suggests improved maximal performance. Detry et al. (17) and Varnauskas et al. (18) found an increase in arteriovenous difference during submaximal exercise without any change of stroke volume at the same level of exercise. Hagberg et al. (19) have reported impressive cardiac changes in a highly selected group of cardiac patients with asymptomatic ST-segment depression at very high levels of exercise. The question remains whether the normal cardiac patient can safely take exercise at higher levels than these and if so, whether more definite cardiac changes can be demonstrated (20). Hossack & Hartwick (21) have reported an increased risk of exercise- induced events in similar patients. Letac et al. (22) found that hae- modynamic and angiographic investigations showed no significant changes after training in left ventricular end-diastolic pressure, ventricular volume, ejection fraction, mean shortening velocity of circumferential fibres (VCF), percentage of shortening and segmental contractility in those patients whose contractility was considerably impaired, or in those who had large dyskinetic areas or widespread akinesia. As a result, the authors concluded that training has no direct beneficial or detrimental effect on the myocardium. There was no change in segmental contractility as evalu- ated by the percentage of ventricular shortening and by VCF measured at three positions of the left ventricle. The pressures, especially the end- diastolic, showed considerable variations in both directions. It may be noted that patients who have left ventricular end-diastolic pressures above 15 mm Hg (2.0 kPa) have lower values after training. This could be the result of improved left ventricular compliance and may indicate some improvement in performance. However, it is recog·nized that pressure read- ings, unlike angiography, are difficult to reproduce exactly. Letac et al. (22) 14 found no change on repeat angiography in patients with areas of akinesia and widespread dyskinesia on a first examination. It appears that training has metabolic effects at cellular and subcellular level. After exercise on the treadmill, the concentration of myoglobin in muscles increases by 80%, the change occurring only in those groups immedi- ately involved. This is accompanied by a 100% increase in the activity of mitochondrial respiratory enzymes (23). The increased enzymatic activity of the myocardium as a result of exercise may improve the utilization of individual energy-producing components in the myocardium. Studies on arteriovenous oxygen differences in the coronary bed suggest that, during ischaemic heart disease, the myocardium is capable of extracting more oxygen than normal at both low and high levels of exercise. Increased fibrinolytic activity after exercise was first described by Biggs et al. in 1947 (24) and has since been confirmed by many studies. The effects of exercise on coagulation and on fibrinolysis act independently, the increase of fibrinolytic activity being due mainly to activation of plasminogen. Experimental data in dogs and pigs show that physical exercise acceler- ates the development of coronary collateral circulation (25-27). Angiogra- phic studies in man, however, have reported negative findings or minimal changes of collateral circulation (28-30). Whether the negative findings can be explained by limitations in the techniques, patient selection, inadequate intensity or length of training is uncertain. Recently, improvement in myocardial perfusion after training has been reported in a selected group of middle-aged men with angina (20). The most powerful stimulus to the formation of collaterals is ischaemia itself. It could be that exercise can increase this stimulus. Effects on peripheral circulation Training has a beneficial effect on the peripheral vascular system. Haemo- dynamic studies carried out before and after physical rehabilitation have shown that training results in a clear fall in heart rate, a moderate decrease in blood pressure, a decrease in cardiac output and an increase in the arterio- venous oxygen difference. These vascular changes, which are due, at least in part, to an increased vagal and decreased sympathetic tone, lead to a better distribution of blood in the visceral and peripheral muscles. During submaximal exercise, blood flow through the working muscles decreases, their capacity to extract oxygen improves and cellular metab- olism at the mitochondrial level becomes more efficient (31). Effects on risk factors Regular physical activity may decrease a number of risk factors. Mann et al. (32) showed a decreased level of triglycerides following exercise. There are contradicting views on the effect of exercise upon cholesterol. Most authors have found that there are no changes. After 10 weeks of high- intensity physical training, fasting serum cholesterol and glucagon levels remained as before, although there was significant reduction in both fasting triglyceride and insulin levels (33). On the other hand, it has been shown that participation in a moderate exercise programme increases high-density 15 lipoprotein cholesterol levels in myocardial infarction survivors (34). Train- ing can be an effective means of lowering fasting triglyceride and insulin levels in Type IV hyperlipoproteinaemic individuals. This occurs in both supervised and unsupervised programmes providing that those taking part are highly motivated. Why this should be so is obscure, but it may be that the decrease in triglyceride levels may be secondary to the reduction in plasma insulin (33). After training, the mean plasma norepinephrine level at rest and during exercise is reduced. Cooksey et al. (35) feel that the beneficial effects on the cardiovascular system are at least partially mediated by changes in the catecholamine response to exercise. Trained patients tolerate sympathetic activity better than those who have not been trained; they can reach higher maximal heart rates, blood pressure levels and circulating catecholamines. This view is supported by the fact that arterial blood pressure and heart rate are lower in the trained patient for a given workload. This results in decreased myocardial oxygen consumption and the patient can do more before he is stopped by angina. These physiological results of training are exactly the same as the effect of treatment with beta-adrenergic blocking drugs such as propranolol (] 5). Stimulation of the sympathetic nervous system by the intravascular administration of catecholamines produces serious ventricular arrhythmias and increases myocardial necrosis in ex- perimental animals. Beta-adrenergic blocking agents reduce these effects. Training can reduce electrocardiographical ST-segment changes for a given level of exercise. If the amount of change reflects the degree of myocardial ischaemia, this lends additional support to the hypothesis that exercise training reduces oxygen consumption or increases its delivery. Changes in ventricular excitability have been investigated. Since ele- vated levels of catecholamines may be associated with an increased occur- rence of premature ventricular contractions, adrenergic inhibition due to training might reduce ventricular arrhythmias (36). Laslett et al. (37) could not, however, confirm this interesting hypothesis in their study. Effect on morbidity and mortality No study of adequate design, size and duration has yet been completed to determine whether a systematic increase in physical activity reduces mor- bidity or mortality from ischaemic heart disease, but data from several sources suggest that such a benefit might exist. In a collaborative study planned to answer this question, the American National Exercise and Heart Disease Project (38) reported significant physiological and psychological improvement in 651 post-infarction patients during a prerandomized low- level exercise programme. The organizers were unable to find a definitive answer on the effects of exercise on mortality and morbidity from this study because of small sample size and inadequate duration of follow-up (39). Shephard (11) has recently reported some of the results of the Ontario Multicentre Exercise Heart Trial which involved 751 post- infarction patients randomly allocated to a high-level and a low-level exer- cise programme ( 40). In the course of the study, 51 of the participants had another myocardial infarction, 46% of which were apparently related to 16 some form of exercise. The majority of exercise-related episodes occurred in individuals who did not attend the programme regularly and had ST- segment depression on testing, but the episodes were unrelated to the intensity of the prescribed programme. Exercise-induced ST-segment depression was associated with a significantly higher number of fatal recur- rences in high- than in low-intensity exercisers. There may be a "high-risk" subgroup for whom vigorous exercise is contraindicated. The inclusion of these patients has a marked effect on overall mortality, and the existence of such a group could disguise the beneficial effect of exercise on the remaining subjects in the trial. Kellerman ( 41) compared the performance, mortality and morbidity of subjects exposed to long-term or short-term training programmes and in a non-training group. At the beginning of the study exercise performance in all subgroups was identical. After five years it remained unchanged in short-term training subjects, it was increased by 8% in those undergoing long-term training and decreased by 13% in the control group. The mor- tality in the control group and in subjects participating in short-term train- ing programmes was 22% compared with 6% in long-term training subjects. Hellerstein & Franklin (16) found similar results after a three-year training programme. The annual mortality was 2.1 % in the exercise group, while in the control group it reached 4.3%. Bruce's group ( 42) training in the very intensive CAPRI programme in Seattle had a mortality of 3. 1 %, although the expected mortality was 11.2%. Preliminary results of a follow-up study of 953 selected patients after myocardial infarction, who were included in a ten-year rehabilitation plan, showed that in the first three years mortality was 5.5%. Those patients who were unable to stop smoking and those who were unable to return to their previous heavy physical jobs had a poor prognosis ( 43). Results of other studies are similar. The reported differences in mortality can usually be explained on the basis of the selection of patients for study. Level and duration of training In animal experiments, damage to myocardial cell structure is apparently related to exhausting exercise. This suggests that it is undesirable and unnecessary to push exercise to these levels when treating patients with ischaemic heart disease. It may be that training need not be prolonged. Messin et al. ( 44) de- scribed the effect of three sessions of short-interval training on the bicycle ergometer. Myocardial load decreased and the heart rate and blood pressure-heart rate product were significantly lower for the same oxygen consumption. Maximal working capacity increased significantly after short- term training, the benefit being one third of that obtained after training for six weeks. These early changes in functional capacity are exactly the same as those obtained by a prolonged rehabilitation programme. Risks and limitations of physical training programmes Differing rates of cardiac arrest and reinfarction during an exercise pro- gramme have been reported but in general are low. Haskell ( 45) has reported 17 on 13 570 patients participating in I 629 634 patient-hours of supervised exercise: 50 patients had a cardiac arrest during exercise of which 42 were successfully resuscitated; seven patients had another myocardial infarction and in two this was fatal ; and four others died as a result of acute car- diopulmonary disorders. Complication rates are lower in programmes that continuously monitor the ECG during exercise. Their incidence is also lower if programmes in operation after 1970 are evaluated. The majority of reported complications occurred either during the warm-up phase or during the cool-down or tapering-off period at the end of the exercise session. Not everyone benefits from physical training. Patients who show no improvement in physical fitness after short-term training do not benefit from a more prolonged course. There is a close relationship between early and late increase in the ratio of maximum aerobic power to symptom- limited oxygen consumption (VO 2 max/SL), both in absolute terms as well as in the percentage of the pretraining VO/ SL level, the correlation coef- ficients being 0.87 and 0.88 ( 44). It may be, though it is as yet unproven , that within the first few months of physical training most patients do show physiological improvement, but as training continues its benefits are super- ceded by the natural progression of disease (14) . In modern society, increased mechanization has resulted in jobs becom- ing more a like in their physical requirements . They are lighter and more sedentary and any cardio-protective effect of exercise is being lost. Leisure- time physica l activities are thus of increasing importance. Any study under- taken to test the hypothesis that physical activity enhances the quality of life and possibly its length must take these facts into consideration. More accurate ways to evaluate the physical demands of day-to-day activities are needed . While definitive studies are awaited, it can be said quite positively that the available evidence is that rehabilitation programmes do provide ben- eficial comprehensive treatment though they do not aim to cure the under- lying disease. They enhance the quality of life for the majority of patients and may hopefully prolong it. They are not substitutes for other therapy such as good medical treatment and coronary bypass surgery. Exercise by itself is not enough , but the individual who is aware of increased physical fitness within prescribed safety limits is likely to be happier in himself, more confident of his future and more willing to modify his lifestyle to reduce risk factors. References I . Saltin, B. et al. Maximal oxygen uptake and cardiac output after 2 weeks at 4300 m. Journal of applied physiology, 25: 400-409 ( 1968). 2. Groden, B.M. The management of myocardial infarction . A controlled study of the effects of early mobilisation. Cardiac rehabilitation, 1: 13 (1971). 3. Harpur, J.E. et al. Controlled trial of early mobilisation and discharge from hospital in uncomplicated myocardial infarction . Lancet, 2: I 131- 1134 (1971). 18 4. Lamers, H.J. et al. Early mobilization after myocardial infarction: a controlled study. British medical journal, 1: 257-259 (1973). 5. Thornley, P.E. & Turner, R.W.D. Rapid mobilization after acute myocardial infarction. First step in rehabilitation and secondary prev- ention. British heart journal, 39: 471-476 (1977). 6. Adgey, A.A.J. Prognosis after early discharge from hospital of patients with acute myocardial infarction. British heart journal, 31: 750- 752 (1969). 7. Tucker, H.H. et al. Results of early mobilization and discharge after myocardial infarction. British medical journal, 1: 10-13 (1973). 8. Wohl, A.J. et al. Cardiovascular function during early recovery from acute myocardial infarction. Circulation, 56: 931-937 (1977). 9. Ibsen, H. et al. Routine exercise ECG three weeks after acute myocar- dial infarction. Acta medica scandinavica, 198: 463-469 (1975). 10. Epstein, S.E. et al. Evaluation of patients after acute myocardial infarc- tion. Indications for cardi.ac catheterization and surgical intervention. New England journal of medicine, 307: 1487-1492 (1982). 11. Shephard, R.J. Recurrence of myocardial infarction . Observations on patients participating in the Ontario Multicentre Exercise-Heart Trial. European journal of cardiology. 11: 147-157 (1980). 12. Sanne, H. Exercise tolerance and physical training of nonselected patients after myocardial infarction. Acta medica scandinavica (Suppl. 591): 1-124 (1973). 13 . Kentala, E. Physical fitness and feasibility of physical rehabilitation after myocardial infarction in men of working age. Annals of clinical research, 4(Suppl. 9): (I 972). 14. Bruce, R.A. et al. Differences in cardiac function with prolonged physi- cal training for cardiac rehabilitation. American journal of cardiology, 40: 597-603 ( 1977). 15. Widimsky, J. & Stolz, I. The adaptation of cardiovascular system to exercise and training in healthy subjects and in heart disease. Acta Universitatis Carolinae. Medica, LXXXII: 1-105 (I 977). 16. Hellerstein, H.K. & Franklin, B.A. Exercise testing and prescription. In: Wenger, N.K. & Hellerstein, H.K., ed. Rehabilitation of the coronary patient. New York, John Wiley & Sons, 1978. 17. Detry, J.M. et al. Increased arteriovenous oxygen difference after physi- cal training in coronary heart disease. Circulation. 44: 109-118 ( 1971 ). 18. Varnauskas, E. et al. Haemodynamic effects of physical training in coronary patients. Lancet, 2: 8-12 ( 1966). 19. Hagberg, J.M. et al. Effect of 12 months of intense exercise training on stroke volume in patients with coronary artery disease. Circulation, 67: 1194-1201 (1983). 20. Froelicher, V. et al. A randomized trial of exercise training in patients with coronary heart disease. Journal of the American Medical Associ- ation, 252: 1291-1297 (1984). 21. Hossack, K.F. & Hartwick, R. Cardiac arrest associated with supervised cardiac rehabilitation. Journal of cardiac rehabilitation, 2: 402-410 ( 1982). 19 22. Letac, B. et al. A study of left ventricular function in coronary patients before and after physical training. Circulation, 56: 375-378 ( 1977). 23 . Holloszy, J.O. Adaptations of muscular tissue to training. Progress in cardiovascular diseases, 18: 445-458 ( 1976). 24. Biggs, R. et al. Observations in fibrinolysis ; experimental activity pro- duced by exercise or adrenaline. Lancet, 1: 402-405 (1947). 25. Eckstein, R. W. Effect of exercise and coronary artery narrowing on coronary collateral circulation. Circulation research, 5: 230- 235 ( 1957). 26. Heaton, W.H. et al. Beneficial effect of physical training on blood flow to myocardium perfused by chronic collaterals in the exercising dog. Circulation, 57: 575-581 ( 1978). 27. Bloor, C.M. et al. Effects of exercise on collateral development in myo- cardial ischemia in pigs. Journal of applied physiology, 56: 656-665 ( 1984). 28. Ferguson, R.J. et al. Effect of physical training on treadmill exercise capacity, collateral circulation and progression of coronary disease. American journal of cardiology. 34: 764-772 ( 1974). 29. Nolewajka, A.J. et al. Exercise and human collateralization. An angio- graphic and scintigraphic assessment . Circulation, 60: 114-122 ( I 979). 30. Cobb, F.R. et al. Effects of exercise training on ventricular function in patients with recent myocardial infarction. Circulation, 66: 100-108 ( 1982). 31 . Clausen, J.P. & Trap-Jensen, J. Regulation and distribution of cardiac output during exercise in patients with coronary artery disease and the effects of training. In: Larsen, O.A. & Malmborg, R.O., ed. Coronary heart disease and physical fitness. Copenhagen, Munksgaard, 1971. 32. Mann, G. V. et al. Exercise to prevent coronary heart disease. American journal of medicine, 46: 12-27 ( 1969). 33 . Lampman, R.M. et al. Effectiveness of unsupervised and supervised high intensity physical training in normalizing serum lipids in men with Type IV hyperlipoproteinemia. Circulation, 57: 172-180 (1978). 34. Erkelens, D.W. et al. High-density lipoprotein cholesterol in survivors of myocardial infarction. Journal of the American Medical Association, 242: 2185-2189 (1979). 35 . Cooksey, J.D. et al. Exercise training and plasma catecholamines in patients with ischemic heart disease. American journal of cardiology, 42: 372-376 ( 1978). 36. Blackburn, H. et al. Premature ventricular complexes induced by stress testing; their frequency and response to physical conditioning. Ameri- can journal of cardiology, 31 : 441-449 ( 1973). 37. Laslett, L. et al. Ventricular ectopy frequency and complexity not altered by exercise training in coronary disease patients. Cardiology, 70: 284-290 ( 1983). 38. Naughton, J. The National Exercise and Heart Disease Project. The pre-randomization exercise program. Report No. 2. Cardiology, 63: 352-367 ( 1978). 39 Shaw, L.W. Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after a myocardial infarction . American journal of cardiology, 48: 39-46 ( 1981 ). 20 40. Rechnitzer, P.A. et al. Relati o n o f exercise to the recurrence of myoca r- di a l in farcti o n in men. American journal of cardiology, 51 : 65-69 ( 1983). 41. Kellerman, J .J. Ph ys ical conditioning in patients after myocardial infarct io n. Result s of a co mparative stud y and 9 yea rs fo llo w-up. S chwcizerische medizinische Wochenschrift, 103: 79-85 ( 1973). 42 . Bruce, R.A. Benefi ts of physical training for patients with coronary heart disea se. In: Ingelfinger, F .J. et al., ed. Controversy in internal medicine 11. Philadelphia, PA, Saunders, 1974. 43. Stocksmeier, U. et al. Die Sterblichkeit der Herzinfarktpatienten in der Ho henrieder Uingsschnittstudie. Herz Kreislauf. 7: 455 ( 1975). 44. Messin, R. et al. Influence of short-term physical training on exercise tol erance after myoca rdial infarction. European journal of cardiology, 5: 155- 165 ( 1977). 45 . Haskell, W.L. Cardiovascular complicati o ns during exe rcise tra ini ng of cardiac patients. Circulation, 57: 920-924 ( 1978). 21 3 Exercise testing of cardiac patients S. Degre An exercise test aims to test the individual's fitnes s for wo rk , sport and other activities , to evaluate the functional status of his cardiovascular and respir- atory sys tem, and to evaluate the effect of preventive, therapeutic and rehabilitative progra mmes. Factors Limiting the Exercise Test Physiological factors Although it is very ea sy to measure the limitatio ns o fa ma n's performance capacity by a maximal exercise test, it is essential to know at what point th e orga nism's physical working capacity is at an end. Man's exhaustion appears to occur when his consumption of oxygen leve ls off. Severa l authors ( 1-5) have pointed to the impo rtance of the heart and it s capacity to circu late the blood . They feel that circulat o ry fac tors gove rn the level of man's maximum oxygen upta ke . The dimensions of the hea rt in healthy men prov ide an upper limit for the central circulation , whi ch in turn determines the upper range for arterial oxygen transpo rt and the ex te rnal wo rk that can be performed . Cardiac output can neve rtheless vary in maximal work in which max i- mal oxyge n uptake is attained . Moreover, card iac o utput per se is not the primary reason why a subject has to stop exercising, eithe r in prol o nged o r in brief max imal exe rcise . In spec ia l circumstances, most of the links o r sys- tems involved in oxygen transpo rt a t the cellular leve l have ex tra capacities and these can be used to vary the limits of man' s exercise tolerance. How- ever, in no rmal subjects ma ximum oxygen uptake remains the most accura te measurement of maximal working capacity (5). Physiopathological factors In patients , exe rcise can be interrupted by signs or sympto ms arising befo re oxygen consumption levels off. Respi ratory problem~ due to restrictive or o bstructive di sease, alterations in ve ntilation-perfusio n ratio, decreased oxygen diffusing ca pacit y, mechanica l disturbances o f the thoraco- lung 23 sys tem, corona ry ins ufficiency, ca rdi ac a rrhythm ias a nd d iminished oxygen utili za tio n by the whole periphera l muscula r mass are so me o f the fac to rs tha t will limi t the amou nt of exe rcise in pa ti ent s with ca rdi ac a nd respi ra to ry disease ( 6). Practical Factors that may Limit Exercise Stress Testing Contraindications It is genera ll y agreed tha t stress testing sho uld not be do ne o n: pa ti ents wit h a n ac ute myoca rdia l infarc t ; pat ients suffering fro m ac ute myoca rd iti s o r perica rditi s; pa ti ents with unsta ble progress ive a ngina, including those with fa irly recent o nse t of a ngina at rest , pa rti cu la rl y if their pa in is prolo nged ; pa ti ents with ra pid ve ntricula r o r a tri a l a rrh ythmias; pa ti ents with econd- o r third-degree hea rt block; pa ti ents with conges ti ve hea rt fa ilure; ac utely ill pa tients with infec ti ons or hyperth yroidism; pa ti ents suffe ri ng fro m ao rti c stenosis. Indications for stopping exercise In patient s who a re sympto m-free during exe rcise, the test can be co ntinued until a levelling off of oxygen consumptio n occurs ( 7) . Physical wo rking capacity is expressed by the max imal oxygen consumptio n o r ae robic power. If o xyge n consumptio n is no t measured , exe rcise sho uld be stopped if the hea rt rat e is more tha n the fi gure ca lcula ted by subt racting the individual's age fro m 220 (220 - age). In pa tient s with ca rdi ac o r respirato ry d isease, the test sho uld be sto pped if the fo llowing signs or sy mpto ms a ppea r: 24 increas ing pa in in the chest severe dys pnoea severe fa tigue fa intness and cla udica tio n pa llor co ld , mo ist ski n cyanos1s stagge ring confusio n in respo nse to inquiries head nodding systo li c blood pressure above 250 mm Hg (33 .3 kPa) absence of the no rmal pressure increase o r dec rease of blood pressure during exe rcise significant alterations of the ECG such as paroxysmal arrhythmias, ventricular premature bea ts appearing before the end of the T-wave, conduction disturbances o ther than a slight atrioventricular block, and ST-segment depression of more than 2 mm of the horizontal or descending type . In these cases, working capacity is expressed by a "symptom-limited" oxygen intake. These indicatio ns for sto pping the test represent a consensus o f opinion but, in practice, there are considerable variations among centres. For exam- ple, two , three or more consecutive ventricular premature beats wo uld often be additional indications . Some authors maintain that if no abnormal signs or symptoms occur, the test should be stopped routinely when the heart rate reaches a value o f 200 - age. This level represe nts about 80% of maximal working capacity (8). In ea rly testing after myocardial infarcti o n, a target heart rate of 120 or 130 beats/ min is often ch osen. Practical Use of Exercise Testing Expressing the results Ph ys ical fitness ca n be expressed in physica l o r physio logical unit s (9), bo th o f which are related to the efficiency ratio o f the man-ergometer couple, usua lly of the order of20-25% . For exam ple, a n effo rt at 75 watts requires an oxygen consumption of I litre/min. Thermodynamic principles indicate that 75 watt s corresponds to I Kca l. Calorimetry indicates that consumption o f I litre of oxygen co rresponds to 4.825 Kcal. The efficiency ratio in thi s case is I di vided by 4.825, o r a littl e more than 20% . The ph ys ica l units are the unit of powe r (wa tt) and the unit of wo rk (joule). Th e phys io logica l unit is oxygen cons umpti o n exp ressed as ml / min , as ml/( kg • min) o r as mets, the multiple of th e basal metabolic rate (3 .5 ml / kg • min). These units are related o nl y if work is performed under steady-sta te conditio ns. For example , 100 wa tt s corres ponds to a n oxygen consumption of 1.5 litres/min if the co nditi o n of steady-state has been reached. This requires about three minutes a t a constant workload. Evaluat ing ability to work Physica l wo rking capacity o btained fro m a n exercise test allows an accura te determin a ti o n of the individu a l' s ph ys ica l ability to carry o ut hi s job. Altho ugh in thi s co mpara ti ve ly new field more research is necessa ry, it is possible at this stage to give so me simple guidelines so that data from the tes t can be translated into eve ryday acti vities. If th e individual is to underta ke eight hours o f continuous work, its ph ys ical req uirements sho uld no t exceed 33-40% of hi s maxima l oxygen intake. Repetitive peak activity ove r a n eight-ho ur period sho uld require less than 60% of max imal oxyge n intake . 25 In patients with a symptom-limited oxygen intake an extra fact must be taken into account. Peak act ivities should never exceed the load a t which symptoms or signs appear (JO, J /). In general, a patient should never be allowed to return to work on the basis of a theoretical working capacity, obtai ned by extrapolation from submaximal values, but only on the basis of data actually recorded during the test. Prescribing a suitable rehabilitation programme The principles which underline the prescription of exercise for healthy individuals ( 6, J 2) are the same for those patients who have reached their real maximal oxygen intake. The heart rate at the end of the test forms the basis for prescription . The maximum heart rate for training is set rather arbitrarily at 85% of the heart rate at the end oft he maximal exercise test. This builds in a safety factor, so that a patient may exceed that level in sudden bouts of exercise without damage to himself. Patients with a symptom-limited oxygen consumption must be taught how to estimate their own activity threshold. They should be advised that, once their symptoms occur during exercise training, they must stop activity, take time to recover and then start again. In these cases, intensity of training depends on the heart rate reached in the test at the moment of onset of symptoms. Interpretation of the Results of Exercise Testing Energy requirements The endpoint of an exercise stress test occurs when a maximal or submax- imal load is reached for a predetermined maximal heart rate (220-age) or submaximal heart rate (200-age). In some cases it may be the heart rate at which the patient has onset of symptoms (symptom-l imited exercise). Depending on the protocol used in a particular exercise stress test, each level of exerc ise reached corresponds to a particular oxygen consumption, usually expressed in mets (multiple of the individual basal metabolic rate). In practice, if an exercise stress-testing laboratory is using an increment of 10 W/min or 30 W/3 min, the nomogram shown in Fig. 1 can be used. For each level of exercise reached during the test there is a permissible level of everyday activ iti es. From diagrams such as this, which give the energy requirements of day-to-day activity, leisure pursuits or at work, it is possible to advise the cardiac patient on a safe, suitable level of exercise (/0). Diagnostic and prognostic implications Observation of a true ST-segment depression (hor izontal or down-slop ing ST-segment depression of I mm or more, for at least 60 ms after the J point, in an ST-segment which was normal prior to exercise) denotes the presence of myocardia l ischaemia. It s severity can be deduced from considera tion of the depth of the exe rci se-induced ST-segment depression and the hea rt rate or the load a t which the ST-segment becomes depressed. Important 26 Fig. 1. Prescription o f su itabl e daily actIvItIes from the result s o f exe rc ise testing (30 W 3 min in c rements) Watts vo, Mets Activity Physical fitness Functional (I/min) (VO 2 ) (I/min) class 240 Males Females BM R 1.1 BMR 0.9 Sporti ng Excel lent 3.1 3 .1 210 Physically 3.0 13 16 active individuals Very Very 180 high good 2.5 11 13.5 150 2.3 2 .3 Healthy sedentary 11 people 2.0 9 120 High Good 1.6 1.6 90 1.5 6.6 8 High to Good to medium moderate ~ E a; 60 s 1 1.1 1.1 C. "' E C: 5.4 ~ -~ II 1.0 4.4 > Medium Moderate ;S 0 i ill a: ~ 30 0 .8 0 .8 .~ Light Fair ~ 0. .5 Ill 0.5 2 2.5 0 Sedentary Poor IV 27 information on the patient's likely prognosis can be obtained from the amou nt of physical work that has been performed. If the individual being tested is symptom-free, the implications of a positive exerc ise ECG are different from those in patients with known coronary disease. This is because the diagnostic accuracy of a positive ECG depends not on ly on the spec ifi city and ·sensi ti vity of t he test but also on th e prevalence of ischaemic heart disease in the community ( 13). There is evidence which suggests that, in these circumstances, a true positive must include an ST-segment a lteration of more than 2 mm at a low workload in an individual with at least some of the well recognized coronary risk factors. Typical appearances of myocardial ischaemia on the test isolate some 10- 15% of the population who, independently of other risk factors, have at least twice the chance of developing the symptoms of ischaemic heart disease (14). In the patient with ischaemic heart disease ST-segment depression must be eva luated within its clinica l con text. Its importance as a prognostic indicator is not necessarily the same in all patients with ischaemic heart disease. It depends on whether o r not the indi vidua l has symptoms and ifhe has a history of a previous myocardial infarction. In patients with angina who have not had an infarction the exercise ECG correla tes closely with pathological changes in the coronary arteries and is of great value in making the choice between medical or surgical treatment (/J). Sensitivity of the test is lowest and the proportion of false negatives highest in patients with mild coronary artery disease who are relatively at "low risk" within the coronary population. Considerable work has been done on these aspects and, as a result, it can be said that 40-42% of patients with one-vessel disease, 65-66% of those with two-vessel disease a nd 80-85% with three-vessel disease have a positive exercise ECG (13). The annual mortality from coronary heart diseases increases with severity; th ose with one-vesse l disease having a rate of 2.2-2.9% rising to 6.8-13.7% for those with two-vessel disease and 10.7- 16.7% for those with three-vessel disease. The prognostic value of a positive exercise ECG is thus best when the annual mortality rate from the disease is highest. Rate of progression of ST-segment depression with respect to increases in heart rate has recently been shown to be reliable in the diagnosis of coronary heart disease and in evaluating its severity in individuals wi th angina. This was also true in patients being treated with beta-blockers (/5). The amount of exercise-induced, ischaemic ST-segment depression is correla ted with the severity of coronary artery disease. Ellestad ( 7) has conc luded from a stud y of the literature that in patients undergoing exercise electrocardiography, the lik elih ood of the presence of coronary disease in associa ti on with ST-segment depression of 1.0 mm is 90% , with ST-segment depression of 1.5 mm it is 94-96% and with ST-segment depression of > 2.0 mm it is 98 % . Stenosis of the main left coronary artery shou ld a lways be suspec ted when the exercise ECG is strongly positive, with depression of the ST-segment of a t leas t 2.0 mm. In post-infarction patients th e diagnosis is already es tablis hed. The resu lt s of exerc ise testing have different implications in thi s group of 28 patients. A negative test in patients with a reasonably good left ventricular function indicates a subgroup whose prognosis is good in that their mor- tality in the year after their infarction is less than 3%. On the othe r hand, patients with a pos itive test have a 20% risk of dying ( 16). In a populatio n who have a strongly positive stress test (> 2 mm ST-segment depressio n), coronary arte ri ography has been shown to be a more reliable technique to detect a high mo rtality risk (14) . Other methods of interpreta ti o n for exercise-ECG analysis have been proposed, particularly R-wave amplitude variations. Unfortunately, thi s technique is less specific and sensitive than the exerci se-induced ST-segment depression for detection of coronary insufficiency. It can nevertheless be of help in patients who take digitali s or beta-bl ockers (17). The significance of heart rate, workload, physical working capacity and blood pressure The cha nce of identifying correctly coronary artery disease in an indi vidual with o r withou t symptoms increases in proportion to the magni tude of ST-segment depression, particularl y if it occurs at a low exercising heart rate ( 13). Of the many variables that predict whether or not the patient will survive, the ejection fraction of the left ve ntricle is the most accurate. Of the exercise variables, hea rt rate, blood pressure and the level of maximal working capacity have been shown to contribute to predicting su rvival. Blood pressure va lues reaching a plateau or decreasing during exercise are indicators of inadequate left ventricular function during exercise whether the exe rcise test takes place early , a week or so after myocardial infarction , or at the rou tine six weeks. Under beta-blocking or calcium- blocking agents these parameters must nevertheless be carefully a nalysed. Exertional ST-segment depression did not increase the accuracy of predic- tion (18, 19). The significance of radionuclide imaging Performed a fter limited exercise, non-invasive radionuclide cineangi- ography has been employed to determine left ventricular function in the post-infarcti on setting, permitting accuracy not possible by clinical assess- ment (20). Parallel studies have demonstrated that myocardial perfusion sci ntigraphy (thallium-201) surpasses the accuracy of exercise electro- cardiography alone in detecting patients with multivessel disease (21). The prognostic value of a positive exercise test in women Fa lse positive ECGs are fo ur times more common in women than in men (22) . There is an expected rate of 33% of true positive exerc ise test results in women as compared with 89% in men, though the incidence rate of false nega tive exe rcise test results is higher in men , 37% for men as compared with 12% in women. As a result, a posi ti ve exercise test in women is of little va lue in predicting the presence of significant coronary artery disease, whereas a negative test is quite useful in ruling it out (22). As a prognostic indicator, a positive exercise ECG in women is thus of little use. 29 The prognostic value of exercise-induced arrhythmias Ventricular arrhythmias induced by maximal exercise are not associated with increased mortality (23.24). On the other hand, ventricular arrhyth- mias detected at rest, during daily activ ities or at low levels of exertion on an exercise test have been reported to be associated with a poor prognosis (23). Early exercise testing after myocardial infarction A recent review of the literature (25) underlines the interes t of ea rly exercise testing after myocardial infarction. The poten ti a l benefits of such testi ng include better psycho logica l adaptation, detection of arrhyt hmias and residual angina, and determination of post-hospital prognosis. In addition, early exercise testing facilitates exercise prescription in the post-hospital phase . It is nevertheless necessa ry to take into account the fact that exercise tests reported to have been early have been performed at anything from three days to eight weeks after infarction . The intensity of the exercise is also variable. The following conclusions appear, at the present time, to be warranted. Exercise testing prior to discharge from hospital appears to be rela- tively safe, as far as it is performed in strictly controlled research settings. Exercise testing prior to discharge can provide information to formu- late a safe post-hospital exercise prescription. Arrhythmias are detected better by 24-hour electrocardiography than by exercise testing. Although exercise testing occasionally has revealed arrhythmias not detected by 24-hour electrocardiography, the clinical importance of such discordance is unclear. Exercise-induced ST-segment depression ear ly after infarction appears to have prognostic sign ificance in terms of subsequent development of fatal and nonfatal coronary events. The level of work reached may give additiona l information . The significance of exercise-induced ventricular arrhythmias and angina in this context remains unclear ( 13). References I. Christensen, E.H. Das Herzminutenvolumen. Ergebnisse der Physiologie, biologischen Chemie und experimentellen Pharmakologie, 39: 348-407 ( 1937). 2. Hill, A. V. et al. Muscular exerc ise, lactic acid and the supply and utiliza- tion of oxygen. Part VIII. Muscular exe rcise and oxygen intake. Pro- ceedings of the Royal Society of London, 97: 155 ( 1924). 3. Margaria, R. et al. The possible mechanisms of contractions and paying the oxygen debt and the role of lactic acid in muscular contraction. American journal of physiology, 106: 689 ( 1933). 4. Nielsen, M. & Hansen, 0. Maximale korperliche Arbeit bei Atmung 0 2-reicher Luft. Skandinavisches Archiv fur Physiologie, 76: 37-59 ( 1937). 30 5. Saltin, B. Oxygen transport by the circulatory system during exercise in man . In: Keul, J., ed. Limiting factors of physical performance. Inter- national Symposium, Gravenbruch, 1971. Stuttgart, Thieme, 1973. 6. Degre, S. Entrainement muscu/aire chez le ma/ade cardiaque et pul- monaire, 2nd ed. Paris , Maloine, 1978. 7. Ellestad, M.H., ed. Stress testing: principles and practice. Philadelphia, PA, F.A. Davis Co., 1975. 8. American College of Sport Medicine. Guidelines for graded exercise testing and exercise prescription. Philadelphia, PA, Lea & Febiger, 1975. 9. Degre, S. General principles of exercise testing. In: James, W.E. & Amsterdam, E.A. , ed. Coronary heart disease, exercise testing and car- diac rehabilitation. Miami, FL, Symposia Specialist Medical Boo ks, 1977. 10. Lange Andersen, K. et al. Habitual physical activity and health. Copen- hagen , WHO Regional Office for Europe, 1978 (WHO Regio nal Publi- cations , European Series, No. 6) . 11. Messin, R. et al. L'evaluation fonc tion nelle du patient cardiaque en pratique courante. In: Denolin , H. et al., ed. L'ergometrieen cardio/ogie. Symposium, Frei burg im Br. 1967. Mannheim, Boehringer, 1968. 12. Shephard, R.J. Exercise test methodology and exercise prescription . In: James, W.E. & Amsterdam, E.A., ed. Coronary heart disease, exercise testing and cardiac rehabilitation. Miami, FL, Symposia Specialist Medi- cal Books, 1977. 13. Amsterdam, E.A. & Mason, D.T. Prognostic importance of exercise tests. In: James, W.E. & Amsterdam, E.A., ed. Coronary heart disease, exercise testing and cardiac rehabilitation. Miami, FL, Symposia Special- ist Medical Books, 1977. 14. Redwood, D.R. et al. Whither the ST segment during exerc ise? Circu- lation, 54: 703-706 ( 1976). 15 . Kardash, M. et al. The slope of ST-segment/ heart rate relationship during exercise in the prediction of severi ty of coronary artery disease . European heart journal, 3: 449-458 ( 1982). 16. Epstein, S.E. et al. Eva I uation of patients after acute myoca rd ia l infarc- tion. Indica tions for cardiac cathete ri zation and surgical interve nti o n. New England journal of medicine, 307: 1487-1492 (1982). 17 . Degre, S. et al. Analisis de los cambios en la a mplitud de la o nda R inducidos po r el eje rci cio en la detecci6n de cardiopatia isquemica en pacientes bajo trata miento con betabloqueantes y digital. Revis ta latino- americana de cardio/ogia, 3(Suppl. 1): 102 (1982). 18. Bruce, R.A. et al. No ninvasive predictors of sudden cardiac death in men with coronary disease. Predictive va lue of maximal stress testing. Amer- ican journal of cardiology, 39: 833-840 ( 1977). 19. Hammermeister, K.E. et al. Variables predictive of survival in patients with coronary di sease. Selection by univariate and multivariate analy- ses from the clinical electrocardiographic, exe rcise, arteriographic, and quantitative angiographic evaluations. Circulation, 59: 421-430 ( 1979). 31 20. Borer, J .S. et al. Sensitivity specificity a nd predictive acc uracy of radio- nuclide cineangiography during exe rcise in patients with coronary artery disease. Circulation, 60: 572-580 ( 1979) . 2 1. Gibson, R.S. et al. Predicting the extent a nd location of coronary artery di sease during the ea rl y post infarction period by quantitative 20 I thal- lium scin tigraphy. American journal of cardiology, 47: 1010- 10 19 ( 198 1 ). 22. Lesbre, J. et al. L'electrocardiogramme d'effort chez la femme. Archives des maladies du coeur et des vaisseaux, 69: 935-942 ( 1976). 23. De Backer, G. & Van Durme, J.P. Early work load tes ts for eva luat io n of long-term prognosis of acute myocardial infarct. British heart journal, 40: 1194-1 195 ( 1978). 24. Kentala, E. et al. Factors related to long-term prognosis fo llowing ac ute myocardial in farc tion. Scandinavian journal of rehabilitation medicine, 7: 11 8- 124 ( 1975). 25. Miller, D.H. & Borer, J.S. Exercise testing ea rl y after myocard ial in farc- ti o n. Ri sks and benefits. American journal of medicine, 72: 427-438 ( 1982). 32 4 Psychological factors in patients after myocardial infarction E. Cay, V.P. Zaitsev & S. Rudnicki Until the middle of this century, psychological interest in coronary heart disease was almost totally preoccupied with problems of etiology. But towards the end of the 1950s papers began to appear suggesting that psycho- logical factors were important in determining outcome of treatment. This occurred as a direct consequence oft he changing pattern in incidence and in treatment of acute myocardial infarction. The rate of ischaemic heart disease was increasing rapidly in most of the developed countries of the world, as was the number of young people affected; they were not satisfied with mere survival but wanted life afterwards to be as near normal as possible. With the demonstration by Levine & Lown in I 952 (]) of the advantages of early mobilization, and with the growth of coronary care units, new drugs and investigative techniques, the medical profession became more "aggressive" in treating infarction patients and the I 960s and 1970s saw the growth of planned, graduated exercise training programmes. Physicians and cardiolo- gists began to evaluate these new methods of treatment. Causes of failure were not purely physical; a variety of personal factors, soc ioeconomic problems and family and cultural influences emerged (2,3). Precise identifi- cation of psychosocial factors was frequently not attempted and they were classified as "adverse psychological influences". Psychologists and psychologically-oriented research workers then entered the field and although much of this early work can be criticized on the grounds that it was anecdotal , often based on biased patient selection, used inappropriate methods of measurement, and was couched in terms that physicians could not understand, nevertheless, it became apparent that there was considerable agreement on the psychological factors that were particularly important in determining outcome. Emotional reaction to the illness. Anxiety and fear were common and there was cons iderable unwarranted emotional distress in patients after a heart attack ( 4, 5) . Anxiety, if severe, might well be the main reason for fai lure to return to work. Unrelieved depression, with loss of confidence and a sense of insecurity, was also a cause of poor outcome (6). 33 Personality. Traits were important, rather than a specific personality type. The inadequate, overdependent individua l was likely to be sat isfied with the sick role ( 7). The methods of coping with stress which the individual had developed ove r the years determined how he coped with ischaemic heart disease ( 6). These personal attitudes were influenced by a number of environmental factors: att itudes to heart disease prevalent in the patient's cu lture (J); the attitudes of his family (8); his age (9); his social class ( IO); the reactions of fellow workers and employe rs to the individual who has had an infarc- tion (/ /); and the socioeconomic situat ion prevailing at the time of his illness (3) . The past decade has seen patchy but increasing recognition that rehabili- tation must be comprehensive, with phys ical , psychological and social components, a nd is app licable to a ll patients. The skrlls of the physician may not be sufficient to cope with every aspect, particularly in those with severe psychological or social problems, and this has led to acceptance of the va lue of the multidisciplinary team . Most recently, our knowledge of ri sk factors after myocardial infarction has increased and secondary prevention has become an essential element of any cardiac rehabilitation programme. These changes in treatment are reflected in research trends over the past few years. There has been a distinct move towards investigation by a research team so that physical, psychologica l and social variables are exam- ined in the same group of patients, enabling interactions between them to be studied. There is ev idence now concerning the "nat ural history" of the individua l's reactions from the onset of pain, while he is confined to bed , during initial mobilization, increasing activity and resumption of work and leisure activities (/ 2, 13) . The influence of family attitudes has been studied and the effect ofan infarction on the individual's ro le within the fami ly, on the family structure (14) , on sexual functioning (/5-/7) and o n social network s exam ined. Much work has been concerned with the psychol ogical impact o n the patient of physical method of treatment ( 18, 19) . New tech- niques to measure psychol ogical variables have been devised , and efforts are being made to improve the identification of th ose patients who will have difficulty in returning to an active life (/3,20,21). The advantages and disadvantages of various psychological methods of treatment have been critica ll y assessed (22.23). Natural History Psychol ogical reactions to a myocardial infarction and their appropriate care will be different at each stage of illness and parallel changes in phys ical state. Psychological reactions during the acute illness To the patient , the onset of an acute m yoca rdial infarction means a sudden and bewildering progress ion of pain , emergency admission to hospital - 34 usually to an intensive care unit - and forced complete inactivity. Not surprisingly , his immediate reaction is fear - in some a specific fear of death , but more commonly fear that the illness represents a potent threat to his established pattern of living. Continuing symptoms, chest pain and breathlessness , may also increase anxiety. Hackett & Cassem (24) have shown that a less obvious symptom which may provoke anxiety is weakness ,. particularly in young, previo usly healthy , men. Patients regard weakness as proving that their illness is irreve rsible and that hea rt da mage is perma nent. Methods of treatment may provo ke anxiety: the dash to hospital, admission to a coronary care un it, immobiliza tio n in bed and dependence o n others for care. The attitude of the physician is a ll impo rtant. Hellerstein & Ford (25) have shown that anxious doctors have anxious patients. Not a ll patients present a picture of manifest anxiety. They may appear overdependent , demanding immediate attention a nd care. Hostility may occur when various external sources, including the physician , are bJa·med for the illness, with disregard o f sensible medical adv ice. Such patients may use their illness as a good solution for premorbid neuroti c probl ems (26). If anxiety is unreli eved, depress io n may become o bvious, pa rticularl y afte r a second infarction (27). Hackett & Cassem (24) have reported that thi s is reactive in nature and rarely assu mes psychotic proportions. In their experi ence, anx- iety occurs early, usua ll y o n the first o r second day , whilst depression has its highest incidence o n the third day after the onset of physical symptoms. The depressed patient appears sad, disinterested a nd li st less, is slow of speech and despondent a bo ut the future; he foresees reinfarction, reduced ea rning power, sexua l incompetence, invalidism and premature old age. Various studies have exami ned the frequency of these emotiona l reactions. In the series of Hackett & Cassem (24), 30% were mildly anxious, 40% were rated as moderate a nd only 5% had severe symptoms. In the same series, 33% were mildly depressed , 36% moderately so and only 6% were rated as severe ly disturbed . Cay et a l. (27) found cl in ica l evidence of emotional upset in 6 1 % of patients after a first infarction, with 40% scoring in the "significantly di st urbed" range, using a questionnaire to estimate severity of sy mptoms. Stern et al. (28) fo und that 49% of their patients were anxious and/o r depressed. These reactions are independent of the physical severity of the infarct but are influenced by the patient's premorbid personality, the methods of coping with stress developed over the years, by his previous experi ence , by atti tudes to hea rt disease in hi s cultu re a nd by existing environmental p ro blems (27,28). Emotional reactions to a heart attack a re not static but involve a continuous process of readjustment. Wrzesniewski (29) reported high initial levels of anx iety in hi s pa ti ents, a low leve l by the fifth day, when cardiac sta te had stabi lized , and a considerable rise two days before discharge from hospita l. The effect of family attitudes is extremely important. During the acute illness the wife' s anxiety is often greater than her husband 's (30). On the other hand, in a study of pa ti ents a nd their spo uses, Rusk in (31) found that neuroticism scores were higher for patient than for spouse, but that her level of anxiety depended o n the severit y of her husba nd's illness. 35 Psychological reactions during convalescence During this phase, there is steadily increasing physical activity designed to provide the patient with tangible evidence of return to normal health. There are considerable psychological hazards for the patient in his efforts to return to normal daily life and he seldom foresees them. With greater activity there may be increased appreciation of physical limitations and common com- plaints at this stage are weakness and tiredness. There is a tendency to interpret such symptoms as evidence of deterioration in cardiac function and as a result depression and anxiety may persist or appear in the first month of convalescence. The lack of structure in the lives of those accus- tomed to a busy existence results in boredom, frustration and loss of confidence. Insomnia is common and, as a result, the individual may be irritable and quick to take offence, and may seek to prolong his invalid role and impose excessive demands on his family. Untreated, such reactions tend to persist. Cay et al. (6) found that 51 % of their patients were still anxious or depressed four months after their infarction and 56% at one year. Stern et al. (28) reported that 73% of those depressed immediately after infarction remained so throughout follow-up; and in the group examined by Singh et al. (32) 34% of patients remained depressed or anxious for two years following an infarction. Outcome in these disturbed patients was poor; fewer returned to work and of those who did return few regained their previous level of activity, even after prolonged convalescence ( 6). Return to work does not always depend on the physical severity of the infarct ion; Goble et al. (2) found that in 40% , reasons for fai lure to return to work were psychological without any somatic justification; and Nagle et al. (33) reported that non-cardiac causes of invalidism were just as important as cardiac causes in failure to earn a living. As a result of the patient's uncertainties , problems connected with work and possible financial stringencies, his wife may be uncertain how to cope with the situation and be anxious whether her attitude is promoting or retarding rehabilitation. If her anxiety is exaggerated and disproportionate to the patient's current disability, her attempts to shield and overprotect him will be resented and may provoke outbursts of hostility. Mayou et al. (14), in a study of wives of patients with infarction, found 42% of wives depressed at two months, with 30% still depressed at one year. Predictive factors for the wife's progress at one year were mental state , work satisfaction , marital satisfaction and a previous history of psychiatric illness. It is important that the whole family should adjust to the new situation; if the family is experi- encing serious problems in interpersonal life, and social and economic difficulties, the patient's chances of successful rehabilitation are decreased. In this context, it is important to remember that anxiety related to resump- tion of sexual intercourse may cause considerable strain between husband and wife. Tuttle (/5) found that two thirds of his patients after an infarction reported a marked and lasting reduction in the frequency of intercourse as a result of misinformation and fear. Several studies have examined the physio- logical effect of sexua l activity on the cardiovascular system, but Heller- stein & Friedman ( 16) measured this for the first time in middle-aged males after an infarction, and demonstrated that the mean maximum heart beat 36 during intercourse with their wives was less than during dail y work activity. The frequency of death during interco urse, a repeated source of anxiety, was investigated by Ueno (34). He found that death was precipitated by sexual activity in on ly 34 out of 5559 cases of sudden death . In mo re tha n three quarters of these cases, death occ urred during intercourse with o ther than an "established" marital or sexual partner in a secretive encounter in a hotel and not in the privacy of home. During convalescence, other external factors influence the individual's emotional reactions. Problems connected with return to work are para- mount. The attitudes of workmates may increase the patient's fear that physically he may not be ab le to cope, especially if he has residual angina or breathlessness . The family's economic circumsta nces determine when he ret urns to work . Self-employed men go back ea rly (25), while continuation o f salary during illness and adequate social security benefits have the reverse effect (8) . As might be expected, professional and managerial workers find it easier to earn their living after a heart attack than do those with semi- skilled or unskilled jobs (6). !fat all feasible, every effort sho uld be made to a llow the individual to return to his previous employer. Serious problems arise when he cannot, for legal or other reasons, return to hi s former jo b, as success in finding alternative employment depends o n man y factors, such as employers' prejudice, the patient's educational and vocational skill s and the local economic climate (35). Psychological reactions after rehabilitation As active rehabilitation ends, patients should have reached their max imal possible physical and psychological recovery . For the majority, the next significant step is return to work, and patient and family may be apprehen- sive. The doctor should re-emphasize that return to work is not dangerous and that feeling weak or tired during the first few days or weeks is not infrequent and soon di sappears. Life after an infarction involves consider- able adjustment, with the individua l remaining aware of the continuing value of phys ical fitness , avoidance of risk factors and the cultivation of suitable ho bbies and outside interests. Advantages gained during the acute and convalescent stages will be lost if the individual slips back into previo us bad habit s. The detrimental effect of restrictive and ove r-protective atti- tudes is a t leas t as great from this time o n as it was earlier. The post-arrest patient Some years ago, the first repo rt s were published desc ribing the quality of life in th ose surviving cardiac arrest - they were depressing reading. The incidence of depress ion , nightmares and the level of chronic anxiety were high and the survivors complained of "being different from other people" (36). These obse rvati o ns ha ve not been subs tantiated in later studies, and there now seem to be few or no psychological sequelae to cardiac arrest (37) . The reasons for this may lie in the way the pa tient lea rns about hi s a rrest. In the beginning there was no uniform policy , and often the wife o r relative informed the patient, frequently in highly dramatic terms. Doctors, possibly 37 unsure o f th emselves, usua ll y remained sil ent. Sin ce th e experi ence was unique to doc to r and pa ti ent a like, di sto rti o n, exaggera tio n a nd misinfo r- ma ti o n acc rued . Do bso n et a l. (3 7) fo llowed a se ri es o f those who survived ca rdi ac a rres t fo r some yea rs. They comm ented o n the a bsence o f emotio na l upse t a nd sho wed th a t ventri cul a r fi brilla ti on , in it se lf, did no t ad ve rse ly a ffect the pa ti ent 's p rog nos is. They advised tha t the pa ti ent sho uld be to ld o f hi s arrest by the docto r within 24 ho urs o f the event , th a t its routine na ture be emphas ized a nd tha t the pa ti ent a nd hi s fa mil y sho uld be in fo rmed ~h a t hi s future was no t mo re gloomy because o f it. Nine o ut o f ten pa ti ents d o no t remember much o f th e a rres t , a ltho ugh the patient who has had mo re than o ne i lik ely to remember th e events. A few patients d o , however, remain al ert and co nscio us th roughout. They ma y co mpla in o f a nger a bo ut the pain they suffe red but they do no t a ppea r to be mo re a nxious than the majorit y, who remember little o r no thing (24). Psychological aspects of coronary bypass surgery The ad vent of corona ry bypass surge ry was a spec tac ula r step in the treat - ment of ischae mic hea rt di sease, and the number o f pa ti ents being o perated o n has increased rapidl y over the past few yea rs. Improvem ent in a ngina pec to ri s occurs in abo ut 90% o f the pa ti ent s, with complete re li ef of symp- to ms in a bo ut two thirds. Sympto mati c improve ment is thu s often sufficient to allo w pa ti ents to return to wo rk . However , a combina tio n of socia l, eco no mic and psychological fact o rs ma y prevent successful reha bilitati on . The lo nger the period of inactivit y befo re surge ry, the less likely is a return to wo rk (38). A signifi ca nt number o f o lder pa ti ent s see the major event of surgery as a n o ppo rtunit y to ta ke ea rl y retirement , a ltho ugh the majo rit y o f these pa ti ents a re sy mpto m-free and ma inta in a high leve l o f ac tivity (39) . An ove r-p rotective fa mil y o r ph ysic ian has a signifi cantl y inhibiting effec t ( 40). Pa tients wh o a re less well educa ted a nd those in se mi-skill ed o r unskill ed jobs have problems in ea rning their li ving a ft er their o pera tio n ( 12). As yet , very littl e is kno wn abo ut the incidence a nd effect o f psycho logi- ca l ma nifes ta ti ons in pa ti ents after coronary bypass surge ry, a lthough Ra bine r & Willner ( 41) fo und tha t 16% o f their gro up of 51 pa ti ents had acute psychia tric sy mpt o ms in the immedi a te pos t-o pera ti ve period. There was no indi ca tio n tha t th ose who had psychia tri c sy mpto ms in hospita l were likely to have sympt o ms 18 mo nths la ter, sugges ting tha t delirio us pa ti ents tend to recove r spo nta neo usly. O f the 15% o f pa ti ent s who did have psychi- a tri c disturba nce a t 18 mo nths, the majo rity had evidence o f bra in da mage. A recent repo rt o f a la rge se ries o f pa ti ents tending to co nfirm the findin gs o f thi s sma ll group indica tes tha t mo re research in thi s a rea is required ( 42). Assessment of the Patient It is impo rt a nt to stress tha t psycho logica l assessme nt is pa rt of to ta l pa ti ent ca re a nd mu st be close ly a lli ed to a n acc ura te assess ment of phys ica l sta te. The meth ods o f assess ing the patient th a t ca n be ca rri ed o ut a t a n ea rl y stage will depend o n the seve rit y o f the in fa rcti o n , the deg ree o f recove ry, a nd the prese nce o f complicat io ns and o ther medica l illnesses. La ter o n, the interplay 38 of residual di sability (angina or breathlessness), physica l working capacity, psychological morbid ity a nd va rio us socia l factors will influence the patient's rehabilitatio n potential. At each stage of illness the psycho logical assessment of the pa tient must include an asessment of those factors within the patient which promo te o r hinder rehabilitati o n and a n assessment o f factors in the patient 's envi ro n-. ment at home, at wo rk o r in the pursuit o f leisure activities which will influence rehabilitatio n (1 2). Aims of assessment The phys icia n has two aims in hi s assessment of the psychological state of hi s patient : diagnosis a nd prediction. Diagnos is o f the individual's psycho logi- ca l reactions to the acute st ress sit uation and the methods of defence which he mo bilizes to help him to cope with it a llow the ph ys icia n to predict how successful hi s patient will be in returning to an active productive life. Using thi s information he can then trea t his patient rationally. It is important to see the spo use sepa ra tely; the pa tient may not be telling the truth and the wife herself may need guidance and trea tment. Guidelines for assessment Awareness by the physic ia n that his patient , a ft er a hea rt attack, is likely to be anxious or depressed a nd that he may have socia l problems is the first step in pos iti ve identifica tio n of these aspects of patient care. It would see m that the physician's a ttitude a nd the image he conveys is one of the most potent factors in combating anxiety a nd preventing iatrogenic disease (25,35). Authors have stressed the importance of the o ptimisti c approach, though Mendel ( 43) feels that thi s is too si mple; he ma intai ns that the physicia n must strike the bala nce between the powe rful protecting fi gure and o ne who a pprecia tes the situat ion rea li sti ca ll y. This is particularly importan t in patients who have shown evidence befo re the infarctio n of inability to cope with o ther stresses of adult life. Indicato rs of this are poor work records, previo us psychiatric illness, excess ive inva lidism after other illnesses, a poor marital rela tio nship and pre-existing fina ncial problems (JO) . The reasons why the patient is reacting badly are as important as diagnosis of disturb- a nce. They determine the method of treatment, which may be relati ve ly sim ple - involving only minor adjustments a t work - or prolonged a nd difficult if emotio na l disturbance is arising o n the basis of pre mo rbid person- ality traits which may cause the individual to seek to maintain the invalid ro le. Hackett & Cassem (24) have pointed o ut tha t anxiety may be difficult to identify beca use patients consc io usly o r unco nsciously deny it. There has been considerable controve rsy on the role of denial in cardiac rehabi lita tio n. Some a utho rs fee l tha t denial hinders adjustment because it preve nts the patient's objec tive assessment of the situation ( 43) . This was supported by the finding o f Ruskin et al. (31) that the aware a nd cautious pat ien t improves most during follow-up , coopera tes best with hi s medica l adv ise rs and returns to work readi ly. Other workers have shown that denial , as a belief in the "self ' witho ut disease, promotes rehabilitation ( 44) . Recen t work by the Bosto n group (24) tends to support this view. They found that modera te 39 de ni a l may be assoc ia ted wi th dec reased morta lit y a nd mo rbid ity after in farc ti o n a nd tha t it is the sma ll p ro portio n of minima l deni ers who a re likely to rema in ma ladj usted . T he results of a recen t Swed ish study ( 45) sugges t tha t the ro le of denia l as a n adequa te defence mecha ni s m may be cultura ll y determined . Unlike the A me ri ca n pa tient s, deni a l did no t p rotect the pa ti ents fro m a nxiety a nd de pressio n . A lth o ugh no conclusio ns could be draw n fro n this stud y o n the lo ng-term consequences o f denia l, the Swedish wo rkers po inted o ut the ma rked d iffe rences betwee n men a nd wo men in thei r psyc hologica l reac- ti o ns to a n in fa rcti o n. Men were mo re likely to ex hibit denia l a nd repo rt ed fe wer ph ys ica l sympto ms tha n wo men. Methods of assessment Ma ny meth ods have been used in resea rch to es tim a te leve l o f a nxiety, depress io n, denial , personalit y trait s a nd moti va tio n. Psycho logists have used a co mbina ti o n of in te rviews, p rojecti ve tes ts a nd questi o nna ires. In a n interna ti o na l survey in 1970, F ishe r ( 4) fou nd tha t th e mos t co mmo nl y used method o f assess ment was the interview, fo ll owed by a va ri ety o f projecti ve tes ts. Ques tio nna ires we re less po pula r a nd tended to be co nfined to the two persona lit y in ve nto ries mos t in vog ue a t tha t time, the Minnesota Multiple Perso na lit y Inve nt o ry a nd the Six teen Persona lit y Factor Ques ti o nn a ire o f Ca tt ell. Ma ny we re unsuit a ble fo r the no n-psycho logica ll y t ra ined phys icia n to administer a nd interpret , whil e o thers, o rigina ll y deve lo ped fo r neu roti c pa ti ents, we re no t ve ry relevant to pa tient s after a myoca rdia l in fa rcti o n. They refl ec ted the need a t tha t time fo r ma ximum informa tio n, were very lo ng a nd , therefo re, q uit e unsuit ed to rou t ine clinica l prac ti ce. Rece ntl y, resea rch wo rkers have tended to use ques tio nna ires rather tha n p rojecti ve tests in the ques t fo r objecti ve reproducible ha rd d a ta. These tes ts have bee n much sho rt er a nd a number have co me into use which we re o ri gina ll y d eve lo ped to es tim a te e mo ti o na l di s t u rba nce in a " no rm a l" po pu- la ti o n (1 2.46). Th ese incl ude the Ge nera l Hea lth Ques ti o nna ire (47), the Neuro ti c ism Scale Ques ti o nna ire (48), the Sta te-Tra it A nxie ty In ve nto ry ( 49) a nd th e 8- Pa ra ll el Form An xie ty Ba ttery (50) . Oth er wo rkers have co nce ntra ted o n deve lo ping spec ific sca les to es tima te di sturba nce in the ca rdi ac pa ti ent (5 1,52). A signi fica nt step fo rwa rd in assess ing emo tiona l upse t in ro utine cl in ica l p racti ce has bee n ta ken as a result of a rece nt stud y by T aylor et a l. (53). T hey showed th a t a technician on the sta ff of the ca rdio logy depa rtment , t ra ined to use a sta nda rdi zed interview, was as acc urate as a psyc hia trist in detect ing those pa ti ent s req ui ri ng trea tment fo r depress io n a fte r myoca rdi a l in fa rcti o n. Philip (54) has demo nstrated tha t a se lf-admin is tered ques tio nna ire of emotiona l upse t , ta kin g 5-10 minutes to complete , was suffic ientl y acc urate to be used to sc ree n pa tient s; 85% of the emotio na l di sturba nce estima ted by a psychia tri st using a n interview a nd questio nna ires was detected by th e test. The importa nce of predi cting success o r fa ilure o f reha bilita ti o n fo r psychosocia l reaso ns has led to considera ble effo rts to fi nd meas ures to es tim a te thi s. Rum baugh et a l. (55) , in the mid-1 960s, deve lo ped a ques ti o n- na ire o f 160 it ems fo r p red ictin g the adj ustment of the ca rdi ac pa ti ent to hi s 40 illness and his subsequent return to work. Later, Josten (56) produced his "subjective load" questionnaire, measuring the degree to which the patient is occupied with his illness and the problems created by it. Scores correlated well with physical complaints and with psychiatric ratings of emotional problems and differentiated between those who achieved various levels of subsequent activity at work. Other measurements have been shown to predict outcome: patient performance in a sheltered workshop, breath- holding time and perception of instructions by the medical staff (57). At present, several workers are concentrating on the important task of produc- ing a simple, practical screening method for routine clinical use to predict those likely to have psychosocial problems in rehabilitation ( 46). Promising scales in this area are those of Schiller & Baker (58) and Hoffman et al. (20). Frequently, the criterion for successful rehabilitation has been return to work. Recent thinking is that this is much too narrow and, in the present climate of world recession , may not necessarily represent a "good" out- come. If overambition and high job dissatisfaction is a factor in developing a myocardial infarction ( 45), return to previous employment without alter- ation of prior work behaviour is not always successful rehabilitation. For these reasons measurement of outcome must involve measurement of the individual's quality of life . Andrews & Withey (59) have demonstrated that it is possible to do this in a general American population, using a question- naire. More recently, it has been shown that the quality of the patient's life after myocardial infarction can be represented by four independent scales of outcome comprising some ten items (54). Although such work is promising, for the physician faced with the task of assessing his patient there is at present no one simple screening test. He knows that several psychosocial factors are important in predicting which of his patients will do well and which will do badly. The clinical interview is the most reliable method at the moment to obtain the information he needs. At a symposium in 1976 held by the Scientific Council on Rehabilitation, the International Society of Cardiology ( 46), a working group outlined the format of a semi-structured interview designed to help the physician in his assessment. Psychosocial factors included in the interview were anxiety, depression, denial , work problems, family problems - including sexual activity, problems involving leisure activities and problems in complying with medical advice. Its purpose was screening for the presence of psycho- social problems, assessing their severity and judging whether or not special- ist advice should be sought. Obviously, the details of the interview will depend on local clinical practice, but a possible general outline can be given. (a) Initial psychological reactions to a heart attack (when the clinical state of the patient has become stable in the coronary care unit): anxiety, depression , denial. (b) Psychosocial state during hospitalization: anxiety, depression, denial. Social items: present occupation, educational level, problems antici- pated and real in returning to work, and problems anticipated and real within the family as a result of the heart attack. 41 (c) Psychosoc ia l sta te a ft er di sc ha rge fr o m hospit a l (a pprox imately two wee ks afte r disc ha rge): a nxiety, de pressio n , denia l. Social items: a ttitudes of fri ends a nd employer , wo rk pro blems, problems within the fa mily, co mpli a nce with medica l a d vice, a nd a ttitude to wards a phys ica l rehabilitatio n progra mme. (d) Evalua ti o n of o utcome (w hen the grea t majo rit y o f pa ti ent s sho uld ha ve returned to wo rk ): a nxiety, depression, denia l. Wo rk items: return to wo rk , level o f ac ti vit y, reasons fo r fa ilure to return to wo rk , fin a ncia l situa tio n, a ttitudes abo ut wo rking. Other social items: effect of the heart a tt ack o n the famil y, effec t on lei sure ac ti vities, a nd co mplia nce with medica l ad vice. Treatment The grea t majo rit y o f pa ti ent s with psychosocia l p ro blems ca n be trea ted by the phys icia n looking after their ph ys ical needs (/ 2). Onl y a minorit y with seve re di sturba nce o r grave soc ia l problems will req uire spec ia li st trea t- ment - a pprox ima tely 15-20% of pa ti ent s (6.28). Treatment during the acute illness Psychologica ll y, the pa ti ent's first po int of contact with the medica l p ro fes- sio n after o nse t o f th e ac ute sympt o ms is critica l beca use it is hi s int roduc- tio n to the setting of ca re. It is usua ll y with hi s medica l practitio ner o r hospita l casua lty doc to r. Pro mpt a tt enda nce with speedy reli ef of pa in by seda ti ves a nd a na lges ics, acco mpa nied by a n a ttitude of pos iti ve enco ur- age ment , will go far to d ispel initi a l a nxiety. Pa ti ent s a pprec ia te being to ld the truth directl y a nd in a ma tt er-of-fac t way, a nd menti o n of di scha rge within a week o r two - eve n a t thi s stage - ve ry o ft en serves as a reassuring yardsti ck fo r the pa ti ent in a new a nd fri ghtenin g wo rld full o f unce rt a inties. It is helpful fo r the rela t ives to be seen by the d octor as soo n as poss ible, to expla in the na ture of the illness a nd to out line the trea tment in hospita l. Ma ny pa ti ents wi th suspected myoca rd ia l infarction are ad mitted to a corona ry ca re un it a t the ea rli es t poss ib le mo men t in orde r to dea l with se ri o us co mplica ti o ns, especia ll y a rrh yth mias. Such emergency admiss io n may, in itse lf, presen t psychologica l problems, as the speed of events gives the pa ti ent littl e t ime to adjust and emphas izes to him a nd to his fa mily tha t he is se ri o usly ill. T he corona ry care uni t ca n, howeve r , be a po tent source of reass ura nce (24,60,61) . Provided th a t s taff are aware tha t pa ti ent s a re lik ely to be an xio us o r depressed a nd tha t suppo rti ve measures a re give n , such as expla na tio n of the mo nitoring eq uipmen t an d t ra nquilli ze rs to seda te the pa ti ent and reduce anxiety, presen t experience is tha t pa ti ent s are reass ured by their stay in these specia lized un its . Transfer fro m the unit is no t a psycho logica l hazard provided that the pa ti ent knows fro m the time of admi ssio n tha t hi s stay is o nl y fo r a sho rt time, until hi s hea rt has stabili zed and no lo nge r req ui res mo ni to ring. Fear a nd a nxiety may stem fro m the pa ti ent 's inadequa te knowledge of the na tu ra l hi story of the d isease and it s 42 treatment. A calm, competent staff who take emergencies in their stride and explain to the patient what they are doing and what is the next stage in treatment are the most powerful weapon against this. They should have rehabilitation in mind from the very beginning, and the fact that the great majority of patients do return to work and to an active life should be stressed, even in the coronary care unit. Patients and their relatives vary in, educational level and anxiety decreases understanding. It is important that explanations are given in terms that they can understand (24) and are repeated at frequent intervals. Time to allow patients and relatives to ask questions is not wasted. There is some debate as to whether single rooms are better than two- or four-bedded rooms in a coronary care unit. Companionship is an argument in favour of the latter , while fear of witnessing a cardiac arrest is cited by those who favour single rooms. Studies have shown that patients in a coronary care unit ra rely complain of being lonely; many like privacy to adjust to having had a heart attack (61). Witnessing a cardiac arrest was found by Hackett et al. (51) to have frightened only 20% of their patients, who seemed to be reassured by the speed and efficiency of the medical and nursing staff. Lack of identification with the victim, particularly if he died, was the usual response and this was deliberately fostered by the staff, who explained that the deceased's heart was much worse than that of the other patients in the unit. In spite of this, requests for tranquillizers, sedatives and analgesics in the unit rose immediately following an arrest, and patients who had witnessed an arrest said they would prefer a single room should they require readmission. It appears that the anxiety provoked by witnessing a cardiac arrest may be greater than the patient admits. Transition to the medical ward, provided that simple measures to allay anxiety, such as explanation, reassurance and perhaps some increase in sedation, are taken, is viewed as a tangible sign of progress. Early mo- bilization decreases anxiety and depression (J, 62). Some centres start a programme of physical conditioning on about the third day of illness. Reports to date indicate that emotional disturbance is much less when the patient is thus actively engaged. He feels that he is taking part in his own recovery and gains confidence from the realization that physical activity under carefully supervised conditions is not only possible but safe. Equally important, his family have concrete evidence of his increasing physical abilities (63,64). With the decrease in cardiac symptoms and improving physical well- being, the patient, in order to allay anxiety, wants to discuss the nature of his illness, the rationale of treatment and the prognosis, especially regarding his future capacity for work. From his assessment of the patient and his family (see above) and his knowledge of the severity of the attack, the physician can judge how much he can tell the patient. His aim is to minimize anxiety, to help the patient set up some norms for the future, and to reduce the ambigui ty and uncertainty induced by the sudden onset of illness. Enlight- ened optimism is the keynote of the rehabilitation programme. An attitude of encouragement by the doctor is essential. He should try to explain the nature of the heart attack in terms that the patient can understand. If the 43 individual asks about his chances of dying and recurrence, the doctor can emphasize the hopeful and positive aspects of the illness without minimizing the risks. Ample time should be allowed for the patient to ask questions and to correct false impressions. It may be helpful to quote the later achieve- ments of well known people who have had heart attacks. At an early stage the doctor should encourage discussion about return to work. The family should be included in these discussions so that the adverse effects of over- protection by relatives can be avoided. Although a programme of increasing activity and education of the patient is the best antidote for emotional disturbance, tranquillizers, es- pecially the benzodiazepines which do not have hypotensive side effects, have a definite place in the management of anxiety. Tricyclic anti- depressants have been reported as causing cardiac arrhythmias and possibly sudden death (65), so their use should be avoided if at all possible. The monoamine oxidase inhibitors can cause fatal hypertensive crises if a tyramine-free diet is not adhered to , so are seldom used in patients with cardiovascular disease. Patients who have been identified as having environmental problems connected with work or within the family should receive special attention. Their physical state will determine how much can be achieved at this relatively early stage, but the aim should be that these patients can leave hospital with the knowledge that help to overcome such difficulties has already begun (27). In recent years, the period of hospitalization after myocardial infarction has been progressively shortened. In many countries the average stay in hospital is now 10-14 days. While this has undoubted psychological bene- fits, it means that preparation of patient and family for the return home becomes very important. In a proportion of patients, the impending loss of security implicit in discharge can increase anxiety in the day or two before returning home (29). Overt evidence that the patient is physically capable of, for example, climbing the stairs to his flat, and precise instructions about gradually increasing his physical mobility at home, with advice about avoid- ance of risk factors and drug regimes, are necessary. Recognizi ng that patients may be worried and anxious, some centres have instituted regimes whereby an individual who has been involved with the patient and his family from the beginning of his illness remains in contact, if only by telephone, and is available to deal with problems as they arise. The general principles of comprehensive rehabilitation are the same irrespective of the actual way in which it is implemented (12). The diverse nature of problems encountered has led, in many hospitals, to the formation of a rehabilitation team, each member contributing his own special ski lls depending on the individual's needs. The doctor prescribes the physical programme which is carried out by the physiotherapist. Nurses, psychol- ogists, social workers and occupational therapists have been variously used to permit free discussion with the patient and his wife. Treatment can be on an individual basis , but groups are increasingly being formed in many centres (22). 44 Treatment during convalescence Management of the patient is the sa me as during the acute phase . Expla- nation to the patient and his family is essential to prepare them to accept that feeling weak, fearful and uncertain is common, and almost a normal reac- tion during early convalescence. A wife should be warned aga inst totally suppressing annoyance and impatience towards her husband. The psycho- logical advantages of exercise testing followed by a definitive programme of physical rehabilitation cannot be underestimated (5 7), but if such pro- grammes are not available the patient and his wife should have a clear prescription from his doctor of a gradual increase of physical activity. Vague advice "to take things easily" must be avoided, as it is open to wide variations in individual interpretation. Strained marital relationships may arise from uncertainties about the advisability of resuming sexual inter- course, and husband and wife should be counselled that it is safe to do so within a few weeks of discharge from hospital (17). Gradual resumption of former social activities should be recommended during this time, as this has great psychological benefit in demonstrating that the patient is capable of a normal and useful life in the community. It should be stressed that some former activities may not be suitable and that this is an opportunity to cultivate new habits and interests. The question of sedation and the use of tranquillizers is important. The indicat ions for their prescription and the possible dangers of some of them are the same as during the acute illness. The physician should emphasize the necessity for sleep and tranquillity and should reassure the patient that the use of these drugs is for a short time only. Their eventual withdrawal should be gradual. Regular visits to the doctor and to members of the hospital rehabilitation team are advisable to supervise the so lution of problems identified earlier, or to detect new problems as they arise . Some patients may minimize symp- toms and deny emotional problems at follow-up visits, as they are afraid that they may appear unmanly . Others may remain withdrawn or anxious, even though they may have coped satisfactorily during the acute phase. A clue to the continued presence of anxiety or depression is exaggerated compliance with medical advice and a certain satisfaction at hearing the seriousness of their illness stressed by others ( 66). Preparation for return to work signifies the end of convalescence. The evidence is that this should not be unduly delayed (about 4-6 weeks in the uncomplicated case) . Contact with the patient's employer beforehand about the individual' s ability to cope with his job will reduce uncertainty and help to allay anxiety in both employer and employee. Specialist rehabilitation services With modern methods of treatment , the majority of patients adjust success- fully to infarction. Specialist rehabilitation se rvices have been developed to improve outcome in those who, for a variety of reasons, do badly. Within these centres a highly trained staff, drawn from several disciplines, use a variety of methods not generally available in routine clinical practice. Dur- ing the 1970s there was considerable enthusiastic growth of specia li st centres 45 and units in many parts of the world. Many practising physicians and cardiologists, however, remained sceptical of their value. In the last few years, it has become increasingly clear that an important role of these units is to examine critically the various methods of rehabilitation now being used. An essential component of any rehabilitation programme is graduated exercise training. Although developed to improve the patient's physical fitness, group programmes have a large psychological impact on the partici- pants. Wintner & Kellermann (57) pointed out that, with subjective and objective evidence of improved physical fitness, anxiety and depression became less as the feeling of being treated as an invalid disappeared. This finding has been confirmed in other studies (18, 19) and it is now recognized that one of the chief aims of an exercise programme is to give the patient confidence in his physical capacity after his infarction. Group training has other benefits; individuals with similar experiences, facing the same prob- lems, form a cohesive unit with support for individual members which no family, however understanding, can give. Group pressures also serve to cement resolutions about altering harmful habits, particularly smoking. Identification of patients likely to have a poor outcome because of psychological problems is important. They have the potential to do as well as anyone else, provided they have not had more severe heart attacks (27,45); it does, however, require a greater effort to rehabilitate them. In the rehabili- tation centre, a much more accurate assessment of the patient's psychologi- cal problems can be made using psychiatric interviews and psychological testing of personality, emotional state and intelligence, many of which have now been developed as a result of increasing knowledge of the special problems of post-infarction patients. Family members may be interviewed either at home or within the centre to estimate their personalities and their attitudes to the patient's illness. Psychological treatment methods vary considerably, depending on the individual's needs and, to some extent, on the practice of the centre. There is growing evidence of the results of such methods of treatment. In a controlled trial, individual psychological counsel- ling was of value; patients with neurotic, introverted personalities had a poor outcome in the control group but a satisfactory outcome when rehabili- tated. Neurotic patients responded to help and rehabilitation measures did not increase neurosis (67). Group therapy has received considerable atten- tion, as it makes efficient use of medical and paramedical staff. Rahe et al. (68) found, in a small study, that patients who received group therapy had significantly less coronary morbidity and mortality during a three-year follow-up than control patients, although they were not able to demonstrate any reduction in conventional coronary risk factors in either group. Those receiving group therapy successfully modified coronary-prone behaviour patterns . Other studies have produced similar findings (22), although the reasons for the apparent success of group therapy are far from clear. It may be the combined result of emotional social support and behaviour modifica- tion. Relaxation techniques are used widely and biofeedback has its adherents, but the results of these types of psychological treatment await evaluation. Return to work is of major psychological importance to the individual recovering from an infarction as it represents a combination of physical 46 recovery and successful emotional adjustment. Because many patients in a rehabilitation centre will have problems in getting back to work, vocational guidance is an important aspect of care. This can be exceedingly complex and requires the careful assessment of many factors. An example of such assessment is the cardiac rehabilitation occupational stress inventory devel- oped by Mitchell (69), which covers several major areas, both physical and. psychological, concerned with the working life of the individual and forms the basis for rational vocational guidance. In the 1980s there may well be less emphasis placed on work after an infarction, and individuals who cannot return to employment need psychological treatment to help them and their families adjust to a very different lifestyle . Alternatives to work which still enable the individual to continue as a useful member of society must be found. Rehabilitation after coronary bypass surgery The avai lable evidence on factors that may delay or prevent successful rehabilitation in post-surgical patients suggests that their problems are very simi lar to those in patients after a myocardial infarction. They have the same psychosocial difficulties, and treatment programmes to rehabilitate them are in progress which differ very little from those undertaken by post- infarction patients with, in addition , special attention being paid to the possibility of cerebral damage. Follow-up after rehabilitation Return to work is the outward sign of recovery but it is important to review the individual at least once more to make sure that he is coping, both physically and psychologically. Thereafter, it is the responsibility of the individual to adhere to the principles of secondary prevention which he has learned during rehabilitation . It is all too easy to slip into previous bad habits and some centres do offer continuing regular group training. Some patients like to continue this indefinitely as they find that it has beneficial effects beyond the maintenance of physical fitness . Group pressures and friendly rivalry help to fortify such people in a new and healthy way of life, especially in relation to eating habits, smoking and physical activity . The recent growth of "coronary clubs" and "heart clubs", a combination of social organizations and disease-oriented clubs set up and run by former patients, is an example of this (22) . The Future Although many studies have shown that various kinds of rehabilitation programme for patients after myocardial infarction have undoubted physi- cal and psychological benefits, many physicians remain sceptical of their value. They point out that recent multicentre studies have failed to demon- strate that rehabilitation results in a decrease in mortality or further infarc- tion ( 70) . It is only in the last year or so that the question has been raised that these aims may be asking too much of a rehabilitation programme. More attention should be paid to its influence on the quality of life during the 47 patient's remaining years ( 71) . The results of the WHO collaborative stud y on the effect of rehabilitation and comprehensive seco ndary prevention ( 72) would seem to support this view. Despite uncontrolled and subjective methods of assessing anxiety, depression and social problems, the results from various centres suggest that their rehabilitation groups adjusted more quickly and had fewer social problems a year after their infarction than the control groups, with the difference disappearing by the end of three years. It appears that those of us working in the field of rehabilitation, con- vinced at a clinical level of its value, will have to define clearly what is meant by a "good" outcome if we are to in0uence our coll eagues. It has been shown that it is relatively easy to assess psychological and social problems and their effect on outcome if only one aspect, namely return to work, is chosen as the outcome measure . It is much more difficult if outcome embraces a variety of physical, psychological and social factors - the quality of a patient's life afte r his illness. Yet this is obviously the only realistic way to judge success or failure of rehabilitation and will become increasingly important in the future if, as seems possible, work will play a less important part in our lives than at present. Measurement of these "soft" data has been shown to be perfectly feasible in large centres with access to psychologically trained staff who have time to devote to research (54, 73). The cha ll enge for the future is to develop methods which are suitable for use on a service basis in any busy cardiological department or district general hospital. Current medical practice, in0uenced by the enormous amount of research in the last 20 years on all aspects of rehabilitation, emphasizes early mobilization and a much more positive medical attitude to the patient's capabi lities after his infarction. Commenting on their finding that there was no difference in outcome at 18 months between a control group, an exercise group and those given counselling by a psychiatrist, Mayou et a l. (73) suggested that the good outcome in all their groups was a reOection of this, and that nowadays there was no need for routine rehabilitation programmes for all patients. Many studies have shown that approximately three quarters of patients do well with modern routine medical care. The others do badly, most because they have had more severe heart attacks, but some for a variety of psychological and social factors. The "worst" patients in this respect can be identified early (30). Selection of the proportion requiring intensive rehabilitation thus beco mes the important question. It is tempting to select this proportion for special efforts, but there is evidence that they may not be the ones who benefit most from a rehabilitation programme (30). Should we be concentrating o ur rehabilitation efforts on those with less severe upset and minor social problems? Cost-benefit analysis of rehabilitation pro- grammes has barely been tackled, as yet. Many different methods of psychological treatment are now incor- porated in comprehensive rehabilitation programmes but , as yet, few studies have assessed their efficacy in controlled trials. There is need for much more critical evaluation of our efforts to help patients . We do not yet know enough to delineate subgroups which would benefit from a particular therapy. Although the good outcome in many patients is encouraging, a proportion 48 still have undue distress and limitations. If well tried types of treatment are relatively ineffective in preventing this, we must be prepared to look at new ways. On the whole, substantial beneficial changes have been reported follow- ing cardiac rehabilitation programmes. Most deal with short-term outcomes variously defined. There is some evidence that these changes may not be sustained . But does this matter? If rehabilitation speeds up the recovery process, helping the patient during the difficult months following an infarc- tion, is this not enough? These are but a few of some of the unsolved problems in this very complicated area. The prospect of finding answers is daunting but must be undertaken if physicians as a whole are to be convinced that attention to the patient's emotional wellbeing is an integral part of patient care and not, as many view it, a luxurious extra. References I. Levine, S.A. & Lown, B. "Armchair" treatment of acute coronary thrombosis. Journal of the American Medical Association, 148: 1365- 1369 ( 1952). 2. Goble, A.J. et al. Rehabilitation of the cardiac patient. Medical journal of Australia, 2: 975-982 ( 1963). 3. Psychological aspects of the rehabilitation of cardiovascular patients: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1970 (document EURO 5030(2)). 4. Fisher, S.H . International survey of the psychological aspects of cardiac rehabilitation . Scandinavian journal of rehabilitation medicine, 2: 71-77 ( 1970). 5. Wynn, A. Unwarranted emotional distress in men with ischaemic heart disease. Medical journal of Australia, 2: 847-851 ( 1967). 6. 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Attitudes a nd lo ng term adjustment o f pa ti ent s surviv- ing ca rdiac a rrest. British medical journal, 3: 207-2 12 ( 197 1 ). 38. The long-term effects of coronary bypass surgery: repo rt o n a Wo rking Group. Co penhage n, WHO Regio na l Office fo r Eu ro pe, 1978 (d ocu- ment ICP/ CVD 003(8)) . 39. Morris, G.C. & Lawrie, G.M. Corona ry artery bypass surge ry in rehabil- ita ti o n . In: Lo ng, C., ed. Prevention and rehabilitation in ischaemic heart disease. Ba ltimo re, MD , Willi a ms & Wilkins, 1980. 40. David, P. Contributing fac tors preventing return to work of cardiac surgery patients. Syllabus: the f irst decade of bypass graf t surgery fo r coronary artery disease. Cleveland , OH , Cleve la nd Clinic Fo unda ti o n, 1977. 41. Rabiner, C.J. & Willner, A.E. Psycho pathology obse rved on foll ow up aft er coro na ry bypass surge ry. Journal of nervous and mental diseases, 163: 295- 301 ( 1976). 42. Gi:itze, P. et al. Rela tio nship betwee n psycho patho logica l synd ro mes before a nd a ft er o pen-hea rt surge ry. In: Becker, R. et a l. , ed . Psycho- pathological and neurological dysfunctions fo l/owing open-heart surgery. Berlin , Springer-Verlag, 1982. 43. Mendel, A.J. The psychologic ma nagement of corona ry pa ti ents. Gen- eral practitioner, 27: 82 ( 1963). 44 . Fisher, S.H. Mecha nism of denia l in phys ica l di sabilities. Archives of neurology and psychiatry, 80: 782-784 ( 1958). 45. Billing, E. et al. Denia l, a nxiety a nd depress io n fo llowing myoca rd ia l in fa rctio n . Psychosomatics, 21: 639-641 ( 1980). 46. Stocksmeier, U., ed. Psychological approach to the rehabilitation of cor- onary patients. Symposium of the Scientific Council on Rehabilitation. International Society of Cardiology, Hohenried. Berlin , Springe r-Verlag, 1976. 47. Goldberg, D.P. & Blackwell, B. Psychia tri c illness in genera l p rac tice: a de ta iled study using a new method of case identi fica ti o n. British medical j ournal, I : 439- 443 ( 1970). 48. Cattell, R.B. The specific analysis of personality. Ha rmo ndswo rth , Penguin Books, 1965. 49 . Spielberger, C.D. et al. S TAI manual. Pa lo Alto, CA , Consulting Psy- chologists Press, 1970. 51 50. Scheier, I.H. & Cattell, R.B. Handbook for /PAT 8 parallel form anxiety battery. Champaign, IL, IPAT, 1960. 51. Hackett, T.P. et al. Detection and treatment of anxiety in the coronary care unit. American heart journal, 78: 727-730 ( 1969). 52. Hackett, T.P. & Cassem, N.H. Development of a quantitative rating sca le to assess denial. Journal of psychosomatic research, 18: 93-100 ( 1974). 53. Taylor, C.B. et al. Optimal methods for identifying depression fo ll owing hospitalisation for myocardial infarction. Journal of chronic diseases, 34: 127-133(1981). 54. Philip, A.E. Measuring the outcome of rehabilitation. Advances in cardi- ology, 31 : 232-236 (1982). 55. Rumbaugh, D.M. et al. Predictions of work potential in heart patients through the use of the cardiac adjustment scale. Journal of consulting psychology, 29: 597 ( 1965). 56. Josten, J. Emotional adaptation of cardiac patients. Scandinavian journal of rehabilitation medicine, 2: 49-52 ( 1970). 57. Wintner, I. & Kellermann, J.J. Psychological factors involved in cardiac rehabilitation: a survey. In: Stocksmeier, U., ed. Psychological approach to the rehabilitation of coronary patients. Berlin, Springer-Verlag, 1976. 58. Schiller, E. & Baker, J. Return to work after a myocardial infarction: eva luation of planned rehabilitation and of a predictive rating scale. Medical journal of Australia, l: 859-862 ( 1976). 59. Andrews, F.M. & Withey, S.B. Social indicators of well-being: Americans' perception of life quality. New York, Plenum Press, I 976. 60. Dominian, J. & Dobson, M. Study of patients' psychological attitudes to a coronary care unit. British medical journal, 4: 795-798 ( I 969). 6 1. Cay, E.L. et al. Psychological reactions to a coronary care unit. Journal of psychosomatic research, 16: 437-447 ( I 972) . 62. Groden, B.M. & Brown, R.I.F. Differential psychological effects of early and late mobilisation after myocardial infarction. Scandinavianjournal of rehabilitation medicine, 2: 60-64 ( 1970). 63. Cassem, N.H. & Hackett, T.P. Psychological rehabilitation of myocar- dial infarction patients in the acute phase. Heart and lung, 2: 382 ( 1973). 64. Naughton, J.P. & Hellerstein, H.K. Exercise testing and exercise training in coronary heart disease. New York, Academic Press, 1971. 65. Coull, D.C. et al. Amitryptyline and cardiac disease: risk of sudden death identified by monitoring system. Lancet, 2: 590-591 ( 1970). 66. Braceland, F.J. The coronary spectrum. Psychiatric aspect. Journal of rehabilitation, 32: 53-55 ( 1966). 67. Naismith, L.D. et al. Psychological rehabilitation after myocardial infarction. British medical journal, 1: 439-442 (1979). 68. Rahe, R.H. et al. Brief group therapy in myocardial infarctions: 3-4 year fol low-up in a controlled trial. Psychosomatic medicine, 41: 229-242 ( 1979). 69. Mitchell, D.K. Principles of vocational rehabilitation: a contemporary view. In: Long, C., ed. Prevention and rehabilitation in ischaemic heart disease. Baltimore, MD, Williams & Wilkins, 1980. 52 70. Tristini, F.E. National intervention trials and their descendants. In: Long, C., ed. Prevention and rehabilitation in ischaemic heart disease. Baltimore, MD, Williams & Wilkins , 1980. 71. Shephard, R.J. Recurrence of myocardial infarction. Observations on patients participating in the Ontario Multicentre Exercise-Heart Trial. European journal of cardiology, 11: 147-157 (1980). 72. Dorossiev, D. Rehabilitation and comprehensive secondary prevention after acute myocardial infarction: report on a study. Copenhagen, WHO Regional Office for Europe, 1983 (EURO Reports and Studies, No. 84). 73. Mayou, R. et al. Early rehabilitation after myocardial infarction. Lancet, 2: 1399-140 l ( 1981 ). 53 5 Implications of social factors in cardiac rehabilitation S. Laaksovirta & V. Kallio The role of social factors in the development of many chronic illnesses, including coronary heart disease (CHO), has recently received much atten- tion. Also, outcome of treatment depends on environmental influences. Family and work problems and financial difficulties may often present major obstacles to readjustment, an aspect not always recognized by the patient and his treating physicians. Existing legislation too , can influence the patient's reaction to his illness and its outcome. In the past , rehabilitation of patients after acute myocardial infarction consisted mainly of programmes of gradually increasing physical exercise. Social factors and, particularly, methods to relieve environmental problems were given scant attention . As a result , current knowledge of reliable valid methods to measure the severity of social problems is relatively meagre . Furthermore, the effects of these difficulties on the outcome of illness may vary depending on the country of origin of the patient. This makes it difficult to compare the results of the studies that have been undertaken. Neverthe- less, there is general agreement that social problems should be identified , evaluated and treated in order to ensure the best possible outcome for the patient. The role of social support services, both formal and informal, has never been properly evaluated. More detailed information is needed on the effect of some of the factors which are known to prevent the individual from earning his living after an infarction - his own attitude, the attitudes of his family, his physician, his employer, his fellow employees and the local employment situation. Social Factors as Risk Indicators after Acute Myocardial Infarction Occupation, education, level of income and other social factors Scientific interest in the role of social and psychological factors as risk characteristics for CHO has arisen only recently (1-3) . Emphasis has been placed on occupation, education , income, marital status, religion, ethnic 55 group and population density. The results of these studies are difficult to wmpare as they vary in their design and methods of evaluation, so that it is not easy to obtain a clear picture of the relative importance of each factor. Certain occupational groups seem more likely to develop CHO, although why this should be so is not clear. Many studies ignore special features of the job and the socioeconomic background of the individual performing it . Possibly more stress should be placed on variables such as income and education. In spite of these shortcomings, early studies point to certain occupational conditions, such as socioeconomic ascent or descent , depriva- tion, stress at work and a feeling of responsibility, as potential risk factors (3). The risk of developing CHO is indirectly related to being married ( 4) . Its incidence has been found to be smaller in rural or sparsely populated areas. Recently, a Finnish research group (5) has reported a change in Finland in respect of this earlier experience which is due to the decline in mortality that began in the cities in the l 960s. Results of the effects of religious and ethnic factors are difficult to interpret because of the many genetic, cultural and environmental differences (3) . Industrialization and social class The relationship between social class and CHO has been reviewed by Lehman (6) and Antonovsky (7). Studies have not always given consistent results. Some indicate that the process of industrialization and subsequent urbanization, is related to increased incidence. Mortality due to CHO in white men in a rural district in North Carolina increased markedly during a period of rapid industrialization and the resulting changes in lifestyle (8) . The effect of social class was described by Cassel et al. (9). In the early 1960s white men in a rural area belonging to the lower social classes had a smaller risk of developing CHO than men in the upper and middle social classes. By the end of the 1960s this difference had almost disappeared. Mortality from CHO has been found to be higher in white-collar workers than in agricultu- ral labourers. It has been suggested that the characteristic way of life of individuals in certain occupations may be more important than the physical strain of the job itse1f(2,J0). While in the 1960s myocardial infarction was considered to be a "managerial" disease , a recent study of London civil servants showed that mortality from CHO was highest in the lower occupa- tional groups(] 1). This was not explained by any difference in incidence of recognized risk factors of the disease. Marmot et al. (12) have also shown that mortality from CHO in England & Wales has increased to a greater extent in the working class than in the upper and middle classes . Such a change could be explained only partly by increased knowledge of risk factors and improved methods of diagnosis. Some investigations have revealed that, as the degree of industrialization increases, a movement in the occurrence of myocardial infarction towards lower socioeconomic levels can be noticed. Life changes and other difficult life situations There are many studies on the relationship between myocardial infarction and life changes. It has been suggested that the increased risk of developing 56 CHO as a result of certain changes in the individual's life situation is due to human "adaptation energy" being limited. Others consider that life changes trigger an alarm reaction rendering the organism more vulnerable to having a myocardial infarction. It may also be that patients, sensitized by the sudden onset of acute symptoms, are more aware of preceding life change events as shown by their increased test scores when compared to a normal population (2). The conflicting evidence in this complex field and the various theories to explain this have recently been critically reviewed by Dohrenwend & Dohrenwend (13). Dissatisfaction with his life situation may also be associated with an increased risk of developing CHO in the individual. It has been shown prospectively that family, work and financial difficulties preceded the onset of angina pectoris. Intensity of the problem was more important than the type of difficulty ( I 4, I 5). Theorell & Rahe (16) have reported from Sweden that patients with myocardial infarction had more work problems and less economic difficulties than their healthy controls. Overemphasis on work In a series of studies, Jenkins ( /) has outlined characteristic attitudes towards work in patients with myocardial infarction. They work extra-long hours, assume too much responsibility, seek emotionally stressful work, take on more than one job at a time, are over-involved in the obligations of their working life and are preoccupied with apparent lack of recognition of their worth or loss of appreciation by employers and fellow employees. He believes that there has been a steady increase in this risk factor over the years (2). The Swedish patients ofTheorell & Rahe (16) worked much more overtime than their healthy controls, though they held positions involving less responsibility. The role of overtime working in infarction patients has also been stressed by Thiel et al. (17), who reported that many of their patients worked more than 70 hours per week. A compulsive attitude towards work may manifest itself in ways which at first sight appear dia- metrically opposed. The individual may seem to be intensely involved and perfectionistic in his work while in other situations he may behave in a passive manner. This has been explained as evidence of a conflict, said to be typical of patients with myocardial infarction; the patient uses his work as a means of expressing repressed aggression while in social activities he longs for other people to take care of him. The seeming inconsistency is the expression of the conflict between fight and flight (18, 19). The importance of work problems has also been stressed by Friedman & Rosen man (20) who described the behaviour of individuals said to be prone to develop early CHO. They called this type-A behaviour, which was further amplified by Jenkins et al. (2 I) as being specially characterized by speed and impatience, involvement in work and hard-driving and competitiveness. The type-A person is so involved in his work or profession that he neglects all other aspects of life. He demands of himself more than he is able to give (22). It has been suggested that type-A behaviour is the result of environ- mental challenge and the way in which the individual responds to this. When he realizes that he cannot completely control his life situation he 57 becomes anxious. The enforced activity characteristic of type-A behaviour is then used to control anxiety or depression and will lead to a chronic, psychologically and physiologically agitated state (23). Investigators in this fie ld stress that they do not believe that there are pathological personality traits typical of patients with CHO. They feel that it is an adopted pattern of behaviour that is characteristic (20,24). The sociological approach to com- prehensive rehabilitation of patients after myocardial infarction is based on the view that it is possible to change behaviour. If the patient is self-controlled and reserved he may not admit to social problems, particularly those connected with work, and the interviewer, quite erroneously, may gain the impression of a well adapted personality who can cope with all difficulties encountered ( 18, 25). Social problems may thus remain unidentified and will not be considered in planning the patient's rehabilitation programme. Type-A behaviour may not be unique to patients with CHO. In Hinkle's study (26) patients with poor physical health for a variety of reasons experienced their environment as more demanding and their jobs as less sa tis factory than healthy controls. The Importance of Social Support Services in Rehabilitation Many investigators have emphasized the importance of social services, both fo rmal and info rmal, in supporting patients and improving their confidence after an acute myocardial infarction. This is particularly important in those who a re over-anxious and who lack the capacity to relax (27-29). Psycho- socia l fac to rs, while so metimes creating stress , can also be used as a defence to protect the individual in a difficult life situation (30, 31). In a well planned rehabilitat ion programme, the patient should be advised that a new situ- at ion has arisen which wi ll require new methods of coping (23) . It is important to recognize that it is no easy matter to ask a patient to change the way oflife he has developed over many years (32). There may be a prolonged struggle to persuade him to adhere to a new, healthier mode of life and this should be taken into account when setting goals for rehabilitation. The patient will require support to face the situation realistically. Aft er a myocardial infarction patients frequently deny or underrate the severity of their symptoms and the implications of the underlying disease. By so do ing they are attempting to lead a normal life for as long as possible (33,34) . The symptoms are explained away as temporary, possibly due to fatigue or occasional difficulties at work or in the family. Although the o nset of acute infarction is sudden, it often is not unexpected; the patient may well have had prodromal symptoms which he has not connected, either consciously or subconsciously, with heart disease. This "playing down" or normalization of symptoms is relatively easy as prodromal symptoms may be vague and ill defined, and the process continues as long as his capacity to work, particularly important in these patients, is not threatened (35). This results in delay in seeking medical advice. Rehabilitation thus should always include an "adaptation programme" to help the patient to accept his disease, the physical limitations of symptoms 58 and the consequent changes in his mode of living. It is especially important that he can adapt to changes at work, which plays a central role in the life of patients with myocardial infarction. Various authors have suggested that work to these patients becomes even more important after the acute attack than it was previously (33,36). While they may apparently return to work successfully, they may have considerable problems in doing their jobs and re-adapting to the routine of a working day. So much energy may be required for this that there is little left for family living and leisure activities. After the acute symptoms subside and cardiac state is stable, recovery of the patient will depend more on social factors than physical state and traditional medical care. There is increasing awareness among physicians that their infarction patients, while they do have medical problems, are individuals who must be able to play their full part in the life of the community. These aspects of patient care may well require the skills of social workers and similar members of the rehabilitation team. The well trained social worker can evaluate the chances of the patient being able to work again and help with problems at work or within the family. These social support services then become an integral part of treatment of patients with myocardial infarction. Croog & Levine (36), however, have pointed out that this new approach does mean considerable changes in the "traditional" role of the social worker. Social Factors and Return to Work Return to work is considered to be a good outcome of treatment following myocardial infarction . Croog & Levine (36), however, pointed out that if this is accepted as the only criterion of a good outcome it is all too easy to overlook its negative aspects. If the rate of return to work is high, many patients may be working in jobs that are too demanding both physically and emotionally. Such men are often anxious and worried but are unwilling to accept any limitations caused by their illness. The socioeconomic sequelae of a myocardial infarction are as important as its physical consequences and merit attention and care so that patients can return to an active social life confident of their ability to cope, while at the same time adjusting to residual physical disability. Safilios-Rothschild (34) has stated that, in our century, work is univer- sally valued more than ever before not only for its usefulness but also for the psychological "side-effects" given by economic independence. Ability to work is thought to play a crucial role in forming the individual's core identity, his self-esteem, the overall organization of his life, his physical and mental health and in maintaining family life. It may acquire a different meaning depending on social class, sociopsychological background and learned experience. For many professional men work is of supreme import- ance. Success is highly valued amongst all upper and middle class males and work is usually instrumental in achieving this . These men are said to be able to establish a valid identity because their work enables them to have a successful career. Too much of themselves is invested in their job so that if they are prevented by illness from working they cannot cope with the 59 resulting psychological, social and financial loss. They try to deny their illness and resulting disability and seek to continue their way of life unchanged, ignoring possible fatal consequences. It is important that the rehabilitation team takes into account how important work may be to the individual patient. Society, too, should take the responsibility for organiz- ing suitable working conditions not only for disabled people but for the general population. Factors affecting return to work have been studied by many investi- gators (37-46) . Age has been one of the best predictors of rctu1 n to work (37,39,44,47). More patients return to work after a myocardial infarc- tion if the job does not involve physically strenuous labour (22.44). Social Casework in Cardiac Rehabilitation Definition and contents of social casework Social casework has been defined as a problem-solving process ( 48). Using this model, the social aspects of rehabilitation become a series of events during which the client must solve the socia l and emotional problems arising as a result of his disease, particularly those in his social environment. Problems may occur within the family or at work, or may be connected with finances or unsuitable housing, or may arise as a result of strained social relationships and unsuitable leisure activities . Solving these problems ensures the best possible outcome of medical treatment. An essential part of the process is the confidential relationship between social worker and patient. This relationship is not a goal in itself but forms the professional framework within which problem-solving becomes possible and aims of treatment can be met. It is also necessary to make use of informal social supportive networks within the patient's environment as well as statutory social services (29). Social work is directed towards solving present prob- lems and discussions take place on those difficulties which the patient sees consciously as being the ones he must overcome. In a study reported from Colorado, Ezra ( 49) found that practical help with and discussion of environmental problems had most impact early in the acute illness, as this directed the patient's thoughts constructively and realistically. These conversations on practical issues gave the patients emo- tional relief, increased their activity and reduced dependence on others. Ezra also pointed out that patients with myocardial infarction are often hard- working individuals who need to maintain the role of a useful person, though they require help to formulate realistic plans for earning their living after their heart attacks. The best results of vocational rehabilitation were usually obtained when the patient could return to his former occupation, regarded as providing a safe and familiar way of life. Counselling was most effective when the family could be persuaded to maintain their previous roles. If the patient could not return to work and was forced to retire, plans for his future were most successful when they included opportunities to lead a life similar to that preceding the acute illness. Patients living alone and those left dependent on others had to be guaranteed some degree of independence. 60 Attention to the social aspects of care cannot begin too early. In a study from Los Angeles it was found that the social workers in the coronary care unit team were extremely effective in recognizing psychosocial problems at this early stage in the illness. By introducing immediate intervention measures, excess social and psychological disability was prevented (50). Similar find- ings were reported by Sokol (51). Special attention in the coronary care unit was directed towards those patients who tended to deny problems, suppress their emotions and who were over-involved in their work. The social worker dealt with real environmental difficulties at home and at work and, where necessary, mobilized the help of statutory support services including sick- ness payments and mental health services. In addition, the social worker had special responsibility to help patients who found it difficult to leave the security of the hospital ward. Such patients were found to have severe social problems. The Finnish project on the role of social casework Comprehensive rehabilitation should include, as one of its components, a programme of social rehabilitation. This aspect is often neglected in practice and to date no study has been published on the evaluation of the effects of introducing such a programme. There are several reasons for this: social rehabilitation is a new idea not yet universally accepted; methods of measur- ing social outcome are in their infancy; and the thought of handling such "soft" data appals more "scientifically" oriented workers. As an example of how to develop methods of measurement and demon- strating that it is possible to use acceptable outcome measures in this area, the Finnish project to evaluate a programme of social rehabilitation is given in some detail. Aims and method of the study The social casework programme for patients after myocardial infarction was based on the results of earlier studies and the general principles des- cribed by Laaksovirta (52,53), in that special attention was given to family , work and financial problems. The study included 297 male patients, 147 of whom (the intervention group) participated in the rehabilitation pro- gramme. The aims of the programme were: to help the individual to adapt to the acute illness and the consequent changes in his way of life necessary for successful rehabilitation; to help the patient to return to appropriate work or, if this was not possible, to help him to adapt to retirement; to improve his financial situation, if necessary making use of appro- priate social security services; to advise on family and social problems where appropriate. Fulfilment of the first aim was felt to be particularly important, as a myocardial infarction usually occurs during the patient's working life and may cause considerable changes in his way of living. The patient was taught 61 to recognize situations that might precipitate pain and damage his health and he was advised to identify for himself the necessary alterations in his habits. The programme consisted of regular sessions which were most frequent in the six months following the acute attack. On average, each patient participated in nine sessions. As the social casework programme was part of a comprehensive rehabilitation programme, the interview often took place when patients were attending for other types of rehabilitation session. The necessity for social intervention varied from patient to patient and the number and contents of the sessions depended on individual need. If poss- ible, husband and wife attended for the first interview. Evaluating social problems When the study started in 1973, there was no suitable rating scale to measure severity of social problems, though authors had suggested that formulating such scales could be partly based on previous experience (52,54-56). Social problems may arise in differing aspects of the patient's total life circumstances and will obviously vary considerably in their impact on the patient and his family . In order to classify the severity of various social problems, a list of some 80 items, comprising problems within the family, at work or with financial matters, was presented to 47 experienced rehabili- tation workers who were asked to score each item on a scale ranging from 0 to 6 depending on its degree of difficulty. In the event , none of the items was rated as O (no problem) or 1 (minimal problem). The classification of difficulties ranging from 2 to 6 followed a normal distribution curve, with very few items rated as either 2 or 6, so that these extreme cases were assimilated into the grade next to them, leaving a final three-point grading of severity of various social problems; mild, moderate and severe. The final score for severity for each problem was the mean of the ratings. Family difficulties classified as severe included the recent death of the spouse or a child or ill treatment by the spouse. Moderately severe problems occurred if another member of the family was ill or disabled or if the patient lived alone. A poor relationship between husband and wife constituted a mild problem. None of the work problems presented to the evaluators was classified as being severe. Moderately severe work difficulties included being unemployed, engaged in demanding work either physically or mentally, or a recent decision to place the patient on a disability pension. Work problems were rated as mild if, for example, the patient had a job that was unsuitable for his occupational skills or was otherwise unsatisfactory, or if he had been on a disability pension for a long time. Living in overcrowded conditions was rated as a severe financial problem. Moderate difficulty was present if the patient was on a form of social benefit or had to rely on others for financial support. Those who had continuing money problems, which they could just manage without seeking outside help, were classified as having slight financial problems. Rating the overall severity of patients' environmental problems The team of social workers involved in the programme made written reports of their interviews with the patients. Using these, severity of social problems 62 was rated by a social worker who had not been involved in treating that particular patient. Each social worker participating in the study was given the classification of social problems as defined by the panel of experienced rehabilitation workers. She was also informed of the results of the severity ratings of individual social problems for each of her patients. Using this information, it was possible to construct an overall severity rating for each patient taking into account all his different problems. The same scale (0-6) was used for rating the severity of individual problems. The reliability of the ratings was tested by the 47 evaluators. A seven-point rating scale was, therefore, used in the study as others have shown this to be a reliable method of evaluation (57,58). Grades I and 2 comprised a slight overall problem, grades 3 and 4 were moderate. and grades 5 and 6 were severe. This rating and the ratings for individual problems were subsequently used in the study. Using this method, the inter-observer reliability was good when Pear- son's product-moment correlation was calculated. For example, the social workers' assessments of general social problems produced coefficients (r) ranging from 0. 78 to 0.90. It was more difficult to determine the validity of the rating scales. In an attempt to do this, the severity of problems, as ra.ted by the social workers, was compared with the results obtained when indi- viduals other than those involved in the study interviewed the patients. It appeared that there was general agreement between ratings and interviews which suggested that it is possible to measure the severity of social problems by the rating scales used in the study with some accuracy. The frequency of environmental difficulties before the onset of their myocardial infarction was compared in 228 of the 297 patients in the study and in 151 randomly selected males of the same age. The only statistically significant difference between the groups was found in their work problems (53). Infarction patients had more problems rated as severe and fewer problems rated as mild than their healthy contemporaries. It may be that infarction patients are over-involved in their work, so that many of their environmental difficulties are concentrated in this aspect of their lives. Social changes during the rehabilitation programme The 228 male patients participating in the Finnish study on the effects of a comprehensive rehabilitation programme following myocardial infarction were included in this study (59). They were randomly allocated into a rehabilitation ( 119 men) or a control group ( 109 men). Patients in the control group received routine follow-up and rehabilitation services avail- able in the community. The intervention group received comprehensive rehabilitation, including services of social work. It was recognized that evaluating the social data might be difficult because patients in the rehabili- tation group would have more therapeutic contacts with the various members of the rehabilitation team, including the social worker, than control patients. They might thus become more aware of social problems, resulting in an apparent increase in problems during the period of intervention. All the patients were seen one year and two years after the myocardial infarction. After one year there were no significant differences between the 63 groups in the changes that had taken place in the environmental problems. Two years after, however, there was more improvement in problems at work, within the family and in their outside activities in the rehabilitation group than in the controls. Though financial problems were rare in both groups, the control patients had, if anything, done better than rehabilitation patients in solving these difficulties. Because the therapeutic contacts were different between the groups it may be that these results underestimate the change in the intervention group. Evaluating social outcome As the control patients were seen by the social workers only at the yearly follow-up appointments, evaluation of social outcome was confined to patients in the rehabilitation group. The evaluation of social outcome was made at the end of the second year. Because of the laborious evaluation procedure, only 83 patients could be included in this part of the study. Evaluation of social outcome was based on reports of progress prepared by the social worker who was treating the patients. Reports were submitted to an independent evaluator 3 months, 6 months, 12 months and 24 months after the onset of infarction. Judgements were made about the patient's attitude to his disease, family, work and economic situation. Changes in these problem areas were recorded for each follow-up interval using a scale ranging from -3 to +3 where positive figures recorded a change for the better and negative figures a change for the worse. The points representing the changes during each follow-up interval were added up to give a total score ranging from -12 to + 12, to represent changes that had taken place over the whole rehabili- tation period. Scores were recorded for each of the four aspects of potential difficulty together with an overall problem score. The period of greatest change occurred in the first six months following the infarction, which coincided with the time when the social worker's intervention was most active (Fig. 1). During this time marked changes occurred in the patient's attitude to his disease and in problems connected with work. There were fewer changes within the family and little or none in the patient's financial situation. These findings are most likely the result of the deliberate decision of the social worker to direct early therapy towards helping the patient adjust to his disease and to aid him to plan a more sensible working day, aspects which have already been shown to be import- ant in this group of patients. It does seem, therefore, that it is possible to modify patients' attitudes and behaviour by appropriate treatment. Changes within the family took place more slowly and over a longer period, the greatest changes occurring during the second year after the infarction. This may be due to the type of problem; difficulties within the family may have been present under the surface for many years but only have become manifest with the onset of illness. Few of the patients had financial prob- lems, but when they did occur they were not modified by the programme, which did not include special resources for financial relief. Overall, there was a definite improvement in the patient's social problems during each of the follow-up intervals. 64 Fig . 1. Median change in various spheres of life at successive intervals from the onset of acute myocardial infarction (number of patients. 83) Months after onset 0-3 3-6 6-12 12-24 - ~ m CJ 3.0 2.5 Cl) 2.0 Cl C n, ..c (.J .... 1.5 0 "' ... C 1.0 0 c.. 0.5 0 Acceptance Family Work Economic General -0.5 of disease problems problems problems situation From this detailed study of 83 men it can be said that behavioural changes to help recovery take place during the rehabilitation programme. Since the programme was a comprehensive one, these patients participated in other activities to help them return to normal life, so that it is impossible to isolate the effect of the social casework programme. As the patients in the control group were not seen by social workers there are no data to show which changes might have occurred spontaneously and which were the direct results of the intervention programme. It has, however, been shown for the whole group of 228 patients that improvements in work, family and overall problems tended to be more obvious in the rehabilitation group than in the controls. This suggests that patients participating in a rehabilitation programme learn to cope more efficiently with their social problems than those treated by routine methods alone. 65 Changing lifestyle The survey of lifestyle (53) based on social workers' treatment reports was also laborious and owing to this it was made only for a group of 80 patients. Out of this group, 42 were considered to belong to the type A and 21 to the more flexible type B, in many ways the opposite to the type A. The remain- ing 17 patients were already retired when taken ill and many of them had been retired for many years . Moreover, they often suffered from many diseases and their lives were quite regular merely because of disease. For this reason the study concentrated on the clearly definable types A and B. In this study the types A and B were not classified according to any commonly used questionnaire but, exceptionally, according to the treatment reports col- lected from the social workers. The researcher and the social worker treating the patient made the classification separately on the basis of data gathered in the beginning. The classifications were almost identical and after checking them a concordant result was decided upon in every case. The social stratification of the type A was the same as in the whole infarction group, clustering around the lowest stratum of the middle group. As far as the type B was concerned, no such clustering could be observed. The types A and B were also classified according to socioeconomic level. The group A consisted of more professional people than the group B and had received a greater degree of training than group B. Among those classified as type A there were more patients working long hours (more than eight hours) than among type-B patients. There were also more professional people of type A than of type B who worked for more than eight hours a day. According to the judgement of the social workers, there were also more work problems among the type-A patients. The rehabilitation careers0 developed during the two years were also examined among the two types. It was thus possible to study the influence of lifestyle on the rehabilitation career and at the same time the influence of the rehabilitation programme in changing the lifestyle. In the type-A group, there were some rehabilitation careers which did not progress well as far as lifestyle was concerned. The lifestyle adopted had obviously been so rigid and dominating that the two years' rehabilitation programme was not able to change it and the negative development con- tinued. The lower level of demand in the working conditions seemed espe- cially difficult to accept. A change of lifestyle in a positive direction took place, however, in most of the patients in both type-A and type-B groups. The difference in rehabilitation careers was as follows: in the type-B group the changes took place quite early, often during the first year of rehabili- tation. This development sometimes continued during the second year, but mostly the change had happened by then. In the type-A group changes were rare at the beginning of the career. A positive development may have started during the later half of the first year but the actual change of lifestyle took place during the second year. a A rehabilitation career is the series of stages through which the patient passes during his rehabilitation . 66 Changes in lifestyle took more time in the type-A than in the type-B group. It seems to be easier for those of type B to change than for those of type A who are more bound to a rigid lifestyle. To some extent the rehabili- tation programme could obviously be made more effective, if the patients were examined more thoroughly in the beginning, keeping the types A and B in mind. Thus more intensive work could be directed to those belonging to the type A, and the resources for this kind of treatment could be examined. Return to work The effect of age, social class, the physical requirements of the job and the rehabilitation programme on return to work was studied using the auto- matic interaction detector method of analysis . The analysis also took into account the severity of infarction using the functional groups defined by the New York Heart Association (NYHA) and the patient's plan to return to work, recorded during the early hospital phase (Fig. 2). Fig. 2 . Fa cto rs affec t ing return to work w ith in one year of th e myocard ial infarct io n All patients y= 56% n = 190 NYHA class I y = 83% n = 76 NYHA classes 11-111 y= 38% n = 114 y = percentage of patients who returned to work n = number of patients Light work y = 95% n = 42 Moderately heavy or heavy work y=68% n = 34 Plan to return to work y= 57% n = 60 Plan to become pensioned or no plan at all y=17% n = 54 Light work y = 67% n = 33 Moderately heavy or heavy work y = 44% n = 27 Rehabilitation group y=25% n = 28 Control group y=8% n = 26 67 On admission to the study, 190 patients were working. Those who reached pensionable age and those who died within a year of infarction were excluded from the analysis. The NYHA functional class turned out to be the factor most signifi- cantly associated with return to work; 83% of patients, who after the infarction had no symptoms restricting their physical activity (NYHA class I), returned to work. This compared with 38% of patients with func- tional restrictions (NYHA classes 11-111). Also the physical strain of the work was connected with the return to work. It was much more common to return to a light job than to a heavy one. In connection with the rehabilitation programme, a number of arrange- ments concerning working conditions had been made and thus resump ion of work was much easier for the rehabilitation group than for the control patients for whom no such arrangements had been made. Social Security Programmes Social security is well developed in all European countries . There are , however, quite considerable differences in the age of retirement and the amount and type of benefit given to individuals who are off work on account of illness. These differences may well account for the difficulty in comparing outcome variables, such as return to work between countries. In many countries retraining and re-education is provided under social security schemes but this kind of support is relatively seldom used by patients after myocardial infarction. Rehabilitation services have not developed very quickly in the last IO years although some progress has been made in providing free rehabilitation programmes and subsistence allowances to cover the period of the patients' attendance. Details of sickness benefits, pension schemes and a note of recent devel- opments in cardiac rehabilitation provided through social insurance schemes in various European countries are given in Annex 1, which is partly based on information received from centres who participated in the WHO study on comprehensive rehabilitation and secondary prevention in myocardial infarction patients and partly on material published on social security programmes (60). References I. Jenkins, C.D. Psychologic and social precursors of coronary disease I- II. New Eng/and journal of medicine, 284: 244-255 and 307-317 (1971). 2. Jenkins, C.D. Recent evidence supporting psychologic and social risk factors for coronary disease 1-11. New Eng/and journal of medicine, 294: 987-994 and 1033-1038 (1976). 3. Marks, R.U. Social stress and cardiovascular disease. Factors involving social and demographic characteristics. A review of empirical findings. Milbank Memorial Fund quarterly, Vol. XLV, (Suppl.): pp. 51-108 (1967). 4. Koskenvuo, M. et al. Differences in mortality from ischemic heart dis- ease by marital status and social class. Journal of chronic diseases, 33: 95-106 (1980). 68 5. Valkonen, T. & Niemi, M.L. Sepelvaltimotautikuolleisuuden alueelliset erot Suomessa. Suomen liiiikiirilehti, 30: 1968-1973 ( 1978). 6. Lehman, E.W. Social class and coronary heart disease: a sociological assessment of the medical literature. Journal of chronic diseases, 20: 381-391 (1967). 7. Antonovsky, A. Social class and the major cardiovascular diseases. Journal of chronic diseases, 21: 65-106 ( 1968). 8. Tyroler, H.A. & Cassel, J. Health consequences of culture change II: the effect of urbanization on coronary heart mortality in rural residents. Journal of chronic diseases, 17: 167-177 (1964). 9. Cassel, J. et al. Incidence of coronary heart disease by ethnic groups, social class, and sex. Archives of internal medicine, 128: 901-906 ( 1971). 10. Keys, A. Coronary heart disease in seven countries. Circulation, 4l(Suppl. I): (1970). 11. Marmot, M.G. et al. Employment grade and coronary heart disease in British civil servants. Journal of epidemiology and community health, 32: 244-249 ( 1978). 12. Marmot, M.G. et al. Changing social-class distribution of heart disease . British medical journal, 2: 1109-1112 ( 1978). 13. Dohrenwend, B.S. & Dohrenwend, B.P ., ed. Stressful life events: their nature and effects. New York, John Wiley & Sons, 1974. 14. Floderus, B. Psycho-social factors in relation to coronary heart disease and associated risk factors . Nordisk hygienisk tidskrift, Suppl. 6 ( 1974). 15. Medalie, J.H. et al. Angina pectoris among 10 000 men: 5 year incidence and univariate analysis. American journal of medicine, 55: 583-594 (1973). 16. Theorell, T. & Rahe, R.H. Behavior and life satisfactions characteristics of Swedish subjects with myocardial infarction. Journal of chronic dis- eases, 25: 139-147 (1972). 17. Thiel, H.G. et al. Stress factors and the risk of myocardial infarction. Journal of psychosomatic research, 17: 43-57 ( 1973). 18. Dunbar, F. Psychosomatic diagnosis. New York, Paul B. Hoeber , 1948. 19. van der Valk, J.M. & Groen, J.J. Personality structure and conflict situation in patients with myocardial infarction. Journal of psycho- somatic research, 11: 41-46 (1967). 20. Friedman, M. & Rosenman, R.H. Type A behavior and your heart. New York, Alfred A. Knopf, 1974. 21 Jenkins, C.D. et al. Association of coronary-prone behavior scores with recurrence of coronary heart disease. Journal of chronic diseases, 24: 601-611 (1971). 22. Croog, S.H. et al. The heart patient and the recovery process. A review of the directions of research on social and psychological factors . Social science and medicine, 2: 111-164 (1968). 23. Rosenman, R.H. Role of type A behaviour pattern in the pathogenesis of ischemic heart disease, and modification for prevention. Advances in cardiology, 25: 35-46 ( 1978). 69 24. Caffrey, B. Factors involving interpersonal and psychological charac- teristics, a review of empirical findings. In: Syme, S.L. & Reeder, L.G., ed. Social st ress and cardiovascular disease. Milbank Memorial Fund quarterly, Vol. XLV: 119-139 (1967). 25. Croog, S.H. et al. Denial among male heart patients . An empirical study. Psychosomatic medicine, 33: 385-397 (1971). 26. Hinkle, L.E. The effect of exposure to cultural change, social change and changes in interpersonal relationships. In: Dohrenwend, B.S. & Dohrenwend, B.P., ed. Stressful life events: their nature and effects. New York, John Wiley & Sons, 1974. 27. Cooper, G.L & Marshall, J. Sources of managerial and white collar stress. In: Cooper, C.L. & Payne, R. , ed. Stress at work. New York, John Wiley & Sons, 1978. 28. Payne, R. "A" type work for "A" type people? Personnel management, 7: 22-24 ( 1975). 29. Smith, R.T. Rehabilitation of the disabled: the role of social networks in the recovery process. International rehabilitation medicine, 2: 63-72 (1979). 30. Cassel, J.C. The contribution of the social environment to host resist- ance. American journal of epidemiology, 104: 107-123 ( 1976). 31. McMichael, A. Personality, behavioural and situational modifiers of work stressors. In: Cooper, C.L. & Payne, R., ed. Stress at work. New York, John Wiley & Sons, 1978. 32. Rose, A. A systematic summary of symbolic interaction theory. In: Rose, A. , ed. Human behavior and social processes. An interaction approach. London, Routledge & Kegan Paul, 1962. 33. Finlayson, A. & McEwen, J. Coronary heart disease and patterns of living. London, Croom Helm, 1977. 34. Safilios-Rothschild, C. The sociology and social psychology of disability and rehabilitation. New York, Random House, 1970. 35. Mechanic, D. Medical sociology. New York, The Free Press, 1968. 36. Croog, S.H. & Levine, S. The heart patient recovers. Social and psycho- logical factors. New York, Human Science Press, 1977. 37. Biorck, G. & Wedelin, E.M. The return to work of patients with myocar- dial infarction. Acta medica scandinavica, 17S: 2 I 5-226 ( 1964). 38. Cay, E. et al. Return to work after a heart attack. Journal of psycho- somatic research, 17: 231-243 ( 1973). 39. Kellermann, J.J. et al. Return to work after myocardial infarction. Comparative study of rehabilitated and non-rehabilitated patients. Geriatrics, 23: 151-156 (1968). 40. Kentala, E. Physical fitness and feasibility of physical rehabilitation after myocardial infarction in men of working age. Annals of clinical research, 4(Suppl. 9): ( 1972). 41. Kjeller, E. Resumption of work after acute myocardial infarction. Acta medico scandinavica, 199: 379-385 (1976). 42. Lewis, C.E. Factors influencing the return to work of men with con- gestive heart failure. Journal of chronic diseases, 19: 1193-1209 (1966). 70 43 . Master, A.M. et al. Survival and rehabilitation after coronary occlusion. Journal of the American Medical Association, 156: 1552-1556 (1954). 44. Pohjola-Sintonen, S. Work-return and five-year prognosis after myocar- dial infarction. Thesis, Helsinki, 1978. 45 . Shapiro, S. et al. Return to work after first myocardial infarction. Archives of environmental health, 24: 17-26 ( 1972). 46. Vuopala, U. Resumption of work after myocardial infarction in north- ern Finland. Acta medica scandinavica, (Suppl. 530): 3-53 ( 1972). 47. Fisher, S. Impact of physical disability on vocational activity: work status following myocardial infarction. Scandinavian journal of rehabili- tation, 2: 65-70 ( 1970). 48 . Perlman, H.H. Social casework, a problem-solving process. Chicago, University Chicago Press, I 971. 49. Ezra, J. Casework in a coronary care unit. Social casework, 50(Part I): 276-281 ( 1969). 50. Obier, K. & Haywood, L.J. Role of the medical social worker in a coronary care unit. Social casework, 53: 14-18 (1972). 51 . Sokol, B. The clinical social worker as a member of the health team in a coronary care unit. Clinical social work journal. 4: 269-275 ( 1976). 52. Laaksovirta, S. Henki/okohtaisen huol/on tuloksellisuuden mittaus kirkon perheneuvontatyossii. Helsinki, 1970 (Publications of the University of Helsinki, Institute of Social Policy, No. 12). 53. Laaksovirta, S. Sydiininfarktipotilaan kuntoutusura erityisesti sosiaali- tyon niikokulmasta tarkasteltuna. Turku, 1982 (Publications of the Social Insurance Institution, AL: 20) [English summary: The rehabilita- tion career of the cardiac patient with special emphasis on social work]. 54. Hunt, J.McV. et al. Testing results in social casework. New York, Family Service Association of America, 1950. 55. Hunt, J.McV. & Kogan, L.S. Measuring results in social casework. New York, Family Service Association of America, 1952. 56. Kogan, L.S. et al. A follow-up study of the results of social casework. New York, Family Service Association of America, 1953. 57 . Scott, W.A. & Wertheimer, M. Introduction to psychological research. New York, John Wiley, 1962. 58. Selltiz, C. et al. Research methods in social relations. New York, Holt, Rinehart & Winston, 1966. 59. Kallio, V. et al. Reduction in sudden deaths by a multifactorial inter- vention programme after acute myocardial infarction. Lancet, 2: 1091- 1094 ( 1979). 60. Office of Research and Statistics. Social security programs throughout the world 1979. Washington, DC, US Department of Health and Human Services. Social Security Administration, Office of Policy, 1979 (Research Report No. 54). 71 6 Secondary prevention I. Orha, L.F. Nikolaeva & J. Velasco The presence of atherosclerosis of the coronary arteries is frequently unsus- pected until the sudden onset of the symptoms of myocardial infarction. Many will die within the first few hours and those who survive the in itial attack run the risk of dying, often suddenly, within the next few weeks or months from one of the known complications of ischaemic heart disease: malignant arrhythmias, cardiac failure, ventricular aneurysm or reinfarc- tion. It is thus important that physicians should try to prevent or delay the development of infarction by all possible means or, if this is unsuccessful, they should make considerable efforts to control the continuing evolution of the underlying disease. This requires at least as much investment on the part of the physician as does treatment of the acute episode. Primary and Secondary Prevention Prevention, in the narrowest sense, is averting the development of a patho- logical state. In practice, the term is used to include all measures to limit progression at any stage in the course of a disease (J). A distinction is made between primary and secondary prevention. Primary prevention aims to avert the occurrence of disease, while secondary prevention aims to stop or slow down the progression of disease or its sequelae at any stage after its first appearance, i.e. it tries to prevent recurrence, complications or death in individuals who have survived their first myocardial infarction. This differentiation between primary and secondary prevention in an insidiously and slowly progressing chronic disease like atherosclerosis has two weak points. First, the causal factors are still poorly established. Second, the interplay between progress of pathology and clinical manifesta- tion of the disease (angina? acute myocardial infarction? arrhythmia?) is also ill defined and there are wide individual variations. It follows that the distinction between primary and secondary preven- tion is - although practical - highly arbitrary. This should be kept in mind when we are discussing later the validity of "primary preventive measures" in secondary prevention. 73 Risk factors In the last two decades, epidemiological studies have identified a number of fauors in the environment, in man's biological structure and in his behav- iour which are considered to be associated with a high risk of developing ischaemic heart disease and myocardial infarction (2,3), though a causal relationship has yet to be established. The presence of a risk factor does not necessarily mean that the individual will develop an infarction in the future - only that the probability of this is 1.5-2 times higher than for somebody without that risk factor. The established risk factors act in an exponential and not simply additive manner, i.e. the presence of three factors increases the probability of getting ill not threefold but four- or fivefold- depending on the level of these factors. By means of this multiple risk factor theory - which befits a pluricausal chronic disease like ischaemic heart disease - it is now possible to explain (and predict) up to 60% of cases of acute myocardial infarction. The exponentiality of risk factors explains why the bulk of infarctions occur among people with only moderately elevated risk factors in a popu- lation and not among those with the highest levels. Simply, the latter constitute only a small fraction of the population and hence their relatively high incidence adds little numerically to the overall population burden of the disease. This in turn means that primary prevention should be aimed at the whole population and not only towards the so-called high-risk groups. Protective factors There is some evidence that factors in the individual or in the environment may act as protection against ischaemic heart disease. Recent studies have shown that its incidence is inversely related to the level of high-density lipoprotein. Similar protective factors may operate, though to date the evidence of this is scanty, and may account for differences in the findings of various population studies. Results like this, if proven, will have an obvious impact on primary preventive measures. Secondary risk factors The concept of risk factors is useful in clinical practice. It helps the physician to evaluate his patient's risk of developing ischaemic heart disease and to estimate the probable natural course of illness in those who have symptoms. It di rects his thinking away from conventional therapeutic regimes towards preventive measures. The clinical manifestations of the slowly developing atherosclerotic process are usually dramatic. Quantitative changes become clinical symp- toms. Imbalance between oxygen demand and supply means angina and occlusion of an artery; formation of a thrombus and necrosis of myocar- dium results in acute myocardial infarction. These changes create a new state of affairs between pathological process and bodily response. In other words, new risk factors for the future of the patient appear. In the short term these are more important than the so-called primary risk factors, obscuring, but certainly not completely abolishing, their impact. Indeed, available evidence is that, following the major attack, 74 hypercholesterolaemia and obesity seem to be of less importance than secondary risk factors associated with the acute phase of illness - extent and degree of myocardial damage, presence of arrhythmias and cardiac failure ( 4). Smoking and, to a lesser degree, hypertension seem to maintain their earlier influence on the development of the disease. While primary prevention deals with populations, secondary prevention is di rected to the high-risk individual and entails clinical intervention aiding psychological adjustment to the disease and help with the social problems caused by it. Secondary preventive measures to limit myocardial damage, slow down atherosclerosis and improve the patient's clinical state by medi- cal or surgica l treatment, start during the acute attack and later become part of active comprehensive rehabilitation. Principles and Objectives of Secondary Prevention Recent studies have succeeded in identifying subgroups of patients at vary- ing degrees of risk following infarction. During a five-year follow-up of 940 survivors of an acute myocardial infarction, previous infarction, left ventricular dysfunction, one or more ventricular premature beats on a 6-hour Holter recording and an anterior infarct, were significantly more frequent in patients who died of cardiac causes than in survivors. A combi- nation of these risk factors was present in 15% and of these patients 70% were alive three years later. In contrast, 24% had none of these risk factors and of these 94% survived ( 4). A transmural infarct carries a higher risk of mortality than a non-transmural one; of 728 post-infarction patients, 34% who had had transmural infarcts were dead five years later compared with 19.4% of those who had had non-transmural ones (5). It appears possible that secondary preventive measures can be planned rationally. They are based on the hypothesis that even when coronary disease is evident, the progression of vascular lesions, arterial thrombosis and the occurrence of arrhythmias is not inevitable but can be favourably influenced by a variety of cardiovascular and metabolic factors. Implied in this is the belief that atherosclerosis is potentially reversible, thrombo- genesis can be controlled and life-threatening arrhythmias can be treated successfully . Basic principles A programme of secondary prevention consists of a systematic attempt to minimize the effect of existing risk factors. This must be tailored to the needs of the individual and any action taken must be part of a comprehensive medical regime of treatment, taking into account the patient's clinical state and his pre-existing lifestyle. The theory of risk factors provides a rational basis for secondary prevention and indicates where and when intervention and treatment can most effectively be applied. Diseases which accelerate the manifestation of coronary heart disease and modify its natural course, hypertension, hypercholesterolaemia and diabetes mellitus, and a number of behavioural and social factors, nicotine abuse, sedentary living, psychological stress and socioeconomic problems, 75 may well continue to be important after a myocardial infarction. However, because the acute event has occ urred, other aspects must be included in a programme of secondary prevention. Cardiovascular factors known to be associated with a poor prognosis, increased cardiac volume, extent of myocardial damage, the presence of abnormalities of rhythm and conduc- tion on the ECG, decreased myocardial capacity, other vascular and meta- bolic disorders , unstable angina and an increased tendency to thrombosis, require specific medical treatment ( 4,6,7). Objectives The aims of a programme of secondary prevention fall into two groups. 1. Changing pre-existing unhealthy behavioural patterns: - rational diet - antismoking programme - increased physical activity - control of body weight - avoiding or controlling psychosocial stress. 2. Treating cardiovascular and other disorders: - limiting the size of the infarct and the extent of myocardial damage - treating cardiac failure - controlling arrhythmias - controlling hypertension - controlling diabetes - anticoagulants - beta-blockers - platelet-active drugs - surgery. This comprehensive programme of care, containing preventive aspects, medical treatment, surgery and rehabilitation measures, aims to reduce the impact of primary and secondary risk factors and to minimize the adverse effect of certain environmental and endogenous influences on the rate of progress of coronary heart disease in the individual who has had a myocar- dial infarction. It does not pretend to include all the known factors but is applicable in the great majority of patients. As new knowledge in this rapidly growing field becomes available, the programme must be regularly reviewed and updated. Changing the Patient's Mode of Life Recalling what was said earlier on the role of "primary" risk factors in secondary prevention, we will briefly discuss the most relevant lifestyle- related risk factors in the light of the recent recommendations issued jointly 76 by the three Councils of the nternational Society and Federation of Cardi- ology (the Councils on Arteril>Sclerosis, Epidemiology, and Prevention and Rehabilitation) (8) . Rational diet It is well established that a relationship exists between the dietary content of saturated fat and cholesterol, the mean levels of plasma cholesterol and triglycerides and the prevalence of and mortality from coronary heart disease (9). The picture is less clear when the possible secondary preventive effect of lowering blood cholesterol is examined. Evidence from adequately controlled tria ls to substantiate the continuing influence of lipids and diet after the first acute myocardial infarction is far from co nvincing (J O). However, logically there is still a good case in favour of the advice given below, as it is likely to slow the progress of atherosclerosis, diminish the te11dency to thrombosis, and encourage the patient's family to lead a more healthy life. Total nutritional intake should be controlled, depending on the patient's need . This depends on his energy expenditure, particularly his physical activity. In obese patients intake should be restricted and body weight regularly controlled. Fat intake should not exceed 30% of the total food energy consumed. Within the total fat consumption, saturated fats - mostly of animal origin - should provide not more than 10% of the total food energy, i.e . one third of the fat energy. There is some evidence that diets with less than 300 mg/day of cholesterol and with a ratio of about 0. 75 between polyunsaturated and saturated fatty acids may contribute to the prevention of atherosclerosis and its complications. Nutrition in industrialized coun- tries is generally poor in gel-forming fibres. They may contribute to proper digestion and balanced lipid metabolism, so it is reasonable to increase the intake of foods rich in such fibres. To provide a balanced diet, the propor- tion of proteins from vegetables should also be increased. The use of antihyperlipidaemic drugs in secondary prevention is a much more controversial issue ( 10, 11). Convincing evidence from controlled trials is lacking and possible untoward side effects should always be balanced against possible benefits. Such drugs may have a place in the treatment of patients with gross hyperlipidaemia who have a major risk of vascular or other serious complications (8). Antismoking programme Cigarette smoking is a major risk factor in coronary heart disease and stopping smoking reduces the risk (3). The results of the American Heart Association Pooling Project (12) have shown that this is independent of other risk factors, such as hypercholesterolaemia and hypertension. Smoking habits influence outcome after myocardial infarction. Studies from Finland, Sweden and the United States have found that mortality after an infarction is doubled in patients who persist in smoking compared with those who stop (] 3-15). Recurrence of non-fatal events is similarly more frequent in those who continue smoking. While some have argued that the association between smoking and infarction is more apparent than real and may be due to other factors such as 77 personality and alcohol abuse (3), it has been shown in Sweden and the United States that smoking by itself increases the risk of having a myocar- dial infarction, of dying from coronary disease and of suffering a second major attack ( 16). In patients who have experienced a myocardial infarction every effort should be made to persuade them to give up smoking for the rest of their lives. No one drug has yet been found that consistently aids the smoker trying to give up the habit, though tranquillizers and a variety of patent medicines have been shown to help some individuals. The physician's per- sonal influence on his patient is the one method likely to succeed and requires him to give a clear explanation of the dangers of smoking followed by a well defined, detailed programme of methods of abstention. Advice should be given from the very beginning of treatment and must be supported by personal example and dedication by all members of the health team in contact with the patient. Continuous support from the spouse and family and a great deal of patience, particularly with those who repeatedly fail in their attempts to stop smoking, is essential. Lengthy supervision and repeated assistance will be necessary as many will otherwise restart the habit. Potential "withdrawal" effects ( e.g. weight gain, depression, irritability) should be taken care of in the process of counselling or group therapy. Specialist care may be needed in exceptional cases. Special pamphlets on the dangers of smoking and containing advice on how to stop are useful adjuncts to the physician's programme. Increasing physical activity Habitual physical activity has been claimed to exert a protective effect against the development of ischaemic heart disease, though the findings are equivocal. While the death rate from coronary heart disease was less in longshoremen who were engaged in heavy work compared with those whose duties were lighter (17), Punsar & Karvonen (18) found that in men in East Finland coronary mortality was not related to physical activity at work and, if anything, was higher in those with the heaviest jobs. It may be that activity does not exert a preventive effect if other risk factors, hyperlipidaemia, hypertension, smoking and obesity are high. The physical activity in general was high in the sample and its range rather narrow. Physical activity after a myocardial infarction improves the patient's working capacity (19,20). There is some evidence that the incidence and severity of reinfarction is less in patients who take part in a physical training programme and there may be some reduction in mortality (JO), but to date no controlled study, with a sufficient number of patients followed up for an adequate length of time, has been completed. For several reasons, Black- burn (21) feels that controlled trials may never give a definitive answer to the question of the possible secondary preventive effect of exercise; the number of patients who must be included in the trial is prohibitive, they must be standardized for all other risk factors and the required duration of follow-up is exceedingly long. It may be, as Shephard (22) says, that more attention should be directed to the influence of physical activity programmes upon the quality of life during the years remaining to the post-infarction patient. 78 Regular dynamic exercise improves physical work capacity and in many cases helps the patient to adjust to his daily workload withou t being ham- pered by angina! attacks. Thus it helps to improve his mood and confidence and facilitates return to work. A clinical and functional evaluation prior to starting training determines the type of programme and identifies high-risk individuals (cardiac enlarge- ment, left ventricular dysfunction, etc.) who may be unsuitable for training or need special attention. All forms of dynamic exercise, particularly if the larger muscle groups are involved, are beneficial. The patient's physical activity at work and at leisure must be taken into account when prescribing suitable exercise (23,24). A training effect can be achieved by sessions of30-45 minutes' duration, repeated 2-3 times in a week . The recommended exercise level is at about 70% of the maximal heart rate achieved during the initial exercise testing. Even lower level activities may be beneficial, however, especially in less fit , elderly patients. It is important that the patient should be advised to return to work as soon as he has recovered from an infarction, provided that there are no defi nite medical contraindications. Return to work and an active physical life represent the best way to achieve, if not physiological at least unequivo- cal, psychological benefit following a myocardial infarction. Control of body weight There is no reliable evidence that weight reduction in patients following an infarction results in decreased mortality or non-fatal reinfarction (25). Nevertheless, correcting obesity is desirable and is recommended as part ofa programme of secondary prevention because of its close relationship with hypertension, hyperlipidaemia, diabetes, cardiopulmonary fitness, mechan- ical disability and psychosocial problems. Clinically, the aim is that the individual should maintain his normal weight , corrected for age, sex and body build. The majority of countries publish such figures which are readily available to the physician. The best method to achieve this is the combination of a low-calorie diet and physical activity. Drugs to suppress appetite should be reserved for a few extreme cases. A voiding or controlling psychosocial stress Behavioural patterns, environmental and social changes, life events and emotional state may well be important in secondary prevention (26). It has been stated that acute psychosocial stress may precipitate arrhythmias, myocardial infarction and sudden death in the susceptible individual. It is, however, difficult to prove that chronic stress definitely influences the natural course of disease after an infarction (27). A voiding and controlling psychosocial stress is admittedly difficult, though it is possible to help the patient to cope with some stress situations within himself, his family or social circumstances. The physician should make his patient aware of the role of psychosocial stress in the development of disease, and treatment of these aspects with simple psychotherapy or medication should be part of good medical management. 79 Treating Cardiovascular and Other Disorders The risk of dying following an infarction depends on the extent of myocar- dial damage, and certain measurements and signs give an accurate indica- tion of this. These include cardiac volume and obvious cardiomegaly, the presence of failure, malignant arrhythmias and conduction defects and the diagnosis of ventricular aneurysm. Morbidity and non-fatal infarction may not necessarily be so closely related to size of infarct, as the further course of the disease is associated with other disorders and factors which influence the continuing development of atherosclerosis and thrombus formation: hyper- tension, hyperlipidaemia, smoking, platelet function and myocardial revascularization. Limiting the size of the infarct Theoretically, assessing the size of an infarct provides a rational basis for treatment and gives an indication of likely prognosis (28) . As a myocardial infarction is not a static event but rather a dynamically evolving process, the determination of whether or not it is extending is important , not only in the acute phase of illness but during further rehabilitation and secondary pre- ventive measures (29) . Several methods have been developed to assess the extent and severity of myocardial damage, many as a result of the growth of intensive care units with their facilities for continuous monitoring. The most widely accepted are measurement of enzyme activity (the serum enzymes serum glutamic-oxaloacetic transaminase (SGOT), lactate dehydrogen- ase (LOH) and creatine kinase (CPK) and the serum isoenzymes LOH and CPK) and electrophysiological methods including ECG mapping, but the more recently developed techniques using radioisotopes, such as infarct imaging, myocardial perfusion scanning and radionuclide angiocardio- graphy look extremely promising. Treatment is directed towards increasing coronary arterial flow and minimizing myocardial oxygen demand. There is some evidence that the use of adrenergic beta-blocking drugs to reduce oxygen demand by decreasing the blood pressure-heart rate product during the infarction may help to prevent complications and thus make secondary prevention later on much easier (10). Treating cardiac failure Cardiac enlargement and failure are very important secondary risk factors in patients after an infarction . There are more fatal cardiac events in those with overt , early or impending cardiac failure , with or without obvious cardiac enlargement, than in those who have no evidence of this (25,30). In these days of sophisticated methods of evaluating cardiac function, it is interesting to note that clinical observation, if used systematically and efficiently, is still the best method to detect impending cardiac failure. The early signs of dyspnoea, tachycardia and pulmonary congestion have the same predictive power as manifest cardiac failure detected by more advanced techniques (16.31). Patients with failure, even those with mild symptoms, form an "at-risk" subgroup who are worth treating vigorously in the hope of lessening the chance of further fatal cardiac events. 80 The clinical management of cardiac failure in patients aft er an infarction requires complete evaluation to ensure early diagnosis, the appropriate choice and adequate dosage of glycosides and diuretics, and long-term follow-up. Other measures include dietary advice such as restriction of salt, prescription of suitable rest periods and level of physical activi ty and control of other risk factors, hypertension, smoking, diabetes and obesity, which may be present. Controlling arrhythmias A high proportion of deaths following infarction are sudden , obviously due to malignant uncontrolled arrhythmias , and many differen t ki nds of arrhythmia and conduction defects are blamed for worsening prognosis after an infarction (6,32). The exact role of arrhythmias is still under debate . Some consider that they act independently of the severity of atherosclerosis (33) whi le others have shown that their power as predictors, either in the early phase of illness or during long-term follow-up, depends on the presence of other secondary risk factors, such as cardiomegaly and cardiac failure , severity of myocar- dial damage and hypertension (31,34). Ventricular premature beats detected during the patient's stay in hospital after a myocardial infarction or at follow-up, occurring at rest or immediately after exercise are of value in predicting mortality over the next 2-5 years . This is especially true if they occur at a rate of more than 10 per minute, if they are complex (paired or bigeminy ventricular tachycardia) or if they occur earlier rather than later (6) . Despite this, the recent WHO project on premonitory symptoms of myocardial infarction and sudden death failed to provide consistent and conclusive data on the place of arrhythmias (35). Similarly, secondary prevention trials of antiarrhythmic drugs have produced conflicting results (36) . Until definite evidence is forthcoming, it can be said that, in the light of present knowledge, it is necessary to identify and control malignant arrhythmias whether they occur early in the illness or later during the period of recovery. There is considerable variation between physicians in their drug regimes to control arrhythmias. Controlling hypertension The contribution of high blood pressure to the risk of developing coronary heart disease is becoming clearer. Treating even mild hypertension can reduce the mortality and morbidity of the disease (37). Knowledge of the relationship in post-infarction patients is more limited. There is as yet no convincing evidence that treatment of hypertension reduces reinfarction or prolongs life. The favourable effect of reducing hypertension on angina pectoris can be explained by improved cardiac function. The number of potent antihypertensive drugs increases yearly but each drug has side effects. This means that certain groups of drugs should be used cautiously in treating patients after acute myocardial infarction. For example, beta-blockers may depress left ventricular function and some diuretics may cause hypokalemia and hyperlipoproteinaemia. General health measures 81 to control blood pressure, often neglected, do not have these undesirable side effects. Control of obesity through caloric restriction, limitation of alcohol consumption and reduction of salt intake may well be relevant. These measures should be preferably accompanied by moderate regular daily exercise. In some cases, this may be enough to lower the blood pressure to normal or at least to keep drug therapy to a minimum. Patients with poor left ventricular function and those whose blood pressure does not rise adequately during exercise require careful choice of drug therapy and adequate control. It has been suggested that sudden and excessive lowering of high blood pressure may precipitate complications, particularly in patients with a poorly functioning cardiovascular system. In each patient, the aim should be steady reduction to approximately normal limits of blood pressure, proceeding in definite stages. An example of such a regime, based on a four-step plan, has been proposed by a WHO Expert Committee (38) . The key to successful treat- ment of hypertension is, howevet, continued cooperation of the patient and all measures to ensure this should be undertaken. In this respect , the importance of positive attitudes of all medical and paramedical staff involved in the care of the patient, a health education programme and a well organized system of follow-up has been stressed (39) . Controlling diabetes The occurrence of myocardial infarction does not change either the diagnos- tic criteria or management of diabetes mellitus. Thus symptom-free patients with impaired glucose tolerance should not be treated, even after an infarction . While, in general, the principles of managing diabetes remain the same as in other patients, it is wise to keep some special considerations in mind. In order to reduce the number of drugs prescribed to a minimum, it is advisable to start treatment with weight control through low-calorie diet and exercise. The diet should be low in saturated fat and contain ample amounts of complex carbohydrates rather than refined sugars. Two types of drug should be used with great care in the post-infarction diabetic patient: thiazides are known to aggravate diabetes, raise serum lipids and cause potassium depletion; beta-blockers may mask the clinical symptoms of hypoglycaemia. Salt restriction should first be tried when treating hypertension or car- diac insufficiency in a diabetic patient. Correction of any other risk factors should, of course, also be included in the prevention scheme. Controlling other metabolic disorders Hypothyroidism and hyperuricaemia can, if present, influence atherogenesis and thrombus formation . In individuals with these metabolic disorders and an infarct it is reasonable that their control should be of secondary preventive value. Early diagnosis and treatment ofhypothyro'idism corrects the associ- ated hypercholesterolaemia. Treating hyperuricaemia with one of the newer 82 potent drugs such as sulfinpyrazone seems to exert a promising secondary preventive effect (40,41). Anticoagulant therapy The role of anticoagulants in secondary prevention has been examined in many studies (10,42-44). There is no doubt that they are of benefit to some patients after a myocardial infarction, especially if there is left ventricular decompensation, cardiac enlargement and atrial fibrillation . A critical review of the literature suggests that the case for anticoagulants in all post-infarction patients has yet to be proved ( 45). Any possible benefit must be weighed against the known risks of haemorrhagic complications and the restrictive effects of treatment. This may explain why at present this treat- ment has lost its original popularity. Long-term anticoagulant treatment should be considered in patients with special risk of thromboembolic complications, previous infarctions and angina, if adequate control of treatment can be achieved. Beta-blockade There are substantial data that beta-blocking agents are of value in treating angina pectoris, arrhythmias and hypertension . Inasmuch as these con- ditions are important risk factors in the clinical course of coronary heart disease after an infarction, their control by beta-blocking drugs is reason- able. More recently, however, a possible protective effect of long-term treatment with beta-blockers has been demonstrated. The main therapeutic effect of the beta-blockers is thought to be due to reduction in myocardial oxygen consumption as a result of the induced bradycardia and hypotension ( 46). They may also slow the velocity of myocar- dial contraction and reduce ventricular ectopic activity ( 47). These modes of action suggest that beta-blockade could potentially lower mortality after an infarction and that treatment with these drugs might have an effect during the in- itial phase of developing ischaemia. It might be possible to prevent an infarc- tion developing or extending and thus to limit the size of the ischaemic area. These ideas have prompted a number of clinical trials to evaluate beta- blockade after infarction. Several studies have shown definite beneficial results of treatment. Prolonged administration of several of these drugs lowered the incidence of subsequent infarction ( 48-51). There were fewer sudden deaths and overall mortality in the first two months following an in farction in patients treated with various beta-blockers, and prolonged administration for one or two years produced similar findings. On the other hand, some trials failed to demonstrate this (52-55). The most up-to-date evidence from trials using four different beta-blockers has demonstrated significant reductions in post-infarction mortality (56-59). The present view is that long-term beta-blockade is of definite value in comprehensive secon- dary prevention in selected groups of patients (60) . Platelet-suppressing drugs Acetylsalicylic acid , whose effect on platelet function is probably the most widely known, is the most potent drug of this group. At least six large 83 clinical trials have been conducted using this either alone or in combination with others (61). Their outcome was inconsistent, but taking all trials together there may be a slight reduction in mortality after myocardial infarction. One controlled trial with sulfinpyrazone suggests a reduced risk of sudden death in the especially vulnerable period of the early months after infarction ( 40). This finding was not confirmed in a later study which, however, showed a marked decrease in the incidence of reinfarction over an average treatment period of 20 months ( 41). Surgical treatment The advent of coronary bypass grafting represents a major step forward in the treatment of coronary heart disease. The operation aims to obtain long-term revascularization of the ischaemic myocardium, but its place in the treatment of this disease is not yet fully established. Clinically, the indication for operation is the relief of severe angina( pain which has failed to respond to medical treatment. Considerable sympto- matic improvement occurs in these patients, 80-90% having a good result. There are still many unanswered questions regarding the effect of operation on survival and the natural history of ischaemic heart disease (62,63). Multicentre controlled trials to try to establish this are at present being undertaken in the United States and Europe; published results of the Euro- pean study suggest that, in patients with stable angina, left main coronary artery disease , triple-vessel disease and certain cases of two-vessel disease fare better under surgical than medical treatment (64). The place of surgical intervention after myocardial infarction is much less clear. The results of uncontrolled studies suggest that the mortality rate following infarction is less in patients who are operated on for post- infarction ventricular aneurysms, ventricular septa) defects or mitral incompetence, even if they do not have angina (65). The effect of surgery in patients with life-threatening arrhythmias and poor ventricular func- tion is also still not established as yet. 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Long-term betablockade: possible protection from myocardial infarction. British medical journal, l : 117-119 ( 1975). 50. Green, K.G. et al. Improvement in prognosis of myocardial infarction by long-term beta-adrenoceptor blockade. American heart journal, 92: 537-539 (1976). 51. Wilhelmsson, C. et al. Reduction of sudden deaths after myocardial infarction by treatment with alprenolol. Preliminary results. Lancet, 2: 1157-1160 (1974). 52. Baber, N.S. et al. Multicentre post infarction trial of propranolol in 49 hospitals in the United Kingdom, Italy and Yugoslavia. British heart journal, 44: 96-100 ( 1980). 53. Barber, J.M. et al. Practolol in acute myocardial infarction. Acta medica scandinavica, (Suppl. 587): 2 I 3-29 I ( I 976). 54. Reynolds, J.L. & Whitlock, R.M. Effects of a beta-adrenergic receptor blocker in myocardial infarction treated for one year from onset. British heart journal, 34: 252-259 ( 1972). 55 . Wilcox, R.G. et al. Randomised trial comparing propranolol with atenolol in immediate treatment of suspected myocardial infarction. British medical journal, 280: 885-888 ( 1980). 56. Andersen, M.P. et al. Effect of alprenolol on mortality among patients with definite or suspected acute myocardial infarction. Lancet, 2: 865- 869 (1979). 87 57. Beta-Blocker Heart Attack Study Group. The beta-blocker heart attack trial : preliminary report. Journal of the American Medical Association, 246: 2073-2074 ( 1981 ). 58 . Hjalmarson, A. et al. Effect on mortality of metoprolol in acute myocar- dial infarction. Lancet, 2: 823-827 ( 1981 ). 59. Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. New England journal of medicine, 304: 801-808 (1981). 60. Moss, A.J. Postinfarction therapy with beta blockers: who should be treated? International journal of cardiology, 1: 343-349 (1982). 61. McNicol, G.P. Antiplatelet drugs in the secondary prevention of myocardial infarction. Lancet, 2: 736-738 ( 1980). 62. Banes, G.K. Changes in working status of patients following coronary by-pass surgery. Journal of the American Medical Association, 238: 1259-1262 ( 1977). 63. Millman, M. Coronary artery bypass surgery: who profits? Nordisk medicin, 93: 5-8 ( 1978). 64. European Coronary Surgery Study Group. Prospective randomised study of coronary artery bypass surgery in stable angina pectoris. Lancet, 2: 491-495 ( 1980). 65. The long-term effects of coronary bypass surgery: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1978 (docu- ment ICP/CVD 003(8)). 88 7 Educational programmes after myocardial infarction W. Geissler, E. Cay & D. Dorossiev The success or failure of any rehabilitation programme depends in the end on the patient's full participation. Mere enthusiasm and cooperation, his motivation, is not all that is needed. He must become an active partner in the combined efforts of his physician and the rehabilitation team to return him to normal living following his infarction. This means a smooth, steady, safe progression from full dependence in the intensive care unit at the onset of acute symptoms to the time when he can assume responsibility for his own continued hea lth and wellbeing with only minimal contact with his treating physician. This is much easier ifhe knows about the nature of his disease, the rationale of its treatment, the principles of rehabilitation and the reasons for secondary preventive measures. Thus, education is crucial in patient man- agement, with its aim a voluntary change in the patient's behaviour so that he readily complies with his doctor's advice. Knowledge, understanding, motivation and cooperation on the part of the patient are the necessary stages to be gone through to achieve this, and the methods used vary considerably. Principles of an Educational Programme Education of the patient starts with the onset of acute symptoms. It should be practical and relevant to him and the particular stage of illness, and should not be couched in vague general terms which only increase his fears and anxieties. An educational programme which meets these specific requirements at each phase in recovery improves the patient's attitude, his knowledge of his illness a nd his performance. It should precede o r at least parallel increasing activity, particularly when introducing changes in ma n- agement such as transfer from the coronary care unit to the general ward , discharge fro m hospital or beginning a graduated exercise programme. Not an isolated act ivity, it is an essentia l part of comprehensive care and should go hand-in-hand with the other components of a rehabilitation programme, such as mobilization and physical training, social and vocational counselling and rational psychotherapy, whether carried out individually or in groups . 89 All who are involved in the care oft he patient should feel it their duty to contribute to his education , though, in practice, during his stay in hospital it is usually the prime responsibility of one individual, be it physician, social worker or nurse counsellor. After discharge, this important aspect of care, like so many other rehabilitati on activities, becomes the reponsibility of the patient's primary care physician. This does not imply that the general practitioner is expected to cope alone with all aspects of post-infarction education during all phases of rehabilitation. He should work in collabor- ation with and receive support from hospital staff, factory doctors, statutory health care authorities and volunta ry associations. But it does mean that he should be clearly informed what he is expected to do himself and what he can expect from others in educating his patient. There are practical difficulties which may limit the effectiveness of an educational programme. Communication between patient and general practitioner may be poor, because the doctor is not particularly interested in this aspect of care, because he may not realize the necessity of teaching his patient about ischaemic heart disease or simply because he may not be able to spare the time to discuss problems. He may be ignorant of existing facilities within his community, such as booklets, leaflets, films, slides and posters. While this can be overcome by providing the general practitioner with a list of such facilities and a directory of names, addresses and phone numbers of individuals and organizations who can help him with, for example, antismoking courses, dietary advice and social and vocational counselling, this is by no means routine in many areas. To be effective, an educational programme should involve not only the patient himself, but his spouse and family, friends, colleagues and employer and anybody else who is directly concerned with the patient's reintegration into society ( J). Aims of an Educational Programme Though it is correct to say that the educational programme aims to change the individual's attitude and behaviour, in practice this is much too vague. It is more useful to define limited objectives for each successive stage of rehabilitation. Experience from many centres and rehabilitation units suggests that an educational programme should aim to instruct the patient on the following items. (a) In hospital: - acceptance of the illness; - understanding the reasons for early mobilization; - understanding the reasons for stopping smoking; - how to recognize possible limiting factors in physical activity; - understanding existing residual symptoms; - advice on diet, social activities, sexual life; - advice on starting work again. 90 It is important to stress encouraging aspects with emphas is o n what the patient can do, ra ther tha n what he cannot. (b) During convalescence: - understanding the importance of regular, graduated phys ical training; - accepting long-term control of possible ri sk fac to rs; - understanding prescribed drug treatment and poss ible adverse reactions; - understanding about the opti mal time to resume sexua l ac- tivity, leisure pursuits and hobbies ; - resumption of travel; - preparing for return to work. (c) After rehabi litat ion: - reinfo rcing secondary preventive measures. Outline of an Educational Programme When planning an educati onal programme for pati ents after myoca rdia l infarctio n it is important to decide what the patient sho uld be to ld a t each stage of illness, how thi s should be do ne and who sho uld be respo nsi ble for carrying thi s o ut (Table I). In the coronary care unit It is enough to begin by explaining the nature and layout o f the unit , the rationale of mo nitoring and any necessa ry procedures that may be carried out. The concept of early rehabilitation should be introduced with an optimistic yet rea listic appraisal of the expected leve l of recovery. The majority of patients react to the initia l shock of hav ing a n infarcti o n with varying degrees of a nxiety a nd depression. They may have difficulty in concentrating and deny thei r illness (2). As a result , they cannot a bsorb much informatio n. So, regardless of the patient's educa tio na l leve l, expla- nations must be short a nd simple and repea ted at frequent intervals. The staff of the unit usua ll y cope wit h this initia l period of education. A booklet of coronary ca re, prefe ra bly in big print with cartoon-like illustrations, is used in many hospita ls to suppl ement verbal information. It is important that the spo use too is included in the educationa l programme from the beginning. She may be just as worri ed and anxious as the patient , and a llowa nce must be made for this. The rest of the time in hospital With the expe ri ence of the acu te illness still fresh in his mind, the patient is most receptive to a n educational programme. He will understand a nd accept having had a n in fa rcti on more readily if simple expla nations are given of the 91 '° N Phase of Illness In the coronary care unit In the ward During convalescence After rehabll1tat1on Tabl e 1. Edu cat io n of the patient after acu te myocardial in farcti on Sub1ect the unit. procedures 1n the unit; 1ntroduc- 1ng early rehab1l1tat1on . prognosis simple cardiac anatomy: heart function . meaning of chest pain and effect of physical act1v1ty. use of glyceryl trinitrate and oth er drugs. stopping smoking. risk fa c tors. physical training . nutrition. weight. early retur n to work. early re turn to sexual act1v1ty healthy l1v1ng habits. nutrition. weight . smoking. sexual problems. regula r graded physi ca l exerc ise. risks . l1m1ting symptoms. monitoring heart rate . prescribed drugs. adverse reactions . leisure act1v1t1es. hobbies. travel . return to work reinforcing secondary prevention measures Method short. simple verbal 1nformat1on. booklet on coronary care non -detailed verbal 1nformat1on. talks . discussion. audiovisual aids. groups 1nvolv1ng spouse and family 1nd1 v1 dual and/or group discussions. 1nvolv1ng family. pos ters. leaflets. booklets discussions. posters . leaflets. audiovisual aids during readmission for spa treatment Staff involved staff of the unit ward staff. physiotherapist staf f o f rehabll1tat1on team (phys10- therap1st. psychologist. social worker. docto r) . su pport fr om family. friends . employer doc tor. remedial gymnast. physio- therapist anatomy of the heart and its blood vessels and its physiological functioning. He should be told of the significance of chest pain and its relation to physical activity, and when he should seek medical help . The use of glyceryl trinitrate should be explained. The importance of stopping smoking should be emphasized. Improvement in physical fitness, resumption of sexual activity, control of risk factors, dieting and weight control, and treatment with drugs should be discussed but not in any great detail, which at this stage the patient does not need and will not absorb. As the patient becomes more mobile, teaching is best carried out in groups. Patients feel more relaxed in such a setting and, therefore, learn more, and teaching by this method is economical of staff time and effort. Talks, posters, slides and booklets can all be used to impart information with ample time given for the patient to ask questions. Booklets are particu- larly useful because the patient and his family can read them in hospital and then take them home, where they form the basis for subsequent discussion. Preparing the patient for discharge from hospital involves his wife and family. Educating the spouse has been successfully undertaken in groups, in which both patient and family participate (3), and in individual sessions with husband and wife. Diet, physical and sexual activity, stopping smoking and a sensible social life are the main topics for discussion. During convalescence Active rehabilitation during recovery has a great impact on the patient's attitude to his future. Ifhe and his family are left to cope by themselves with vague instructions to increase activity and return to work in two months the resulting uncertainty leads to considerable unwarranted distress and mal- adjustment. This can be avoided by a well planned programme, irrespective of the particular way in which the service is organized . An important aspect is continuing education. Continuity of care is essential if contradictions are to be avoided. Thus, when the general practitioner assumes responsibility for his patient after discharge from hospital, he should know about his patient's educational programme during hospitalization and whether its aims have been achieved. While in theory this can be easily found out at interview, this aspect may be overlooked if the doctor is not aware of his patient's problems. To overcome this, some hospitals have developed a check list which is sent to the doctor when the patient leaves hospital. It contains information on what the patient and his family have already been told and what written material they have received. Those who, for various reasons, have been treated at home during the acute illness or those who have not received any education in hospital need special attention. Time and effort spent now will not be wasted, and will result in patients freed from worry and depression , with increased self-confidence in their future, who are motivated to persevere in a rehabili- tation programme. Modifying behaviour is a long-term process. During the rehabilitation phase, the patient has frequent contacts with his doctor and members of the rehabilitation team. This gives an excellent opportunity for everyone involved to discuss healthy living habits , dietary and antismoking measures, 93 the value of exercise, sexual problems and return to work. Physicians are not always at ease discussing some of these topics with their infarction patients; they are not seen traditionally as "medical". It may be useful, therefore, to discuss some of the ways in which these aspects may be approached. Improvement in physical fitness is an essential part of all comprehensive rehabilitation programmes. The patient should be made aware of the risks of sudden exertion, particularly if it is isometric, such as lifting heavy loads or pushing a car. He should know that physical exercise which uses less than half his working capacity will not result in increased fitness. Limiting symptoms, which indicate that exertion beyond this level is unsafe, should be made familiar to him. The significance of angina should be explained in detail, and the meaning of dyspnoea, palpitations and excess fatigue dis- cussed. He should be taught how to check his pulse at rest and during exercise, especially if he is attempting a new form of activity. However, great care must be taken to avoid the patient becoming a hypochondriac and over-addicted to taking his pulse. Starting work is viewed by many patients as equivalent to physical training. While this may be true of some jobs, it is by no means universal. Most patients will require a continuing schedule so that physical fitness gained during rehabilitation is not lost. It must be planned with the patient's cooperation and must fit in with his lifestyle, otherwise he will not follow it. A brisk walk to and from work may be enough if it reaches the required level of intensity and duration to be effective. A prescribed target heart rate provides a simple measure of control. Sexual activity is an important part of most people's lives. Although early resumption of physical activity for the majority of patients after an infarction is now accepted, there is still a wide belief that these patients should not resume an active sexual life for a long time. This may result, and often does, in psychological disturbance, impotence, frustration and tension in family re lationships. The doctor's tendency to neglect this problem, or simply not to mention it, increases uncertainty. Recent studies of the effect of sexual activity on cardiorespiratory function have shown that, in a familiar setting with the accustomed partner, sexual intercourse corresponds to moderate physical exercise, with, at orgasm, heart rates of less than 130 beats per minute ( 4). The level reached by the patient during his exercise programme is a useful indicator of the appropriate time to resume sexual activity. When he can climb three flights of stairs without angina, arrhyth- mias, dyspnoea and excess fatigue, he is fit enough to resume intercourse, gradually increasing its frequency to his accustomed pre-infarction norm, provided that in so doing adverse reactions do not occur. Patients should be encouraged to talk freely about their sexual problems and be asked regularly if any have developed. Some sexologists have suggested that masturbation might be accepted as a way of resuming sexual activity after an infarction but this raises moral and emotional issues and may be unacceptable to many patients (5). Serious sexual problems, whether as a result of illness or present before the infarction, should be dealt with as soon as possible and such patients should be referred to a psychologist or sexologist. Advanced age is not a reason to exclude discussion of sexual problems from the educational 94 programme. As in all other aspects of health education, the inclusion of the spouse is essential. The evidence now of the harmful effects of smoking is so strong that all patients after a myocardial infarction must be strongly urged to stop smok- ing. The aim is to abandon all forms of the habit (6) . This should be done at the very beginning of the illness when the patient is at his most receptive. Later, when he feels better, he is less likely to heed antismoking advice. Considerable psychological support should be given, especially during the first weeks of abstinence, as many patients suffer from the effects of with- drawal of nicotine - nervousness, depression and overeating. Smoking should be treated as a disease and antismoking measures must be adapted to the patient's background, intelligence and motivation. Special antismoking programmes may be necessary in some patients and should be under the direction of a member of the rehabilitation team who is a non-smoker or ex-smoker. Some group programmes have been found to be more effective than individual counselling in persuading patients to give up the habit. Regular physical exercise, breathing exercises, walking, dietary adjust- ment with frequent, small, low-calorie meals, hobbies to distract the patient's attention and music are some of the simple measures used to reinforce the basic antismoking programme. Wide use should be made of posters, leaflets and booklets explaining the harmful effects of smoking and the benefits to be gained by giving it up. It is well worth reminding patients that those who give up smoking after their infarction double their chances of survival compared to those who persist in the habit ( 7). Every contact with the patient should be used to check for possible lapses; those who drop out of the programme should be traced and further attempts to persuade them to sto p must be made. In cases where the patient wants to stop but lacks the necessary will-power, the help of a psychologist may be very useful. Sensible eating should be encouraged, with the emphasis on what the patient can eat rather than what he cannot. The word "diet" should be avo ided and the aim is a long-lasting change in eating habits and not short bouts of fanatic abstinence from favourite food and drink. The con- sumption of saturated fat in the form of lard, fatty meat, butter, hard margarine and high-fat dairy products shou ld be restricted and salad and cooking oi ls, soft margarine, lean meat and low-fat dairy products used instead. Over-eating should be avoided and the patient should weigh himself weekly to ensure that he stays within the normal limits for his age and height. Patients with hyperlipidaemia merit special attention, and they must be aware that, in their case, weight reduction has to come before other forms of treatment. A very important part of any rehabilitation programme is the support of the patient's fami ly, relatives, friends, employer and colleagues at work . The treating physician must be the driving force in obtaining this support. Up till now, although this idea has been generally accepted, attempts to achieve it have not been very successful. Obviously much more effort must be put into this aspect of patient care. 95 After rehabilitation Maintaining what has been achieved during active rehabilitation depends largely on the individual's willingness to adhere to the secondary preventive measures he has been taught. He must view these as fitting comfortably into his new lifestyle . All subsequent contacts with the patient , however infre- quent, should be used to reinforce knowledge already gained. The general practitio ner's waiting room is an ideal place for further continuing edu- cation - appropriate reading matter, posters and leaflets, which can profit- ably be discussed when the patient sees his doctor. Periodic spa treatment, as practised in Central and Eastern Europe, offe rs an excellent opportunity for education using all kinds of audiovisual teaching aids. Evaluating an Educational Programme Attempts to modify patients' behaviour may be rewarding in the individual case but, to date, there have been no research studies to evaluate the effectiveness of an educational programme. There are several reasons for this. Until recently this field has been relatively neglected (8). Epidemio- logical studies have established a number of risk factors that have a statisti- cally significant correlation with the development of ischaemic heart dis- ease, but there is a lack of proof of definite causation. It is not known which behaviour patterns protect from and which predispose to an infarction, nor which part of behaviour influences socia l functioning. Until these questions are answered it is impossible to define which aspects of behaviour must be measured at intervals to assess whether or not the educational programme is successful (9) . With the growth of comprehensive rehabilitation , it is diffi- cult to separate the individual components of a programme to see which part is working well. That there is a demand by patients for more information has been demonstrated in a recent study of 477 outpatients and 566 inpatients. Three quarters of the patients felt that they had not been given sufficient infor- mation about their illness. Even in patients with a presumed mortal disease, 62% wanted a complete explanation. Only 20-30% of their general prac- titioners and 10% of the hospital physicians were willing to explain their patients' illness in more detail. The patients were interested in etiology and prognosis but also in learning how to deal with present symptoms; obviously quite well motivated to change existing behaviour patterns ( 10). Techniques of investigation have an emotional impact that is often unrecognized . In one group of patients, the procedure of coronary angiography was insufficiently explained, with the result that their anxiety was unnecessarily high ( 11). Despite lack of formal evaluation of educationa l programmes, there is informatio n which suggests that , in some aspects at least, educating patients result s in changes in behaviour. In a se ries of 370 men with a n acute infarction, 74% were smoking at the time of admission to hospital. All were advised to stop smoking and in the short term 82% of the smo kers did so. At follow-up two years laters, 44% of the survivors were smoking and the number of those smoking twenty or more per day had dropped fro m 37% to 6% (12). In another study, 125 survivors of acute infarction were given 96 detailed explanations of the dangers of cigarette smoking, followed by firm advice to stop. This was reinforced by written advice and at each clinic follow-up visit. For the next 1-3 years, 62% stopped smoking and continued to refrain. A control group of 62 patients given conventional advice who were not followed up did less well; only 27.5% of these patients were still non-smokers 1-3 years later (13). A community health education pro- gramme over five years did not result in any change in smoking habits in individuals with a first myocardial infarction, but there was a decrease of 33% in smoking in those with a subsequent infarction (14). Following infarction, up to 60% of patients discontinue sexual inter- course or markedly decrease its frequency . This is considered to be a direct result of little or no advice being given by the physician. Couples then set up their own pattern, based on misinformation and fear, which often represents considerable deviation from their previous activity (15). That this can be improved by education was demonstrated by Jackson (16), who studied 24 patients after an infarction. All received verbal sexual counselling and were advised to resume sexual activity about four weeks after the infarction . In addition, 14 patients received a written booklet which contained advice on many rehabi litation aspects, including sex. When questioned two months later sexual activity at preinfarction levels had been resumed in 72% of those with a guide and in 40% of those who had received verbal advice alone. The educational aspect of a physical training programme lasts after patients leave the programme; 48% of "drop outs" continued to be physi- cally active when they were traced about two years later(/7). In a controlled study of 292 patients with a first infarction, 115 had evidence of psychosocial disturbance and were randomly allocated to an intervention group, where they received an educational programme and psychological help, and a control group, who received routine treatment alone. A year later patients in the intervention group were more active than the controls and those who had had no initial psychosocial problems, though no formal physical train- ing was included in the rehabilitation programme (18). It is possible to change an individual's dietary habits by teaching him the value of sensible eating. In a controlled study, 194 patients following a myocardial infarction were randomly allocated to a treatment group, where they participated in a dietary educational programme, and a control group, who received routine care only. The treatment group was further randomly allocated to a group which received a formal, didactic programme on the type of eating suitable for patients after an infarction or a second group which received the same education but using practical demonstrations and preparations of "ideal" meals . There was no difference at the beginning of the study in the dietary habits oft he two groups but at follow-up a year later the treatment group had altered their eating habits significantly more towards the prescribed regime than had the controls. Their weight, serum cholesterol and triglycerides were significantly lower than in the control group. This effect, though a little less striking at follow-up another year later, was still apparent with significant differences between treatment and control groups. The method of teaching made no appreciable dif- ference (19) . 97 Education of the Patient The educational effect of the doctor ca nnot be overestimated. In the opinion of Mulcahy ( 7), the most important single factor that determines uccess is the doctor's knowledge , interest, compassion, attitudes and ability to com- municate. This is no less true of every member of the rehabilitati o n team . In a study of outcome in two groups o f post-arrest patients, the authors found that those treated some years later than the first group did much better physicall y and psychologically. They attributed thi s to improved manage- ment of educational aspects in the later group (20). The effectiveness of different ways to give information to patients has, in the past few years, become of increasing interest. A group of 97 patients awaiting abdominal surgery were randomly allocated to a "special care" group who were visited the night before the operation by their anaesthetist and told what to expect in the immediate post-operative phase, how to relax and how to move so that they would be more comfortable after their operation. Comparing these patients with the control group, their narcotic requirements after operation were reduced by half and they were discharged from hospital 2.7 days ea rlier (21). Verbal information may be more effec- tive if accompanied by written guides and booklets , as, in the stress of an acute illness, patients may not recall any verbal advice or may misinterpret it, no matter how carefully it is given . In a study of patients after a myocar- dial infarction, Jackson (16) found that 30% of those given verbal advice during their stay in hospital had a satisfactory understanding of what had happened to their heart when tested two months later, compared with 93% who had been given a written booklet in addition to verbal instructions. Using these booklets does not mean that the doctor and members of the rehabilitation team can forget their responsibility for educating the patient. Post-operative anxiety , measured by the Spielberger State-Trait Anxiety Inventory, was less in patients who received pre-operative reassurance from an understanding individual who was not an anaesthetist than those in a control group who received no such support. Anxiety levels in a group who read a booklet designed to reassure about anaesthesia were less significantly reduced (22). Education of the Family, Relatives and Employer Discouragement by the family has been found to be o ne of the principal reasons for the patient's failure to return to work (23). If the family is experiencing serious ups and downs in interpersonal life and social and economic problems, the patient's chances of successful rehabilitation are lowered (24). Both the spouse and the children worried excessively about the patient , emphasizing the effect that coronary heart disease has on the whole fami ly structure (25). For these reasons , educating the wife is as important as educating her husband. Success has been reported with individual and group counselling (3), and many educational programmes have a separate wives' group. They are then free to discuss matters, often concerned with resumption of sexual activity, which they may be shy of raising in the 98 presence of their husbands. A particularly important aspect of education of the spouse is to help her to alter family eating and smoking habits and leisure activities, so that chi ldren of patients with infarction are exposed early to healthy behaviour. Like their husbands , wives also benefit from written as we ll as verbal information . In the group studied by Jackson ( 16), 93% of the wives who had received a booklet as well as being told about ischaemic heart disease understood the nature of their husband's illness , compared with 60% of those who had had ve rbal instructions alone. Relatives and friends who req uested this booklet were also given copies. The great majority of patients after infarction return to their previous employer (7,26). This does not occur by chance but is the result of a deliberate effort to inform him that there is now evidence that the work record of individuals after an infarction compares very favourably with that of their "healthy" peers (27). It is important that a member of the rehabilita- tion team should be in touch with the patient's employer to discuss the physical demands of his job and to inform him of the patient's progress and the level of working capacity reached at the end of the training programme. Where this is routine, success in returning patients to their previous em- ployers increases. Education of the Public In the las t decade , ischaemic heart disease has received widespread publicity through the mass media. The public are now very much aware of changes that have taken place in the care of the acute illness , such as the growth of intensive care units, and there have been numerous radio and television programmes throughout most of the developed countries on the dangers of smoking, saturated fat and sedentary living. Though communication and education through the media is not traditionally a medical ro le, it is up to the medical profession to try to ensure that these programmes, reaching a wide audience, should contain a balanced view on the facts of ischaemic heart disease as they are known today. In several countries, medical advisory panels have been set up within broadcasting authorities to do this. As the provision of medical care becomes increasingly expensive, edu- cation is now being taken seriously as a means of reducing the financial burden . Health education units have been set up in many universities to plan and implement publicity campaigns to promote the principles of healthy living. They are beginning to carry out urgently needed operational research on the effectiveness of differing methods of educating the public. Voluntary organizations and statutory authorities have to combine their effo rts to produce the biggest impact and this is feasible, though not easy, as has been demonstrated in the Finnish North Karelia Project (14) . A recent study in the United States (28) has shown that it is possible to change people's behaviour by exposure to an intensive educational programme; there were considerable changes for the better in the target town compared with a control area. In the last few years the incidence of ischaemic heart disease in the United Sta tes has begun to fall. While it is impossible to prove, one factor in this may be the success of intensive programmes of health education. 99 Recentl y, there has been growing interest in educating the public in specific aspects of help at the onset of the acute symptoms. Half the deaths from myocardial infarction occur as a result of arrhythmias within the first few minutes. Mobile intensive care units on the Belfast model (29) have shown that it is possible to save a proportion of these patients by bringing medical help to the patient to avoid delays in getting him to hospital. This is probably feasible only in a small or medium-sized town, and there have been successful experiments in larger towns in the United States using firemen and ambulance personnel trained in defibrillation. This has been further extended by training members of the public. A programme of training sessions for all interested in learning the technique of external cardiac massage has been in operation in a coastal town in the United Kingdom for the last three years. The response has been good; almost half the adult population has been trained and the project leaders have estimated that 13 lives have been saved. The Future Study on the role of educational programmes for patients after myocardial infarction is in its infancy. A promising beginning has been made but there is a great need to develop valid methods to measure the effectiveness of such programmes. Cardiologists, physicians and all involved in patient care must know more about the learning process itself in order to communicate more efficiently with their patients. Only then can a variety of model programmes be evaluated, so that there is a solid body of factual knowledge on which to make recommendations to health care authorities and government bodies planning future community rehabilitation services. References I. Argondizzo, N.T. Patient and family education. In: Wenger, N.K. & Hellerstein, H.K., ed. Rehabilitation of the coronary patient. New York, John Wiley & Sons, 1978. 2. Hackett, T.P. & Cassem, N.H. Coronary care: patient psychology. Dal- las, American Heart Association, 1975. 3. Hackett, T.P. The use of groups in the rehabilitation of the post- coronary patient. Advances in cardiology, 24: 127-135 (1978). 4. Hellerstein, H.K. & Friedman, E.H. Sexual activity and the post- coronary patient. Archives of internal medicine, 125: 987-999 ( 1970). 5. Wagner, M. Some sexual aspects of the rehabilitation of cardiac patients. In: Stocksmeier, U., ed. Psychological approach to the rehabili- tation of coronary patients. Berlin, Springer-Verlag, 1976. 6. Evaluation of comprehensive rehabilitative and preventive programmes for patien ts after acute myocardial infarction: report on two working groups. Copenhagen, WHO Regional Office for Europe, 1973 (docu- ment EURO 8206(8)). 100 7. Mulcahy, R. The rehabilitation of patients with coronary heart disease . A clinician's view. In: Stocksmeier, U., ed. Psychological approach to the rehabilitation of coronary patients. Berlin, Springer-Verlag, I 976. 8. Halhuber, M.J. Health education in cardiac rehabilitation. Advances in cardiology, 24: 146-152 ( 1978). 9. Troschke, J.V. et al. Elements/or death, disease and death education/or grown-ups: how important is our health. I 977. 10. Habeck, D. et al. Patientenmeinungen zur arzlichen Informierung. Munchner medizinische Wochenschrift, 119: 861-864 (1977). 11. Lepper, M. Psychosocial stress caused by cardiological diagnostic tests. In: Halhuber, M.J ., ed. Psychosocial stress and coronary heart disease. Berlin, Springer-Verlag, 1977. 12. Hay, D.R. & Turbott, S. Changes in smoking habits in men under 65 years after myocardial infarction and coronary insufficiency. British heart journal, 32: 738-740 ( I 970). 13. Burt, A. et al. Stopping smoking after myocardial infarction . Lancet, 1: 304-306 (1974). 14. Salonen, J.T. et al. Changes in morbidity and mortality during compre- hensive community programme to control cardiovascular disease from 1972-77 in North Karelia, Finland. British medical journal, 2: I 178- 1183 ( 1979). 15 . Tuttle, W.B. et al. Sexual behaviour in post myocardial infarction patients. American journal of cardiology, 13: 140-153 (1964). 16. Jackson, G. Sexual intercourse and post coronary patients. The value of a written patient guide. British journal of sexual medicine, 6: 44-48 ( 1979). 17. Bruce, E.H. et al. Is coping with life stresses enhanced by cardiac rehabilitation programs? In: Stocksmeier, U., ed. Psychological approach to the rehabilitation of coronary patients. Berlin, Springer-Verlag, 1976. 18. Cay, E.L. et al. Ten years in cardiac rehabilitation . In: Achte , K. & Pakaslahti, A., ed. Psychosomatic factors in chronic illnesses. Supple- ment to Psychiatria Jennica, 198 I, pp. 19-31. 19. Karvetti, R.-L. Effects of nutrition education: changes in the diet of myocardial infarction patients. Journal of the American Dietetic Associ- ation, 6: 660-667 ( 1981 ). 20. Dobson, M. et al. Attitudes and longterm adjustment of patients surviv- ing cardiac arrest. British medical journal, 3: 207-2 I 2 ( 1971 ). 21 . Egbert, L.D. et al. Reduction of post-operative pain by encouragement and instruction of patients. A study of doctor-patients rapport. New England journal of medicine, 270: 825-827 ( 1964). 22. Leigh, J.M. et al. Effect of preoperative anaesthetic visit on anxiety. British medical journal, 2: 987-989 ( I 977). 23 . Mulcahy, R. & Hickey, N. The rehabilitation of patients with coronary heart disease . Scandinavian journal of rehabilitative medicine, 2: 108 ( 1970). 24. Hellerstein, H.K. & Hornsten, T.R. The coronary spec trum . Assessing and preparing the patient for return to a meaningful and productive life . Journal of rehabilitation, 32: 48-52 ( I 966). IOI 25. Mayou, R. et al. The psychological and social effects of myocardial infarction in wives. British medical journal, 1: 699-70 I ( 1978). 26. Cay, E.L. et al. Return to work after a heart at tack . Journal of psycho- somatic research, 17: 231-243 ( 1973). 27. Taylor, P .J. & Fairrie, A.J. Chronic disabilities and capacity for work. A study of 3,299 men aged 16-64 in a general practice and an oil refinery . British journal of preventive and social medicine, 22: 86-93 ( 1968). 28 . Farquhar, J.W. Community educati on for ce rebral vascular health . Lancet, 1: 1192-1195 (1977). 29. Pantridge, J.F. Mobile coronary ca re. Chest, 58: 229-234 ( 1970). 102 8 Organization of rehabilitation services K. Konig, M. Bran & J. Salonen The ways in which rehabilitation services for patients after acute myocardial infarction are organized depend on many socioeconomic and medicolegal fac tors. Local traditions vary considerably from country to country and even within a state or county. As a result, it is impossible to establish a particu lar method of rehabilitation that could be said to be applied universally. To date there is general agreement only on the provision of comprehen- sive care and early rehabilitation during the period of hospitalization immediately after the onset of symptoms. Rehabilitation during Hospitalization The concept of early mobilization and psychological encouragement is now being increasingly accepted by physicians as routine practice during this early phase of treatment in hospital. Active physical mobilization by the trained physiotherapist or nurse begins, in the uncomplicated case, as early as the third or fourth day. Progressive increase of activity is then planned with the aim of discharging the patient home during the third or fourth week (1,2), though many units now consider a stay of some 7-10 days is adequate . The majority of physicians interested in rehabilitation also agree on the necessity of early psychological intervention because, at this time, many patients are anxious and/ or depressed. These symptoms can usually be relieved by the cardiac staff (docto rs , nurses and physiotherapists) whose comforting and encouraging attitude is sufficient to restore psychological balance in the majority of patients . An increasing number of centres , how- ever, has routinely available the services of a psychologist for assessment and management of psychological problems. Despite slight differences in emphasis and timing, these principles are generally accepted and are now standard practice in most hospitals. Results of treating patients in this way have , on the whole, been encour- aging (J, 4). 103 Organization of Services during Convalescence In contrast, there is no uniformity in the way in which comprehensive rehabilitation is o rganized during convalescence. There are several ways of "delivering the package" , which can be listed as follows: outpatient rehabilitation without an organized structure; outpatient rehabilitation in specialized units; inpatient rehabilitation in specialized centres; community care. Outpatient rehabilitation without an organized structure In the United Kingdom, interest in cardiac rehabilitation has grown very slowly (5). After a short period in hospital during the acute illness, the majority of patients return to the care of their general practitioner. This means that implementing structured rehabilitation programmes on a wide sca le would be difficult and would require more trained personnel and resources than are presently available. Similar problems arise in other countries which do not have recognized, well structured, medicosocial rehabilitation organizations. As a result , the approach to rehabilitation is usually informal and depends very much on the attitudes of the individual treating the patient. Exercise testing and programmes of graduated increas- ing exercise are not routine clinical practice. Instead, the patient is advised to take up again his previous leisure activities which involve physical exercise, in the belief that he is more likely to persevere in something which he enjoys. Information on aspects of secondary prevention is usually given by the cardio logist or general practitioner, supplemented by special booklets , which are given routinely to patients in hospital following their infarction or are widely avai lable to the general public from organizations such as the British Chest, Heart and Stroke Association or the British Heart Foun- dation . Rehabilitation is seen as part of good medical care. Provided that he is well informed on modern aspects of treatment, it can be successfully left to the interested general practitioner. Such an informal approach has obvious advantages; it is cheap, does not require a large, trained paramedical staff and there are no great adminis- trative problems. As the patient is not involved in a structured programme, he is more likely to adhere to something which is geared to his particular needs and interests. Difficulties can arise in patients with severe rehabili- tation problems . They may require more specialized and prolonged psycho- logical and social help than can be given by their physician or general practitioner. Improved physical capacity may be less and take longer to achieve in this way compared with the gain expected from an organized exercise programme. Information on the functional state of the heart, such as can be obtained from exercise testing, evaluation of heart volume or monitoring of exercise-induced arrhythmias is less exact, which may be important in the future management of a proportion of patients. 104 Outpatient rehabil itation in specialized units This method of organizing cardiac rehabilitation services has gained wide- spread popularity and reports of successfully functioning programmes have come from various centres in Ireland, Israel and the United States (6-13). The patient , after early mobilizatio n in hospital, goes to the rehabilitation department as an outpatient several times weekly for a period of weeks or months to take part in a comprehensive care programme which includes medical treatment, graduated exercise, psychological and social help, and education about ischaemic heart disease. These rehabilitation departments are staffed by a team of specially trained physicians, physiotherapists, occupational therapists, dietitians, social workers and vocational guidance counsellors . They tend to be part of well equipped university clinics or large district general hospitals and , as such, offer good facilities for speedy, effective rehabilitation. This kind of rehabilitation service has many advantages. It is the least expensive of the structured programmes, costing two or three times less than a similar programme on an inpatient basis in a rehabilitation institute. Given the frequency of ischaemic heart disease in most of the "developed" countries, this difference is considerable, whether the cost is borne by the patient or the community. It can easily be adapted to the needs of the individual. Not all patients, particularly those with uncomplicated infarc- tio n, require intervention in all the different aspects of care provided in the programme. Its flexibility means that attention can be directed to one particular aspect only , representing a considerable saving in time for both patient and rehabilitation team . Very early return to work is possible, as patients, especially those with sedentary or light jobs, can start again on a part-time or modified basis while they are still attending the rehabilitation unit. Training for alternative employment can also begin at this time. The family doctor is involved, as outpatient rehabilitation can be successful only if there is close liaison between him and the rehabilitation team. The gain from this is considerable; the rehabilitation team draws on his knowledge of the patient and his family before the infarction, he is kept abreast of new developments and the patient , aware of the collaboration of those involved in hi s care, increases in confidence and is more willing to take part in the programme. The limitation of this kind o f service is that it cannot readily be deve- loped in large rural areas with a scattered population, where transport to a large district hospital is impractical. Small rural cottage hospitals cannot afford to run rehabilitation departments. In this situation, improved rehabilitation services for those with infarction have to be provided by a specialized rehabilitation institute , which can admit patients from a wide area for periods of 4-6 weeks. Inpatient rehabili tation in specialized centres Institutional rehabilitation starts immediately the patient leaves the acute hospital and provides a comprehensive programme lasting 4-6 weeks and containing the same elements of care as the programme in an outpatient department. 105 There are arguments in favour of rehabilitation being undertaken on an inpatient basis. An exact diagnosis of functional cardiac state can be made. Immediately following infarction it is impossible to perform a thorough investigation of cardiac function in more than a very few patients. Infor- mation on this is necessary to prescribe a safe programme of increasing mobilization. This can be appropriately done in the institute using the noninvasive techniques ofergometry, telemetry and long-term ECG moni- toring, to measure the size of the heart (heart volume) and the coronary reserve and to demonstrate the presence and type of arrhythmias. The results of this investigation , together with the case history , will in a pro- portion of cases indicate the need for further investigation using the invasive techniques of floating catheterization, coronary angiography and ventricu- lography, particularly if the possibility of surgery in the further management of the patient is being discussed . The appropriate level of physical exercise and its supervision can be optimally undertaken on an inpatient basis. One of the main tasks of rehabilitation is to provide the patient with adequate, gradually increasing mobilization adjusted to his tolerance within the framework of an accu- rately prescribed and strictly controlled physical training programme. The intensity and duration of daily physical exercise depend on subjective symp- toms and the results of objective testing, which the resources of the special- ized centre, in terms of trained personnel and expertise, are ideally suited to estimate. The danger of asking the patient to do too much is thus avoided. The quality of psychosocial care is high . One of the essential ingredients of comprehensive rehabilitation is helping the patient to adjust to ischaemic heart disease and to solve resulting social problems. With inpatients, there is time for specially trained staff to select those with major difficulties, using interview techniques and well constructed questionnaires, and to treat them with a variety of psychotherapeutic techniques . Closely allied to this is an intensive programme of education about heart disease. Rehabilitation, if its effect is to be long lasting, must result in the patient replacing harmful behaviour with more healthy habits. Institutional rehabilitation has special advantages in this field, providing a controlled environment with opportunites for group therapy to reinforce weight con- trol and antismoking measures , and to teach the patient relaxation using methods of autogenic training. A continuous period of intensive rehabilitation in the specialist centre may have the advantage over outpatient services in that stronger pressure can be brought to bear on the patient to encourage him to plan his future level of activity at work and at leisure in keeping with the limitations of his disease. On the other hand, there is criticism of this method of organizing rehabilitation services. Stay in such specialist centres is too costly, it extends the length of time that the patient spends in hospital after his infarction and results in delays in return to work (14). Diagnostic facilities and staff available in the general hospital have to be duplicated in the rehabilitation centre. Unless the organization of health services in a particular country is traditionally structured to include sanatorium treatment, a system of spe- cialized centres is difficult to set up. 106 In countries where there is such a tradition, for example, Austria, the Federal Republic of Germany, the USSR and many of the mid-European states, the rehabilitation centre is seen as the modern development of the traditional sanatorium , and institutional rehabilitation is common. Gleich- mann & Fassbender (15) have shown that treatment in a rehabilitation centre more than pays for itself if it is successful in postponing retirement on pension for a bout a year. Today 20% more patients in Austria and the Federal Republic of Germany return to work after their infarction than did so five years ago, which Halhuber & Stocksmeier (16) attribute to the growth of organized rehabilitation. With acceptance of the principle of early mobilization , active rehabilitation in the immediate recovery period now results in return to work in three or four months compared with the six months' delay found some five years ago. These facts suggest that, in these countries at least , the cost of rehabilitation is more than offset by the resultant benefit. Community care The problem of providing rehabilitation services for a wide area with a scattered population can be tackled by deliberately using the services within the community and its existing health resources, rather than by bringing patients to a centralized rehabilitation institute ( 17). The feasibility of doing this has been examined in North Karelia, Finland, a rural area with some 180 000 inhabitants. The incidence of ischaemic heart disease in Finland as a whole is high , the highest figure being found in this district (18) . In an attempt to modify this, the North Karelia Community Project, consisting of a systematic comprehensive community programme to control cardiovascu- lar disease, was launched in 1972 (19.20). The control programme was seen as part of the existing health services, which were modified as far as possible to meet the needs of the programme through written instructions, training of staff-in-post and other guidelines. Some of the activities were partly run by voluntary organizations such as local heart associations. A special subprogramme for the rehabilitation of individuals under 65 years of age who had survived the acute phase of myocardial infarction was included. This consisted of systematic long-term medical follow-up at an outpatient infarction clinic at the central hospital, and decentralized local rehabilitation groups where emphasis was laid on secondary prevention. The components of the subprogramme included regular medical examin- ation and treatment, education on ischaemic heart disease, exercise testing and physical training and vocational and psychosocial counselling. Educa- tional aspects were dealt with individually when patients attended the clinic for their regular checks and during group sessions held locally. Booklets and audiovisual aids were used to supplement personal teaching, and the spouses of patients were included. These new activities were integrated into the routine community health care services and were entirely carried out by existing staff. As the programme was designed to be offered to every patient over a wide geographical area, services were set up within each community, there was no selection of patients and the programme itself was kept simple. More sophisticated rehabilitation services were offered only when sufficient 107 resources were available. In order to make sure that rehabilitation efforts might be as unified as poss ible , a coordinating centre was established within the University of Kuopio . The centre drew up a blueprint for the organiza- tion of rehabilitation courses, with details on the aspects of education and vocational and psychosocial counselling to be covered, and with recom- mendations on exercise testing and physical training. Although local heart associations helped with organization and money, the rehabilitation pro- gramme was part of official public health policy and was largely adminis- tered and financed by the National Board of Health, the county health administration and loca l health centres. The programme ran fro m 1972 to 1977 and, at the end of that time, the results were examined to see if introducing this kind of rehabilitation service was feasible, that is, whether or not it reached the population for which it was designed. Its impact o n mortality , incidence of recurrence and return to work was evaluated by co mparing the North Karelia patients with a similar population in a chosen reference area in another part of Eastern Finland. The feasibility of the programme was good. During the five-year period 1973-1977, 1308 patients under 65 years survived a myocardial infarction and of those, 515 attended the infarction clinic and 575 took part in one of the group programmes. The participation rate rose during this period from 24% to 63% , more than four times the rate in the reference area. The contents of the North Karelia programme were much more comprehensive than similar programmes in the control county. The two areas did not differ in the incidence of first infarctions but in North Karelia there was a 25% decrease of recurrent illness in males, thought to be due mainly to the rehabilitation programme. Smoking was 33% less in those with recurrent illness than in those with a first infarction. There was a reduction in the number of patients in North Karelia who took the option of retiring on an invalidity pension after their infarction , but the difference was not significant. Despite problems in administering the service, in training existing staff and in ensuring that the programme reached as many individuals as poss- ible, the organizers of the study concluded that their efforts had been worthwhile. Coronary Clubs In the past few years, there has been a considerable growth of coronary training groups or coronary clubs . Frequently, they are affiliated to sports centres and individuals who join in their activities can participate for as long as they like. An example of o ne of these clubs has been described by Krasemann (21) and is now known as the Hamburg Model. Patients who have had an infarctio n and who are accepted as suitable for participation in a training programme on the basis of exercise testing meet for evening sessions once o r twice weekly. On each occasion they join in medically supervised training, supplemented by lectures on various aspects of health education . Such regular group meetings, it is felt, increase the individual's motivation to change his lifestyle towards a healthier behaviour pattern . 108 Other clubs can be described as self-help groups, often starting with a small band of enthusiastic individuals who do not want to lose the group support of their peers which they enjoyed during a rehabilitation pro- gramme. They are not necessarily medically supervised, have no connection with rehabilitation units and are frequently backed by voluntary organiza- tions (22). An example of this is the development and rapid growth of the Mended Hearts Club in the United States for patients who have undergone cardiac surgery. The Future While there is considerable agreement on the components of a comprehen- sive rehabilitation programme, there is no clear evidence that one system of implementing such a programme has advantages over the others. The particular method se lected depends usually on specific local needs and existing methods of organizing national health services. There are many questions yet unanswered, and it is now important to set up research projects to evaluate and compare the effectiveness of the various ways of implementing cardiac rehabilitation. Only by doing this can practi- cal recommendations based on fact be given to the appropriate health authorities and to government departments. This is not to deny that there are considerable difficulties in carrying out this type of research . Early return to work is not the sole criterion of effective rehabilitation; the patient who returns to work very soon after his infarction may have to do so for financial or other reasons and may not necessarily be the one who has had the best outcome of treatment. A good outcome of rehabilitation, which includes all aspects of life, must be clearly defined before the effectiveness of various rehabilitation programmes can be compared . References I. Semple, T. et al., ed. Myocardial infarction: How to prevent. How to rehabilitate. Symposium of the Scientific Council on Rehabilitation, International Society of Cardiology, Vienna. Mannheim, Boehringer, 1973. 2. A programme for the physical rehabilitation of patients with acute myocardial infarction: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1968 (document EURO 5030( I)) . 3. Hackett, T.P. & Cassem, N.H. Coronary care: patient psychology. Dallas, American Heart Association, 1975. 4. Lamers, H.J. et al. Early mobilization after myocardial infarction: a controlled study. British medical journal, l : 257-259 ( 1973). 5. Cardiac rehabilitation 1975: report of a Working Group. Journal of the Royal College of Physicians, 9: 281-346 ( I 975). 6. Acker, J.E., Jr. The cardiac rehabilitation unit : experiences with a programme of early activation. Circulation, 44(Suppl. 2): 119 ( 1971 ). 109 7. Bloch, A. et al. Early mobili sa tion after myocardial infarction . A con- trolled study. American journal of cardiology, 34: 152-157 ( 1974). 8. Hutter, A.M., Jr. et al. Early hospital di sc harge after myocardial infarc- tion . New England journal of medicine, 288: 1141-1144 (1973). 9. Kellermann, J.J. Rehabilitation of patients with coronary heart disease. Progress in cardiovascular diseases, 17: 303-328 ( 1975). 10. Mulcahy, R. The rehabilitation of pa tients with coronary heart disease. In: Stocksmeier, U., ed. Psychological approach to the rehabilitation of coronary patients. Berlin, Springer-Verlag, 1976. 11 . Rose, G. Early mobilization and discharge after myocardial infarction. Modern concepts of cardiovascular disease, 41 : 59-63 ( 1972). 12. Royston, G.R. Short stay hospital treatment and rapid rehabilitation of cases of myocardial infarction in a district hospital. British heart journal, 34: 526-532 ( 1972). 13. Wenger, N.K. et al. Uncomplicated myoca rdial infarction. Current phys- ician practice in patient management. Journal of the American Medical Association, 224: 511-514 (1973). 14. Acker, J.E. Pros and cons of organised rehabilitation. Bibliotheca cardi- ologica, 36: 114-117 (1977). 15. Gleichmann, U. & Fassbender, D. Probleme der Fruh- und Spiit- rehabilitation nach Herzinfarkt. Symposium Herzinfarkt, Vienna, 1977. Stuttgart, Schattauer, 1977. 16. Halhuber, M.J. & Stocksmeier, U. Langzeitstudie an Herzinfarkt- patienten ; Zwisc henergebnis nach 5 Jahren. Tutzing-Hohenried, 1975. 17. Moran, L.R. et al. A myocardial infarction rehabilitation programme for community hospitals . Cardiac rehabilitation, 7 /8( I/ 4) ( 1977). 18 . Puska, P. & Mustaniemi, M. The incidence and presentation of myocar- dial infarction in North Karelia, Finland . Acta medica scandinavica, 197: 211-216 (1975). 19 . Puska, P. et al. Changes in coronary ri sk factors during comprehensive five-year community programme to control cardiovascular diseases, North Karelia project. British medical journal, 2: 1173-1178 ( 1979). 20. Salonen, J.T. et al. Changes in morbidity and mortality during compre- hensive community programme to control cardiovascular diseases from I 972-77 in North Karelia, Finland. British medical journal, 2: 1178- 1183 ( 1979). 21. Krasemann, E.O. Herzinfarkt-Rehabilitation in " Cor"; Beitriige zur Kar- diologie. Erlangen, Beiersdorf-Schriftenreihe Pe rimed, 1977. 22. Hackett, T.P. The use of groups in the rehabilitation of the post- coronary patient. Advances in cardiology, 24: 127-135 {1978). I JO 9 Controlled studies on the effects of rehabilitation E. Cay, S. Degre, H. Deno/in, D. Dorossiev, E. Dowd, F. Endersz, D. Grafnetter, J. Hakkila, V. Kallio, G. Lamm, Z. Pisa, P. Szabo/cs & G. Wagner Effects of Physical Training - Studies in Europe Since 1968, a few controlled studies on the feasibility and effects of physical training in patients after myocardial infarction have been performed in Scandinavia. They have given valuable information not only on the physio- logical effects of exercise but also on problems connected with long-term physical training programmes. Their design and main results are briefly summarized here. In 1968, a study was started in Sweden (1,2) on training a non-selected group of patients with verified acute myocardial infarction. Altogether 313 patients were randomly allocated to an experimental or to a control group. All patients were treated at a special post-infarction clinic in order to standardize a follow-up treatment, with the exception of the training pro- gramme. Of the patients originally allocated to the training group, 27% had to be excluded because of cardiac contraindications , poor cooperation or practical difficulties. The training programme was started three months after the acute attack and patients attended the hospital for three half-hour exercise sessions per week. At follow-up one year after the acute myocardial infarction , only 39% of those who had started training were still training at the hospital, and 29% continued to train at home. During the following three years the drop-out rate continuously increased. During the follow-up period of four years, 28 patients ( 18. 18%) died in the training group and 35 (22%) in the control group. Non-fatal infarctions occured in 16% and 18%, respectively. These differences were not signifi- cant. Although the high drop-out rate might be one reason for the negative results of the tria l, the authors suggest that physical training does not deserve high priority in the secondary prevention of acute myocardial infarction. 111 Almost concomitantly with the Swedish stud y, a Finnish study was being performed by Kenta la (J). It a imed to exa mine the feasibility of supervised physical training in an unselected series of patients after myoca r- dial infarction, with specia l emphasis on the effects of the programme on physical fitness and prognosis. The study comp ri sed 298 consec ut ive ly hospitali zed male patients under 65 yea rs of age . On admiss ion, the patients were randomi zed to a control or a training gro up . After exclus ion of fatal cases, patients whose initial diagnosis o f in farc ti on was not confirmed and those living o utside the area , there remained 81 patients in the control group a nd 77 in the training group . All were followed up at the same ou tpatient department. The groups can thus be co nsidered com parab le for the stud y on the feasibility of ph ys ica l training. The exercise programme of the training grou p started 6-8 weeks after infa rction a nd consisted of training sess ions 2-3 times per week. In addi ti on to their hospital progra mme, patients in the training gro up were given written advice on increasing their physical activit y a t home . An a tt endance rate of 70% or more for supervised training was reco rded by a bo ut 20% of the patients in the training group. Their attendance clea rl y dropped during the second ha lf of the training period . The main reasons given by the patients for their infrequent attendance or non-pa rti cipation were work, transport diffi culti es, severe a ngina and other cardiovascular problems. After a yea r, there were 11 patients in the control group mai nta in- ing phys ical activity unsupervised at full traini ng level. As expected from the poor attenda nce by the training group for super- vised ph ysica l training and the number of pa ti en ts in the co nt ro l group who voluntarily took up training , no differences between the control a nd training groups in physical working capaci ty, resumption of work, morbidit y and mortalit y were fo und. Reha bilitation based on spontaneous home training was exam ined in another Finnish study (4) . Starting in 1969, 380 pa ti ents treated in hospital with a myoca rdia l infarction were rec ruited over the nex t two yea rs or so. Six weeks after the onse t of infarction , patients were invited to a ttend a check- up at an o utpatie nt depart ment. Each patien t was allocated to a training group or to a co ntrol group, acco mplished by taking the fir st hundred into the training group a nd the next hundred into the control group. In order to eliminate seasonal va riati ons, subseq uent groups of only 50 subjects were alloca ted for training or controls. Altogether 200 training a nd 200 co ntrol subjects were collected . On furth er exa mination, 20 patients had to be left ou t of the first training group beca use of excess ive age o r unconfirmed diagnosis (pre-infarctional angina). The fina l study group then consisted of 180 training subjects and 200 controls. Subjects with severe locomotor dis- ability and a history of psychia tric disturbance were excluded from the series. Similarly , pa tients with severe decompensated hea rt failure were excluded . Drug therapy was the same for both the training and the control groups. Rehabilitation for the training group started ten weeks after the onset of infarction and consisted, apart from group sessions of calisthenics once a month , of a 30-minute training programme to be performed every day at ho me. The programme was continued for 12 months . The subjects in the 112 control group were seen once a month and an ergometer exercise test was performed. No special programme was organized for these patients. After one year, 51 % of the men and 73% of the women in the training group reported that they were exercising 6-7 days per week; 15% of the men and 14% of the women did a non-significant amount of calisthenic exercises. Home training had no effect on the physical state of the trainers nor on their physical working capacity. The prognosis of the training subjects was followed for an average of 31.5 months and that of the controls for an average of 26 .5 months. During the follow-up period, 21 trainers ( 11 . 7%) and 29 controls ( 14.5% ) suffered a reinfarction. There were 18 ( I 0% ) coronary deaths in the training group and 28 ( 14%) in the control group. These differences were not significant. The effects of physical training after acute myocardial infarction (with maximum intensity) have been studied in a highly selected group of post- infarction patients in Denmark (5). Consecutive patients under 60 years of age admitted to hospital with a confirmed acute myocardial infarction were considered for inclusion in the study. Among the exclusion criteria were a previous myocardial infarction, angina pectoris, heart failure, hypertension , valvular disease , diabetes requiring drug treatment, other complicating diseases, or other factors which would prevent the patients from taking part in a physical training programme. The final series included 54 patients who were randomly allocated to a control group and a training group. During follow-up, 8 patients from the control group and 12 from the training group were excluded because of poor motivation , recurring infarction, etc. This left 19 patients in the control group and 15 in the training group. The groups were comparable in respect of some basic characteristics. The training programme was started one month after discharge. It consisted of interval training for two sessions, each lasting 60 minutes per week, over a period of 12 months. The study turned out to be feasible. Apart from one episode of cardiac arrest during light calisthenics, which was treated successfully, no other cardiovascular morbidity or mortality was seen. The working capacity of the training patients increased by 10 I% compared to an average increase of 28% in the control group. Thus, the studies referred to above have not shown any evidence that physical training, either supervised or advised, is harmful. Even maximum intensity training programmes can be used in selected patients. The high drop-out rate and contamination of the control group observed in these studies, however, may be difficult to overcome and may thus severely invalidate any long-term trial on the effects of physical exercise on morbid- ity and mortality. Although in two studies (1,4) the number of non-fatal reinfarctions and deaths was somewhat smaller in the experimental group compared with controls, the differences were not significant. Comprehensive Rehabilitation and Secondary Prevention: The WHO Collaborative Study The report published in I 964 by WHO (6) reflected the change in pattern throughout Europe in the treatment of patients after myocardial infarction. 113 The physiological effects of physical training were being studied in several centres but results at that time were scanty. Because rehabilitation was an integral component in the long-term programme for the prevention and control of major cardiovascular diseases of the WHO Regional Office for Europe, there was an interest in starting to develop rehabilitation pro- grammes at the community level. During a WHO meeting in 1967 (7), the participants felt that the time had come to urge the setting up of coordinated studies in several European centres in order to evaluate this new method of treatment. There was no clear evidence as to what kind of activity was appropriate and the long-term results were quite unknown. The possibility of designing a long-term project to study the effects of several years of continuous physical training on cardiovascular mortality and morbidity was discussed at length (7,8) . Such a study was not , however, considered to be realistic because of the high drop-out rate shown in earlier feasibility studies, the difficulty of collecting a sufficient number of patients to allow statistically significant results to be obtained, and the effect of the rapid development of physical training in post-infarction patients , with exercise programmes becoming routine in the management of these patients. After several years of preparatory work, it was eventually agreed to design a study based on a more comprehensive approach that would include an efficient application of up-to-date knowledge on secondary prevention in post-infarction patients . By 1971, a working group, which met in Bordeaux, was able to agree on a preliminary protocol for such a study (9). This group reviewed all the new information on the subject and noted that already there were large differences in rehabilitation programmes throughout Europe - in their length, the level of activity reached and their method of organiza- tion. Nevertheless, they decided that a study should be undertaken to evaluate the effects of rehabilitation on mortality and morbidity after myocardial infarction on these patients' employment prospects; it would also look at the effects of rehabilitation on other social aspects. It took another year and two further meetings (10) before the working protocol was accepted. By that time, it was apparent that the problems created by the lack of standardized methods of assessment, treatment and evaluation could not be sufficiently overcome to permit the proposed con- trolled trial to proceed. It was finally decided, therefore , that coordinated studies, using the agreed protocol should be undertaken at each centre or rehabilitation unit. It was hoped that, as standardization improved, it might be possible to combine some of their results. Those involved in the WHO study were aware of another source of difficulty . During the years of preparation, there had been considerable changes in the whole field of cardiac rehabilitation. This would make evaluating data obtained from a study protocol which antedated new improved methods more problematical. But they decided to continue as agreed; it should be possible to evaluate the overall results of a defined programme of intervention though the effect of each component could not be measured . Coordinated research of this nature would draw attention to the need for a comprehensive approach in the care of patients following an 114 infarction. Publication of the difficulties in evaluating results would prompt research on new ways of doing this . The benefits or dangers of training programmes could be assessed. Design and methods The aim of the study was to assess the effectiveness of comprehensive rehabilitative and preventive programmes for post-infarction patients in reducing recurrent myocardial infarction and mortality from cardiovascu- lar disease and in contributing to the early physical , psychosocial and vocational rehabilitation of these patients. Rehabilitation is important in psychological adjustment and in the treatment of any social sequelae of infarction, so evaluation of these aspects was included as a second aim of the study (JO) . The calculation of sample size was based on the assumption that cardiac and other endpoint events occurring in participating centres might be pooled and analysed together. To permit detection of a reduction of 8.25% in subsequent cardiac events (reinfarction and death) at the 0.05% level of statistical significance, approximately 6800 patient years of observation would be required. It was estimated that 2200 patients followed up for three years would be adequate to provide the desired answer. Included in the calculation was allowance for a drop-out rate of 12-15%. Male patients under the age of 65 years with a confirmed myocardial infarction who had been treated in hospital and had survived were admitted to the study. Because physical training was only one component of inter- vention, no exclusion criteria were applied. In order to ensure recruitment of a sufficiently large number of patients , it was reasonable to include males rather than females because the annual incidence of myocardial infarction in Europe is approximately 4-6 times higher in males under 65 years of age than in females. The study was designed to include an intervention group who would receive a programme of comprehensive rehabilitation and a control group who would receive routine care, with patients being randomly allocated to either group using one of the tables of random allocation. This procedure was considered to be ethically justified, because there was no existing evidence on the value of rehabilitation in reducing mortality and reinfarc- tion . On discussion, it became obvious that individual randomization was not going to be feasible in all participating centres. Other types of randomi- zation would have to be permissible; randomization of areas such as hospi- tals, factories and communities , or arbitrary designation of hospitals, etc., as controls. It was realized that the last-mentioned procedure might induce a bias in selection. The first two methods were thus to be preferred. Following a myocardial infarction, all patients were to be given advice while they were in hospital on potentially useful methods of secondary prevention. After discharge , patients in the control group were to be treated by the existing health care services in their particular town or area and no restrictions were to be placed on the way in which they were managed. The control group would be exposed to very different kinds of care, which would vary with place and time, so that there was no possibility of standardizing 115 their treatment. Originally, it was agreed that all patients were to be seen by the study team at three and six months and at one, two and three years after infarction . This decision was changed later. In order to avoid contamination of the control group, as far as possible , the reviews at three months and six months were left optional. Management of patients in the intervention group was the responsibility of the team (at each participating centre) who were involved in the study. The programme consisted of supervised or recommended physical training, appropriate control of major risk factors , such as hypertension, hyper- lipidaemia, smoking, obesity and diabetes, education about ischaemic heart disease, any necessary drug treatment, psychological evaluation and inter- vention, and vocational guidance (11). The intervention measures were to be applied according to the best knowledge available in each individual centre. It was recommended that every centre should make arrangements for either supervised or recommended physical training programmes (or both) adapted to the needs of individual patients. Patients in whom regular physical training was contraindicated had to be advised on suitable physical habits . In these patients, special emphasis was to be placed on other rehabili- tative measures. Although no attempt was made to standardize the methods used to control risk factors, the attention of the participating centres was drawn to existing WHO recommendations on diet (11), smoking, treatment of hyper- tension (12) and physical activity (8). In addition, detailed advice on the control of each of these factors was given in the study protocol. The main endpoints chosen were death (cardiovascular disease death, myocardial infarction death, sudden death and all causes of death), mor- bidity (reinfarction) and return to work. Physical working capacity changes in psychosocial problems and reduc- tion in ischaemic heart disease characteristics (serum cholesterol, arterial blood pressure, smoking habits and overweight) were used as additional criteria for evaluation. The need to standardize methods and measurements of evaluation was emphasized. The serum lipid standardization laboratory set up by WHO at the Institute of Clinical and Experimental Medicine in Prague provided serum samples and technical assistance to improve the performance oflocal labora- tories. An ECG coding laboratory was set up at the Hungarian Institute of Cardiology, Budapest, to assist in coding ECGs using the Minnesota code. The Rehabilitation Clinic in Freiburg-im-Breisgau, Waldkirch , Federal Republic of Germany, acted as a centre for advice on measurement of heart size. The Miasnikov Institute of Cardiology, Moscow, agreed to give advice on psychological problems and their measurement. A reference laboratory for advice on exercise tests was set up at the St Pierre University Hospital, Brussels. Coordination of the study in the various participating centres was under- taken by the WHO Regional Office for Europe, Copenhagen . The govern- ments of the countries where the study was being carried out were informed of the importance attached to the project. Meetings of the principal investi- gators from the participating centres were arranged at approximately yearly 116 intervals, so that the progress of the study, any problems arising, and methods of improving assessment of the patients could be discussed. Since the production of internationally valid data for pooling was not the main aim of the project, the organization was rather loose. A large number of centres involved in the study used very different methods of measurements in routine clinical practice. In spite of the refer- ence laboratories and centres which were set up to improve the comparabil- ity of results from various centres, there were big differences in carrying out measurements to evaluate the effects of the programme. A few firm guide- lines for those taking part in the study were detailed in the study protocol , particularly with reference to resting and exercise ECGs, and measurement of serum lipids, glucose tolerance, heart volume and psychosocial aspects. It turned out , however, that the organization of the project was not firm enough to ensure sufficient standardization of measurements to give com- parable results . The most elaborate attempt at standardization was made in serum lipid analyses . In 1975, 17 centres were cooperating with the Prague reference centre and a further two with the lipid standardization laboratory in Atlanta , GA, USA. Processing of the data was initially undertaken by WHO in Geneva. From 1978 onwards, the facilities for data processing at the Institute for Cancer Research, Heidelberg, were used, although evaluating the final data remained the responsibility of the unit of health statistical methodology at WHO headquarters, Geneva. Statistical analysis of the results of a study of the effects of treating ischaemic heart disease, an illness with a complex natural history and multifactorial etiology, is recognized as being full of pitfalls . The reader interested in these statistical problems and other details of the study is referred to the WHO publication on the subject (I 3). Experience gained during the course of the study In the planning of the WHO study, participants had tried to take account of the difficulties noted in earlier studies regarding the effect of exercise. Medical thinking had changed; physical training was only one aspect of cardiac rehabilitation. The concept of rehabilitation had broadened to include all patients after an infarction, starting almost with the onset of acute symptoms, and to comprise treatment of psychological, social and vocational problems as well as physical care. Enthusiasm for rehabilitation throughout Europe had grown, albeit in a patchy way, and already a variety of different rehabilitation programmes were in existence. Thus, to accord with current medical practice, it was not enough to evaluate physical train- ing; the effectiveness of these comprehensive programmes required assess- ment. As a result, the study immediately became exceedingly complex with many extra variables to be considered. To control for all these would have been impossible without vast numbers of patients, particularly if drop-out rates comparable with those found in the feasibility studies on exercise were to occur. While secondary prevention had defined hard endpoints, death and reinfarction, these are not necessarily the appropriate endpoints when 117 considering the effect of rehabilitation that aims to improve the quality of a patient's life. Although rehabilitation is allied to secondary prevention and comprehensive programmes contain secondary prevention measures, it is probably unreasonable to expect rehabilitation to result in significantly fewer deaths and lower incidence of reinfarction . Nevertheless, the absence of measurable soft endpoints meant that these had to be chosen as the outcome measures of the study. It also dictated its format; it was planned as a series of comparable studies using the same protocol and method of randomization and measuring the same variables. The hope was that, while methods of measurement of psychological and social data were obviously not sufficiently advanced to be standardized, much of the physical data would be, and at least some of the results could be pooled. The number of patients to be included in the study was estimated on the basis that this would be possible. As the study progressed this aim perhaps became too important. Practical problems arose at an international level which had not been obvious in the initial feasibility Studies involving the patients and staff of a single centre. Initially, interest in the study was high, with 24 centres agree- ing to participate. Some were well established, with good facilities and long experience of cardiac rehabilitation . They carried out well organized com- prehensive rehabilitation programmes, but they varied greatly in their methods of selection of patients and in the way in which their programmes were implemented. They seemed reluctant to change well tried, accustomed methods possibly because they were involved in their own research projects which may well have made it difficult for them to change. As a result, though they were able to provide information of high quality, they did not always conform to the criteria and standards of the study. This inability to alter established practice led to three methods of randomization ultimately being acceptable in the study. Centres that had developed short rehabilitation programmes while patients were recovering in hospital from an infarction had to set up new programmes for the subsequent phase of rehabilitation. They had to arrange to follow up patients at the intervals defined in the protocol. These efforts took time and money and were not always successful, so that loss of patients from observation during the follow-up period was higher than expected. Where too many were lost, these centres had to be excluded from the study. There were also relative "newcomers" to the field of rehabilitation who partici pated in the study. They had to develop their facilities and engage and train new members of staff to cope with its requirements. Many did succeed in this but there were problems associated with this type of situation; their level of performance improved during the course of the study, which meant that their intervention programme was changing all the time. For a variety of reasons not all of the newcomers were as successful as this, and these centres had to leave the study because they were unable to comply with the protocol. Delays in forming the study group were thus greater than anticipated and entry to the study extended over three years. Routine medical care was changing throughout the prolonged course of the study, which complicated I 18 its evaluation. On the whole, there was a lack of adequate information on the care that the control groups received. Though it was foreseen at the beginning of the study that routine medical care would vary in the collab- orating European centres, the dramatic changes that took place in the decade of the study were not fully anticipated. Though each centre was reminded in the protocol to monitor these changes very carefully and to report them throughout the period of follow-up, this was not made nearly explicit enough, and the problem of evolving medical care was dealt with only in very general terms. In the end, these essential data on the control group were never really collected from the participating centres. One can only speculate that, as the control group was drawn from academic centres , they may have received much the same care as the intervention group, and not the "routine" medical care of the country. These factors meant that 2602 patients drawn from 17 centres were available for study with seven centres contributing less than 100 each . Though the data which had been sent to Geneva for central processing were officially "complete", it was found that one fifth of all record forms required correction. Even after these forms had been returned to individual centres to be amended, about 7% of data were still missing. This meant that the number of patients in the study was less than that calculated as necessary for statistical significance between rehabilitation and control groups, and the small numbers in various centres seriously limited analyses of the data. The 17 centres which finally remained in the study did not produce data of the same quality for central processing. Though this had been expected with psychological and social items, it had been thought that many physical factors could be standardized , and facilities for standardizing various measures were provided for all participants. These were not used success- fully, if at all, and much potentially valuable information, for example, data on heart size and ECG coding, could not be used. The decision to change the protocol by abandoning the reviews at three months and at six months caused confusion. It was left to individual centres to make up their own minds whether or not they continued to see their patients at these intervals . It turned out that some did while some others did not. Also some centres supplied these data for central processing while others kept them as part of their own studies. The decision was taken in order to prevent contaminating the control patients by too frequent contact with members of the research teams at the rehabilitation centres. The outcome measures of death, reinfarction and return to work were not affected by the change. Some may argue that data were lost at a time when rehabilitation efforts were at their most intense and thus when major changes would be expected to occur. The data which might have been lost are likely to relate to soft endpoints, and as these proved impossible to standardize they were not as much use as had been anticipated at the beginning. This did, however, complicate the administration of the study in a way that could have been avoided. Managing the study was not easy, largely because there was no principal investigator or central steering committee with overall responsibility. This resulted in insufficient communication between the participating centres 119 and poor monitoring of the progress of the study. Problems were not detected early enough or were missed altogether. Convening the Working Group once a year certainly led to a useful exchange of opinions, but recommendations quite clearly formulated at these meetings were usually regarded by the participants as advice rather than commands. It is the policy of WHO, as coordinator of studies, to rely on a consensus of views. A more rigid type of leadership would, however, seem to be necessary, even in running comparable studies in different centres, if the desired information is to be obtained. Mortality and morbidity were, however, monitored throughout the period of the study to ensure that rehabilitation programmes would not continue if there was evidence that patients were being harmed. Reports of the Working Groups were sent regularly to the governments of all Member States of the European Region of WHO. It is not known exactly how these authorities used this information and how much assist- ance they gave, but it does seem to have varied considerably. Cardiac rehabilitation was included in national health programmes in some, while in others the study remained a purely local research activity within the centre, and the rehabilitation programme ceased on completion of the study. Results Partly owing to the design of the study but also owing to the type and quality of the available information, outcome of treatment could only be expressed in terms of reduction of death or reinfarction. Return to work was influ- enced by so many extraneous factors, such as amount of sickness benefit, difference in age of retirement, maximum duration of permissible sick leave, changes in the economic climate that occurred in Europe while the study was in progress, and local differences in the suitability of available jobs, that it was impossible to interpret the results from the centres in any meaningful way. The study failed to provide the answer to the question of whether or not comprehensive programmes, as practised in the participating centres, reduce long-term mortality and reinfarction in patients who have had a myocardial infarction. Statistically significant differences in mortality were found in only two centres but their results were contradictory. In one, with comparable rehabilitation and control groups (total number of patients, 168), there were fewer deaths among controls than among rehabili- tated patients. In the other (total number of patients, 405), there were fewer deaths in the rehabilitated group, but the groups were not comparable on entry to the study and the differences between them favoured the rehabilita- tion group. The result of a further I 99 patients, where the groups were comparable, showed less mortality in rehabilitated patients but the differ- ence just failed to reach statistical significance at the accepted probability level of 5%. This centre, furthermore, was the only one where the incidence of sudden death was significantly less in the rehabilitation group. The incidence of reinfarction varied widely throughout the centres but there was a significant difference between rehabilitation and control groups in only one; of their 160 patients there were no further infarctions in the controls over 3 years but reinfarction occurred in 8.2% of the rehabilitated group. 120 Angina of effort was more frequent in these patients on entry to the study than in the controls. With hindsight , these results can be explained. It is easy now to be critical of the methods of measurement that were available in 1970-197 l and, indeed, during the study the investigators were aware that developments were taking place, often as a result of the study, that would have solved many of their problems but were too late to be included in the protocol. The delays inherent in planning and implementing multicentre studies mean that methods are outmoded long before the end of such studies. This was obvious particularly in the psychosocial items, where information , though scarce in general, was found to be fairly complete on research forms from the centres where particular attention had been paid to these problems. As anticipated, the overall validity of data related to outcome measures of the quality of life was low. The apparent wide variation in initial psycho- logical disturbance and extent of social problems, which ranged from none to 60%, does not mean that patients in one centre must be different from those in another. While patient selection may account for some of these differences , the subjective nature and lack of uniformity in assessment may well play the major role. In some centres, psychologists assessed the patients using a number of standardized tests while in others the assessment was made by a clinician using information from a clinical interview. As the data do not reveal which method was used in a particular centre , it is not possible to state if one kind of assessment was responsible for producing high rates of disturbance or social problems. Differences did appear during the course of follow-up; on the whole, control patients were more anxious and depressed and had more social problems in the earlier reviews than rehabilitated patients, with this difference tending to disappear later on . That this was apparent, using crude methods of measurement, suggests that rehabilitation speeds up the recovery process. Much the same can be inferred when the data on return to work is examined. There did seem to be a trend in 14 out of 17 centres toward a larger number of rehabilitated patients than controls working at the end of the first year after their infarction. Analysis of the data and interpretation of results was, however, made difficult because there was an element of preselection. Only three centres kept community registers of myocardial infarction during the period of the study, though nine centres had taken part in previous community registers (14) . Using this information it appeared that patients in the WHO study were drawn from very different populations in their risk of having an infarction ; the annual rates were in the range of l .4-4.3 per 1000 males. Selection of patients eligible for rehabilitation and thus for randomization obviously also varied from centre to centre; there were wide age differences in the study groups with about half of the rehabilitation patients in four centres being under 50 years of age. Much the same was found in control patients; those over 60 years of age comprised 53.8% of the control group in one centre and only IO% in another. There was no information available to find out whether or not the ages of the study patients were representative of their own populations of infarction patients. Similarly, the groups from the various centres were not comparable in the level of risk factors or severity of 121 infarction. Frequency of reported congestive cardiac failure or malignant arrhythmias ranged from total absence to being present in over one third of patients. While this might be due to the symptoms and signs of failure being interpreted differently and to variations in monitoring heart rhythm , it is more likely to reflect real differences in patients' physical state and severity of infarction, that is , differences in the source from which patients for the study were drawn. Differing methods of selection of patients and the lack of information on them was a large factor in rendering the pooling of data unfeasible . Analysis was then curtailed by the small numbers of patients in each centre. Appropriate statistical methods were readily available but for these reasons could not be used. The impact of the study The study, as a planned and centrally coordinated systematic series of studies on cardiac rehabilitation, had very distinct effects. The concept of comprehensive rehabilitation and secondary prevention, as distinct from mere physical reconditioning, were publicized throughout Europe among members of the medical professions and public health administrators. Scat- tered individual efforts in this field were amalgamated into an up-to-date formal package which served as a guideline for existing rehabilitation centres and, possibly more importantly, for those thinking of setting up rehabilita- tion units. The concept of early mobilization and shortening the time spent in hospital recovering from a myocardial infarction also became known, and over the decade of the study has become widely accepted. In some measure at least , this is a direct result of the study, as knowledge spread that this was current practice in all the leading centres taking part in the study. Those interested in cardiac rehabilitation have become more aware of the fact that various countries have organized their rehabilitation services very differently . This study was not designed to find out whether inpatient or outpatient programmes are more effective; to find an answer to this question involves many aspects, such as organization of other health services, con- siderations of cost, acceptance by members of the medical and allied profes- sions and by the public, to name but a few. But at least the first steps have been taken in considering this problem. It is apparent from the results of the study that with modern, more enlightened and active methods of treatment of the acute illness about two thirds of patients will do well following an infarction . They do not all need sophisticated, expensive rehabilitation programmes and some only need to be reassured and given help with quite minor social problems. At the other end of the scale, a few require continu- ous medical care. Between these two extremes are those in need of easily available ways to improve physical fitness and psychological and social assistance, given by well trained and devoted members of a rehabilitation team . Selection for .these various forms of rehabilitation is obviously neces- sary and the best methods to identify these subgroups and when this should be done are not yet known. It follows that more than one kind of programme may be necessary within a particular area. 122 Selection does not, of course, apply to secondary preventive measures which must form part of the treatment of all patients after infarction. The great differences in age, presence of risk factors, severity of infarc- tion and possible reactions to their illness in patients from different centres increased awareness of a problem that, in the early seventies, did not feature prominently in cardiological thinking: the presence of subgroups of patients after myocardial infarction with very different prognoses. Now these sub- groups have been well defined and there is more knowledge of the risk they face. That they will have different rehabilitation needs is self-evident and more research is required to examine these aspects of patient care. The WHO study should really be regarded as a series of coordinated efforts carried out simultaneously in 24 centres scattered throughout Europe and in Israel. It has highlighted the enormous difficulties that have to be overcome when any new method of treatment is evaluated, particularly if, as occurred here, an attempt is made to do this in many Centres. Begun with much enthusiasm and the laudable premise that individuals have a duty to monitor how they treat patients, it was soon apparent that the means to evaluate outcome, to standardize measurements and to train sufficient personnel in research methods were not available. Some of these factors certainly influenced some centres to withdraw. Awareness of these prob- lems, particularly in the centres remaining in the study, has resulted in a vast amount of new research to produce the means of carrying out an evaluative study successfully . There is no doubt that this was facilitated by the regular yearly meetings of the Working Group; members knew which aspects were being tackled, problems were common to all, and often solutions were reached more quickly than they otherwise would have been . Numerous publications have appeared from the centres with the results of individual studies undertaken within the WHO framework. It is im- possible to detail all thei r results but the findings of one of them can be given as an example of the work done. The Finnish study was performed in two centres, one in Turku and the other in Helsinki , using carefully standardized methods and identical data collection ( 15). The study aimed to assess the effectiveness of comprehensive rehabilitative and preventive programmes in reducing recurrent myocardial infarction, death from cardiovascular disease and sudden death , and in contributing to the early physical, psychosocial and vocational rehabilita- tion of these patients. The study group consisted of 375 consecutive patients under 65 years, all (30 I males and 74 females) hospitalized after myocardial infarction . They were entirely non-selected. At discharge they were randomly allocated, controlling for age and sex, to an intervention ( 188 patients) or to a control group (187 patients). The mean age of the men was 53.4 years in the intervention group and 53.0 years in the controls. The corresponding figures for women were 58 .0 and 58.4 years. There were no significant differences between the groups in history, heart failure and/or arrhythmias in hospital, and characteristics on discharge. Five patients refused to participate in the intervention programme. Three of them died during the first year. All these patients are included in the mortality statistics. 123 In hospital, all patients were given general advice on rehabilitation and secondary preventive measures. The programme for the intervention group was started two weeks after discharge from hospital, and consisted of optimal medical care, anti- smoking advice, dietary intervention, a physical exercise programme, and advice on psychosocial problems. Medical examination by an internist was performed at least once a month during the first six months and after that when necessary, or at least at three-monthly intervals. The rehabilitation team also included a social worker, a psychologist, a dietitian, and a physio- therapist. In Turku, the programme was based on the local special institute for rehabilitation with a 10-day residential period at the beginning of the rehabilitation programme. In Helsinki, the programme was carried out at the outpatient department of the hospital, with less emphasis on supervised physical training sessions. Patients in the control group were followed up by their own doctors, and they were seen by the study team only once a year during the follow-up period. Body weight, serum cholesterol, serum triglycerides, and systolic and diastolic blood pressure values, recorded at the 1-, 2- and 3-year follow-up were significantly lower in the intervention group than in the control patients. Differences were most marked one year after myocardial infarc- tion . There were no significant differences between the groups in their smoking habits. The number of cigarettes smoked daily was, however. significantly reduced in the intervention group. These results indicate that the patients in the intervention group adhered well to the intervention programme, and that the risk characteristics chosen for intervention were amenable to treatment after myocardial infarction. Coronary mortality three years after myocardial infarction was signifi- cantly lower in the intervention group (18,61/c ) than in controls (29.4l)f- ; p = 0.02). This difference was mainly due to the reduction in sudden deaths. which were 5.8 % in the intervention group and J4.4c7c in controls (p < 0.01 ). The numbers of non-sudden deaths were not significantly different in the two groups . There was a trend towards reduced total mortality in the intervention group (21.8 % ) compared with the controls (29 .9</r,) three years after myocardial infarction (p = 0.093). The rate of clinically verified reinfarcti o n during the three-year follow- up period was somewhat, but not significantly, higher in the interventi ll n group ( 18.1 % ) compared with the control group ( I J .2<7c ). This may. at least partly, have been due to improved medical supervision in the intervention group, who were often hospitalized and carefully examined even after a minor attack of pain . The number of reinfarctions may have been under- estimated clinically in the control group, a hypothesis which is supported h,· the fact that the number of new Q or QS findings in the electrocardiogram was practically identical in both groups during follow-up . It is alsl> l>I' importance that five reinfarctions in the intervention group occurred in the first month following myocardial infarction. before the intervention pro- gramme had started. 124 Evidence of heart failure indicated a severe prognosis in both interven- tion and control groups, while patients without heart failure had a signifi- cantly lower mortality from coronary heart disease in the intervention group than in the controls. Sudden death, in particular, was quite uncommon in patients in the intervention group who did not have evidence of heart failure during their earlier admission to hospital. It was concluded that coronary mortality and especially the number of sudden deaths can be reduced by using a multifactorial intervention pro- gramme which emphasizes optimal medical control, physical exercise and health education, and starts within a few weeks of an acute myocardial infarction . While the best results are to be expected in relatively low-risk patients, all patients should receive appropriate advice and well organized care, which should start on discharge and be most intensive during the first six months after a myocardial infarction. Controlled Multicentre Studies on the Effects of Exercise Pro- grammes in Canada and the United States The National Exercise and Heart Disease Project The National Exercise and Heart Disease Project (NEHDP) (16-19) is a multicentre clinical trial to determine the effects of medically prescribed and regularly supervised exercise programmes on the rehabilitation, morbidity and mortality of selected survivors of myocardial infarction. The project initially started out with the aim that it would be a definite clinical trial in which up to 4300 post-infarction patients would be studied in a randomized manner for 5-7 years. However, mainly due to lack of finance, the study had to be limited to 651 subjects randomly allocated to an exercise training group (323 subjects) and to a non-training group (328 subjects). Planning and development lasted from June 1972 to September 1974. Patients were referred for study from as early as 8 weeks to as late as 36 months after their myocardial infarction . Originally 931 were referred but 150 patients were not eligible for medical reasons or because they refused to participate in a 6-week pre-randomization exercise programme, conducted as a low-level, non-conditioning programme. It was thought desirable from the outset to include such a programme, in order to permit individuals to drop out early and thus avoid damaging the process of randomization. During the pre-randomization exercise programme an additional 131 subjects either dropped out or were found to be ineligible. The remaining 651 subjects were randomly allocated to an exercise training group or to a non-training group. Those assigned to the training group continued to exercise in the same way as in the pre-randomization period but with a target heart rate of 85% of the maximum heart rate achieved on exercise testing. All patients were re-evaluated 8 weeks later and sub- sequently at 6-monthly intervals until the end of the trial. Eight weeks after randomization the training patients progressed to a group gymnasium programme which was held three times per week. It included games, walk- ing, jogging, calisthenics and swimming and was supervised by project staff, 125 but at this stage no attempt was made to monitor the exercising heart rates accurately, as had occurred during the first 8-week period after randomization. The patients in the control group were re-evaluated at the same intervals as the training patients. The project staff were, however, told not to advise them about physical activity nor to encourage them in any activity that could not be considered as part of their daily routine. All subjects were followed up for at least two and a half years, and 70% for three years . Subjects ranged in age from 30 to 64 years with a mean age of 51.8 years; 20% entered the study 2-6 months after their infarction, 37% at 7- 12 months and 43% at 13-36 months. After follow-up lasting 30-54 months there were 24 deaths in the control group (7.3%) and 15 in the training group (4.6%), a difference which is not significant (19). There was thus a trend towards reduced mortality in the intervention group. The 3-year rate for recurrent myocardial infarction was 7.0% and 5.3% respectively. The study answered many outstanding questions on the methodology of exercise testing and the extent of physiological, psychosocial and vocational problems. The study demonstrated that it is possible to recruit a large sample of US males willing to participate in a long-term project involving physical activity . The authors point out that the study should be considered as a feasibility trial, with the defined clinical trial being performed later, but this attitude may be unrealistic. The pre-randomization exercise programme, although eliminating some potential drop-outs , created some potentially serious problems for the randomized phase of the study. It indicated that as few as 14 exercise sessions at a low level of intensity were sufficient to produce a significant cardiovascular training effect. The controls thus started the randomized phase of the study with a reasonably high work capacity for cardiac patients, and some may have been stimulated to continue an activity programme. The total mortality rate in the exercise group was far below that which had been predicted (only 4.6% in three years compared to an expected 12-15%). The value of having a randomized control group is apparent; from these figures it might have been speculated that the case for a clear benefit from exercise has now been demonstrated. The data on the control group show, however, that the majority of the participants in this study had a good prognosis as their mortality rate was half that "expected" in advance of the trial (19). The Southern Ontario Multicentre Exercise-Heart Trial The aim of this trial (20-23) was to evaluate the influence of vigorous physical activity on prognosis after myocardial infarction. The study involved seven university departments not directly affiliated to hospitals, so that their patients· were referred by cooperating physicians. A total of 751 patients were recruited 3-12 months after a myocardial infarction . Those over the age of 54 years, with heart failure, a diastolic pressure greater than 110 mm Hg, insulin-dependent diabetes, orthopaedic disabilities that 126 would limit progressive exercise or significant airway obstruction were excluded. The patients were randomly allocated to a high-intensity exercise group or to a low-intensity recreational activity group. The high-intensity exercise group attended supervised sessions of jogging and calisthenics at the rehabil- itation centre once or twice per week, supplementing this by personal prescribed exercise on four other days of each week . The emphasis was on a progressive walk/jog training plan , beginning at 60-65% of maximum oxygen uptake and progressing to at least 75% of maximum <;>xygen uptake . The low-intensity exercise group also had regular contact with the rehabili- tation centre through their weekly programme of light recreation. The results of this trial showed that during the 4-year follow-up the incidence of both fatal and non-fatal myocardial infarction was somewhat higher in the high-intensity exercise group compared with the recreational exercise group, at 2.1 % and I. 7% for fatal infarctions and 7.4% and 5.6% for non-fatal infarctions (20). The mortality rate in both exercise and control groups was far less than expected. It had been assumed, incorrectly, that the recurrence rate in the controls would be at least 5% per annum . Were that to have occurred, there would have been a 90% chance of showing a 50% reduction in the exercise group recurrences, with a probability of 0.05 (20). The low mortality rates could possibly be explained as being due to an unintentional preselection of patients with a favourable prognosis, so that not only the treatment group but also control patients benefited from the intervention. And, significantly, in a single cohort, some 20% of the controls were found to be involved in activities such as cross-country skiing, calisthenics and tennis, on a regular basis. The sample size was decided on the assumption that the drop-out rate would not exceed 35%. In point of fact, it amounted to 50%. In the centres participating in the trial there was almost a twofold intercentre difference in the numbers of patients who dropped out of the trial. Many of the drop-outs had a surprisingly positive attitude to the programme. Nevertheless, in comparison with compliers they were less enthusiastic about it. In addition to the problem of drop-out, Shephard (23) pointed out that there are difficulties with the non-complier and the non-respondent. He noted that a few subjects in the high-intensity exercise programme may well have gone through the motions of participating in the classes, while lacking the enthusiasm to carry out their home prescription and thus failing to develop a significant training response. Others may have trained faithfully, yet their response was limited by severe or progressing disease. When considering the future of randomized trials on the effects of exercise following myocardial infarction, it has been concluded (20) that successful randomized control trials require large numbers of subjects from many centres and substantial financial support which may not be available in view of the cu·rrent economic situation. Both the National Exercise and Heart Disease Project and the Southern Ontario Multicentre Exercise- Heart Trial provide examples of the tendency for the controls to participate in regular physical exercise . This is in agreement with the current public 127 worldwide interest in sports and exercise part1c1pation, which militates against the maintenance of a non-exercising control group for the necessary prolonged time period. It is almost impossible to control preselection and noncompliance. Only a relatively small proportion of a post-infarction patient population can be prevailed upon to join and remain in a study. Finally, it has been pointed out (23) that more attention should be directed to the influence of physical activity programmes upon the quality of life during the remaining years of the post-coronary patient and not on the impact of exercise-centred rehabilitation on the frequency of fatal or non- fatal recurrences. Death and reinfarction are easily measurable endpoints, but the average patient is concerned more with the quality than with the quantity of his remaining years. References I. Sanne, H. Exercise tolerance and physical training of non-selected patients after myocardial infarction. Acta medica scandinavica, Suppl. 551 (1973). 2. Wilhelmsen, L. et al. A controlled trial of physical training after myocardial infarction. Effects on risk factors, nonfatal reinfarction and death . Preventive medicine, 4: 491-508 ( 1975). 3. Kentala, E. Physical fitness and feasibility of physica l rehabilitation after myocardial infarction in men of working age. Annals of clinical research, 4(Suppl. 9): ( 1972). 4. Palatsi, I. Feasibility of physical training after myocardial infarction and its effect on return to work, morbidity and mortality. Acta medica scandinavica, Suppl. 599 ( 1976). 5. Saunamaki, K.I. Feasibility and effect of physical training with maxi- mum intensity in men after acute myocardial infarction . Scandinavian journal of rehabilitative medicine, 10: 155-162 ( 1978). 6. WHO Technical Report Series, No. 270, 1964 (Rehabilitation of patients with cardiovascular diseases: report of a WHO Expert Committee). 7. Rehabilitation of patients with cardiovascular diseases: report on a Seminar. Copenhagen, WHO Regional Office for Europe, 1969 (docu- ment EURO 0381). 8. A programme for the physical rehabilitation of patients with acute myocardial infarction: report on a Working Group. Copenhagen, WHO Regional Office for Europe, I 968 (document EURO 5030( I)). 9. Evaluation of rehabilitation programmes for patients with myocardial infarction: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1971 (document EURO 8206(5)). 10. Evaluation of comprehensive rehabilitative and preventive programmes for patients after acute myocardial infarction: report on two Working Groups. Copenhagen , WHO Regional Office for Europe, 1973 (docu- ment EURO 8206(8)). 11. Methodology of multifactor preventive trials in ischaemic heart disease: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1971 (document EURO 5011(3)). 128 12. WHO Technical Report Series, No. 168, 1959 (Hypertension and coro- nary heart disease: classification and criteria/or epidemiological studies: First report of the Expert Committee on Cardiovascular Diseases and Hypertension). 13. Rehabilitation and comprehensive secondary prevention after acute myocardial infarction: report on a Study. Copenhagen, WHO Regional Office for Europe, 1983 (EURO Reports and Studies, No. 84). 14. Myocardial infarction community registers. Copenhagen, WHO Regional Office for Europe, 1976 (Public Health in Europe, No. 5). I 5. Kallio, V. et al. Reduction in sudden deaths by a multifactorial interven- tion programme after acute myocardial infarction. Lancet, 2: 1091- 1094 (1979). 16. Naughton, J. The national exercise and heart disease project. Cardiol- ogy, 63: 352-367 ( 1978). 17. Naughton, J. The national exercise and heart disease project. In: Cohen, L.S. et al. , ed. Physical conditioning and cardiovascular rehabili- tation. New York, John Wiley & Sons, 1981, pp. 247-256. 18. Naughton, J. The national exercise and heart disease project. In: Pol- lock, M.L. & Schmidt, D.H. , ed. Heart disease and rehabilitation. Bos- ton, MA, Houghton Mifflin Professional Publishers, 1979, pp. 330-340. 19. Shaw, L.W. Effects of a prescribed supervised exercise program on mortality and cardiovascular morbidity in patients after a myocardial infarction. The national exercise and heart disease project. American journal of cardiology, 48: 39-46 ( 1981 ). 20. Kavanagh, T. Evidence to date for the beneficial effect of exercise following myocardial infarction . In: Mathes , P. & Halhuber, M.J., ed. Controversies in cardiac rehabilitation. New York , Springer-Verlag, 1982, pp. 43-52. 21. Shephard, R.J. Evaluation of earl ier studies : Canada . In: Cohen, L.S . et al. , ed. Physical conditioning and cardiovascular rehabilitation. New York, John Wiley & Sons, 1981, pp. 271-287. 22. Shephard, R.J. Recurrence of myocardial infarction in an exercising population. British heart journal, 42: 133-138 (1979). 23. Shephard, R.J. Recurrence of myocardial infarction . Observations on patients participating in the Ontario Multicentre Exercise-Heart Trial. European journal of cardiology, 11 : 147-157 (1980). 129 10 Rehabilitation after myocardial infarction: where does current knowledge lead? Z. Pisa, H. Deno/in & G. Lamm The dramatic changes in our approach to the treatment and rehabilitation of patients with myocardial infarction that have occurred during the last 2-3 decades have already been mentioned and discussed in detail in pre- vious chapters. Our present concept can be summarized quite briefly. I. Rehabilitation of the patient after myocardial infarction is an inte- gral part of his treatment, and aims to return him to the activities of his normal life as soon as possible. 2. To achieve this , it should start with the first contact with the patient and be continuous. 3. A comprehensive approach is necessary, and it should deal with physiological, clinical, psychological and social problems. 4. As a result of the differences among patients and in the severity of their disease, individual short- and long-term plans have to be prepared for each patient. These will depend on the existing facilities in his area and on what resources are currently available. 5. In these plans, physical activity, control of risk factors, drug treat- ment and management of social and psychological problems are equal elements of the overall (rehabilitative) care intended to return the patient to an active life and prevent recurrence of the attack, or at least to mitigate its consequences (secondary prevention). 6. The primary physician (be it general practitioner, internist , or cardi- ologist) should be the responsible key element in this system, preparing the plans and coordinating all necessary activities with other health personnel within the limits of available programmes and existing facilities. 131 7. As with most chronic diseases, in addition to encouraging the patient to take responsibility for his own health and setting up a good doctor-patient relationship, the family and (if acceptable to the patient) the employer need to be informed, educated and involved in treatment, in order to create the right "environment" to facilitate the complex rehabilitation process. This approach is based on some scientific evidence, a few hypotheses, and plenty of common sense (J-4). Empirical experience has proved that this type of care, involving revolutionary changes in the attitudes not only of health personnel but also of patients to physical activity and especially to early mobilization, does not harm patients, shortens the time spent in hospital and returns them to work and the activities of a normal life more quickly (5). It improves the quality oflife of the patient with coronary heart disease and has economic advantages for the individual, as well as for society. The attack rate in industrialized societies, which averages 3 per 1000 per year among males aged 20-64 years and 0.8 per I 000 per year in women (6) means that, in Europe alone, every year more than half a million people in this age group surviving a myocardial infarction are being helped and their life improved by this new comprehensive approach to the treatment of acute myocardial infarction. Despite much effort, until now we have only equivocal evidence from long-term prospective studies of patients after a myocardial infarction on the effect of rehabilitation procedures on mortality and morbidity from coronary heart disease or from all causes. The National Exercise and Heart Disease Project (7) which was carried out in several centres in the United States on 651 men (aged 30-64 years) with myocardial infarction, did not reach statistically significant levels, despite the fact that the cumulative 3-year total mortality rate was 7.3% for the control group and 4.6% for the exercise group. The exercise programme did not affect cardiovascular mor- bidity. Similar results were reported from the Ontario Exercise-Heart Col- laborative Study (8). On the contrary, Wilhelmsen et al. (9), reported a 22% reduction in cardiovascular morbidity in a group of patients undergoing an organized physical training programme. Kallio et al. (/0) reported favour- able effects on the incidence of sudden death of a comprehensive interven- tion programme in patients after myocardial infarction . The WHO Study discussed in Chapter 9, of which the Finnish study was a part, did not provide any significant statistical evidence overall, although some positive trends might have been shown in different centres. In spite of the fact that the prognosis of patients as defined by the "hard endpoints", mortality and morbidity, is not significantly changed, there is no doubt that this comprehensive approach to the treatment of myocardial infarction and coronary heart disease patients should continue and be developed further, if only because of the demonstrable improvement in the quality of their life. However, more research is needed to provide the scientific evidence for each step taken in order to justify the costs and benefits of the intervention programmes. In many areas it might be possible to find more effective ways of dealing with certain problems, hopefully to improve the results of treatment. 132 What questions still remain unanswered and where is research needed in the immediate future? Randomized therapeutic intervention trials are generally considered to be the most satisfactory method of proving or disproving effectiveness of treatment. It is only very recently that their limitations, particularly in the field of cardiovascular disease, have been recognized (JI) . Such trials are subject to two types of error: suggesting a relationship where none exists, or being unable to demonstrate existing relationships. When death is used as the outcome of a study, errors are most likely to occur when the study population contains patients with widely varying prognoses, as is the case in patients after myocardia l infarction . Low-risk patients, whose prognosis is favourable regardless of treatment, dilute the mixture, hiding the effect of treatment on high-risk patients whose prognosis might be markedly improved. Ideal randomization should accomplish equal distribution of all variables that could influence outcome in treatment and control groups. To meet this requirement in patients after myocardial infarction it would be necessary to have unattainable numbers of cases and unlimited resources of money and personnel. It may be that the design of trials of the effectiveness of secondary preventive measures requires re-examination . It is possible that the era of large-scale multicentre studies is now past and that there is a move towards smaller, more tightly controlled trials involving defined subgroups of coronary patients from one or two centres. Having considered the issue of study design, there are also problems connected with treatment during the acute stage of illness; identifying the optimal duration of bed-rest and defining precisely the criteria for early discharge from hospital. Denolin (3) lists some of the associated problems as: exact evaluation of the severity of disease , the optimal moment to mobilize the patient, the correct amount of physical training during the first weeks , the optimal duration of hospitalization, and the right time for initial evaluation ofresidual physical capacity. It should not be forgotten that early discharge is influenced not only by the physical state of the patient , but also by the social problems facing him after leaving hospital. Therefore, these aspects also deserve further study. Answers to these questions would very much influence the decision as to how the next phase of rehabilitation - the post-hospitalization period - should be approached . At the moment , based mainly on a pragmatic approach and empirical experience, physical training programmes are being prescribed. Their duration, intensity, number of sessions, and the content of the programmes themselves, depend on the attitudes of individual doctors. WHO recommendations as to the type of exercise, presented in the Freiburg report (5), have been criticized by experts in the field of physical rehabilitation as not being particularly good for the patient's locomotor system. Review of these recommendations by a multidisciplinary group would be helpful. In the post-hospitalization period, research is needed to define criteria to select which patients need institutional rehabilitation and which could be rehabilitated on an ambulatory basis . In current clinical practice, medical indications are hardly ever considered. Decisions depend on cultural tra- dition and social factors . 133 There are many problems still remaining in the area of control of risk factors in patients after myocardial infarction (12). Physical activity improves working capacity, influences cardiocirculatory performance and increases the ability of the individual to function during his daily activities; it improves morale and affects attitudes to return to work . It might help the patient to control his weight and, through this, to influence other risk factors. It increases the patient's confidence in himself. However, the effects of physical activity on the progress of coronary heart disease itself are not clear, and many attempts to study and answer these questions have failed, largely for logistical reasons and the impossibility of carrying out satis- factory long-term follow-up of patients in intervention and control groups. However, this important question must be answered and new ways to do this must be sought. Of the three established risk factors, smoking, hypertension, and diet and lipids, the available scientific evidence is clear-cut in so far as it concerns cessation of smoking and its effects on the incidence of reinfarction and sudden death (13-18) . Those who stopped smoking decreased their risk of fatal as well as non-fatal reinfarction and of sudden death. Present evidence indicates that, by controlling hypertension, angina pectoris and heart function can be influenced. It is still not known whether the risk of infarction or the prospect of survival can also be influenced by controlling the blood pressure level after the onset of a myocardial infarction. Ongoing research on the primary prevention of hypertension might shed new light on these problems. Concerning diet and lipids, there is now sufficient evidence to prove that elevated blood cholesterol levels are involved in atherogenesis and in the incidence of the complications of atherosclerosis, particularly coronary heart disease ( 19-21). In patients after myocardial infarction this evidence is not so clear-cut. More research in this area is needed, as dietary recommendations to decrease plasma cholesterol have other effects as well: they are linked to haemostatic changes which might influence regression of the disease, they cause reduction in weight, affect the level of blood pressure and the risk of hypertensive complications, and contribute to the control of diabetes . All recommendations concerning the "risk factors" are "recommenda- tions for healthy living habits", and cannot harm the patient. For this • specific reason, we are committed to them , but more scientific evidence would end present controversies, especially those on the role of diet and intervention to control blood lipid levels. All secondary preventive measures for the patient after myocardial infarction have to last for the rest of his life. They require, therefore, the cooperation of the patient, his family and the individuals who make up the environment in which he lives. Even when his working capacity remains unchanged after the infarction, his new pattern of life requires considerable psychological adjustment. For this reason, to ensure his compliance with a comprehensive programme, much more research is needed on the psycho- logical and social aspects of rehabilitation. This is a very general statement, repeated in many publications. But its very vagueness shows that the elabo- ration of the individual problems and projects in this area has lagged behind other work in the field of rehabilitation. 134 In summary, the dramatic changes that have occurred in our principles of treatment have resulted in new methods of care of patients with myocar- dial infarction, but have in their turn produced new problems that have to be identified, studied and solved. The new concept of rehabilitation is that it should not only improve the "quality of life", but that it must be applied efficiently so that the individual patient can derive the maximal benefit and so that it can be made available to all patients who stand in need of it. References I. Levine, S.A. & Lown, B. "Armchair" treatment of acute coronary thrombosis . Journal of the American Medical Association, 148: 1365- 1369 (1952). 2. WHO Technical Report Series, No . 270, 1964 (Rehabilitation of patients with cardiovascular diseases: report of a WHO Expert Committee). 3. Denolin, H. Cardiac rehabilita tion: an overview. In: Raineri , A. et al., ed. Selected topics in exercise cardiology and rehabilitation. New York, Plenum, 1980. 4. Rehabilitation of patients with cardiovascular diseases: report on a Seminar. Copenhagen, WHO Regional Office for Europe, 1969 (docu- ment EURO 0381). 5. A programme for the physical rehabilitation of patients with acute myocardial infarction: report on a Working Group. Copenhagen, WHO Regional Office for Europe, 1968 (document EURO 5030(1)). 6. Myocardial infarction community registers. Copenhagen, WHO Re- gional Office for Europe, 1976 (Public Health in Europe, No. 5). 7. Shaw, L.W. Effects of a prescribed supervised exercise programme on morta lity and cardiovascular morbidity in patients after a myocardial infarction. The National Exercise and Heart Disease Project. American journal of cardiology, 48: 39-46 ( 1981 ). 8. Cunningham, D.A. et al. The relationship of exercise to the recurrence rate of myocardial infarction in men - Ontario Exercise-Heart Col- laborative Study. Medicine and science in sports and exercise, 13: 99 ( 198 I). 9. Wilhelmsen, L. et al. A controlled trial of physica l training after myocardial infarction . Preventive medicine, 4: 491-508 ( 1975). 10. Kallio, V. et al. Reduct ion in sudden deaths by a multifactoria l interven- tion programme after acute myocardial infarction. Lancet, 2: 1091- 1094 ( I 979). 11. Selzer, A. On the limitations of therapeutic intervention trials in ischaemic heart disease: a clinician's viewpoint. American journal of cardiology, 49: 252-255 ( 1982). 12. Secondary prevention in myocardial infarction survivors. Joint recom- mendations by the ISFC Scientific Councils. Heart beat, 3: 1-3 ( 1980). 13. Wilhelmsson, C. et al. Smoking and myocardial infarction. Lancet, 1: 415-419 (1975). 135 14. Mulcahy, R. et al. Factors influencing long-term prognosis m male patients surviving a first coronary attack. British heart journal, 37: 158-165 (1975). 15. Jenkins, C.D. et al. Risk of new myocardial infarction in middle-aged men with manifest coronary heart disease. Circulation, 53: 342-347 (1976). 16. Rose, G. et al. Myocardial ischaemia, risk factors and death from coronary heart disease. Lancet, 1: 105-109 (1977). 17. Sparrow, D. et al. The influence of cigarette smoking on prognosis after a first myocardial infarction. Journal of chronic diseases, 31: 425-432 (1978). 18. Meinert, C.L. et al. Cigarette smoking as a risk factor in men with a prior history of myocardial infarction. Journal of chronic diseases, 32: 415-425 ( I 979). 19. Arteriosclerosis 1981. Report of the Working Group on Arteriosclerosis of the National Heart, Lung and Blood Institute, Vol. 2. Bethesda, National Institutes of Health, I 98 I (Publication No. 82-2035). 20. Bethesda conference report. Eleventh Bethesda Conference: Prevention of coronary heart disease, 1980. American journal of cardiology, 47: 713-776 (1981). 21. WHO Technical Report Series, No . 678 , 1982 (Prevention of coronary heart disease: report of a WHO Expert Committee). 136 Annex 1 Social security in different countries involved in the WHO Study V. Kallio, S. Laaksovirta, B. Devetakov & V. Tormo Alfonso In the following brief overview some details of sickness benefits and pension schemes are given, including a note of recent developments in cardiac rehabilitation . The countries are listed in alphabetical order. Belgium Since 1963, current law has included sickness and invalidity insurance . Benefits are paid to employed persons and apprentices. Also, pensioners are covered for medical benefits. Sickness benefit constitutes 60% of earnings up to a certain maximum, with no waiting period. After the first month, insurance continues to pay 60% of earnings for the remainder of the first year of illness. Cash refunds are paid of part of or all medical expenses. The qualifying age for old-age pension is 65 years for men and 60 years for women. The pension is payable up to five years earlier, with a 5% reduction per year. Invalidity pension is paid when there is a loss of two thirds of earning capacity in the usual occupation . For permanent disability, the invalidity pension of 43 .5% of earnings, or of 65% if there are dependants, is payable after one year of incapacity, the first year being paid under sickness benefit . A special foundation, Fonds national de rec/assement social des handicapes, assists patients with medical , social and vocational problems. It may thus finance , for instance, costs for rehabilitation examinations, vocational counselling and reschooling. There have been no major changes during the last ten years . Bulgaria Cash benefits are paid under social insurance and medical care provided under the National Health Service system. These benefits are paid to 137 employees and to members of liberal professions and handicraft coopera- tives. Medical care is provided to all residents. Sickness benefits are payable from the first day for the duration of sickness and are related to years of continuous work. Medical services are provided directly to patients through the facilities of the National Health Service. The qualifying age for old-age pension depends on the character and special conditions of labour. Ac- cordingly, there are three categories of labour, the age of retirement in the first category being 50 years for men and 45 years for women. Patients having worked in normal conditions belong to the third category in which the old-age pension is paid at the age of 60 years in men and 55 years in women. There are three degrees of invalidity qualifying patients to receive a total or partial invalidity pension. Invalidity pension is paid to all employees and workers and takes into account not only the degree of invalidity but also other circumstances, such as profession, length of service, etc. There is no special legislation concerning the medical rehabilitation of patients after acute myocardial infarction. Social and vocational rehabilitation measures are covered by general legislation. There have been no major changes in social legislation concerning the medical and social or vocational re- habilitation of patients after acute myocardial infarction . Czechoslovakia The National Sickness Insurance Scheme is universal and covers all citizens. Medical services are provided directly to all patients, without charge, through the facilities of the Public Health Services. Cash benefits are paid to employees, members of industrial and agricultural cooperatives, and advanced students. Cash sickness and medical benefits are payable from the first day of incapacity for up to one year. In exceptional cases prolongation is possible for a further year. The social insurance system covers all citizens of Czechoslovakia. Old-age pension is payable to men at the age of60 years (55-58 for those in unhealthy and onerous work) and to women at the age of 53-57 years according to the number of children raised. Invalidity pension is paid when incapacity for any work (total invalidity) exists. Partial invalidity starts with a one-third loss of earning capacity in patients having the possibility of working under special conditions. The National Sickness Insurance Scheme covers also the costs of rehabilitation services, including fitness and working capacity testing, educational and vocational training and physical therapy. Rehabilitation centres for those suffering injury or neurological, cardiac and respiratory diseases are now available. Since 1970, a special group coordinating the National Cardiovascular Programme has been working at the Ministry of Health . In cooperation with the Institute for Clinical and Experimental Medicine, an educational programme for cardi- ologists, psychiatrists and general practitioners, including modern aspects of rehabilitation, has been carried out. Rehabilitative therapeutic pro- grammes in spa centres for patients after acute myocardial infarction have been implemented throughout the country since 1977, beginning six weeks after acute heart attack. All these measures have resulted in significant 138 decreases in invalidity rates and better educational and therapeutic treat- ment in all patients. Finland The National Sickness Insurance Scheme covers all residents for medical benefits and all the employed, self-employed and students for cash benefits. The sickness benefits are payable after a seven-day waiting period for up to 300 days. Cash refunds are paid of part of medical expenses (doctor fees, laboratory services, medicines, etc.). Universal pensions and means-tested allowances cover all residents. All regular employees are also covered by an employment-related pensions scheme. The universal pension is paid at the age of 65 years. A means-tested allowance is paid also at the age of 65 ( 60 for single women). Early retirement at the age of 55 years is possible if the person has been unemployed for at least 200 days during the previous year. Universal invalidity pension is paid if there is permanent incapacity for suitable work. Qualifying conditions for employment-related pensions are a three-fifths loss of working capacity, a partial pension being paid for a two-fifths loss. The National Sickness Insurance Scheme also covers its members for rehabilitation services. On application it may thus finance medical rehabilitation, rehabilitation examinations, work testing, edu- cational and vocational training, and vocational rehabilitation. Since 1969, the care of disabled persons has included patients with chronic heart dis- eases, who are entitled to some benefits, such as reschooling and some other forms of rehabilitation. Opportunities for work in sheltered circumstances are unevenly distributed in Finland. Sheltered work was not supported by the Government until 1971, when an experimental five-year programme was started. Final plans for this activity are now being drawn up. All of the sheltered workshops have been run by private organizations of the handi- capped and, according to the law, they mainly serve people who are disabled in terms of the Care of Disabled Persons Act. There are no special sheltered workshops for patients after myocardial infarction . There have been no important changes in the social security regulations or age of retirement during the last ten years. Since 1973, a partial invalidity pension is awarded to an insured person who, as the result of an illness, is incapable of leading a full life. According to recent statistics, partial invalidity pension has gained relatively little in importance as compared with the employment pension scheme in general. Since 1973, responsibility for medical rehabilitation has been given to the community health centres according to the new law on public health . France The social insurance system, including cash and medical benefits, covers employees in industry and commerce. In addition, there are special systems for several occupational groups. Sickness benefits are payable after a three- day waiting period for up to 12 months. If special qualifying conditions are met and there is a chronic or prolonged illness, the period can be extended 139 up to three years . Cash refunds are paid of part of medical expenses. Apart from the social insurance system there are also mandatory private pension systems. The age of retirement for old-age pension is 60 years . Invalidity pension is paid when there is loss of all working capacity (total invalidity) or of two thirds of earning capacity (partial invalidity) in any occupation. German Democratic Republic The social insurance system includes outpatient and inpatient medical care as well as complete drug therapy and supply of technical aids (e.g. pace- makers) - both are free of charge. It covers employed persons, including most public employees . In addition , there are special systems for some occupational groups (miners, railway and post employees, workers in coop- eratives and self-employed persons). Sickness benefit is payable from the first day of incapacity for up to 26 weeks and may be extended to 78 weeks if recovery is likely within that period. The extension to 78 weeks permits the full utilization of rehabilitation measures. Medical benefits include services provided to patients in government clinics and hospitals or by doctors and hospitals under contract with and paid directly by the social insurance system. The coverage is the same as mentioned under sickness benefits. The qualifying age for old-age pension is 65 years for men and 60 years for women. In miners, the old-age pension age is 65-50 years according to length of employment. Qualifying conditions for invalidity pension are loss of two thirds of working capacity. Medical , educational, vocational and social rehabilitation is under the responsibility of the whole of society and is coordinated by the health and social care systems. The right to work for disabled persons is regulated by law. There are special rehabilitation centres for occupational training for disabled and severely disabled patients. All rehabilitation measures are free. Patients with chronic diseases are included in the rehabilitation system. There are comprehensive programmes for selected diseases ensuring systematic and specific rehabilitation . For exam- ple, uninterrupted systematic rehabilitation and follow-up care are guaran- teed for each patient with acute myocardial infarction throughout the country. There have been no important changes in the social security regulations and age of retirement during the last ten years . Germany, Federal Republic of Different insurance systems cover all workers and employees in industry, commerce, agriculture and some other occupational groups. Sickness bene- fits are payable from the first day of incapacity for at least one and a half years , with special individual variation, depending on the type and duration of the disease . The age of retirement is generally 65 years , under special conditions 62 years, for men and 60 years for women. Various occupational groups have different arrangements. The different insurance institutions are responsible for rehabilitation in specifically equipped centres, depending on the types of lesion (cardiac, respiratory, neurological disease and others). Everybody has the right to receive rehabilitation measures after the acute 140 stage of the illness and in later phases, including medical examinations, work testing, educational and vocational training and reschooling. There have been no major changes during the last ten years. Hungary The social insurance system (cash and medical benefits) covers employees and members of agricultural and handicraft cooperatives. There is a special system for railway employees. Sickness benefit is payable from the first day of incapacity for up to one year. Medical services are provided directly to patients through the facilities of the Public Health Services. For social insurance there are special systems for members of agricultural cooper- atives, artisans and self-employed retailers. Old-age pension is payable at the age of 60 years for men and 55 years for women. Qualifying conditions for invalidity pension are incapacity for any paid work (total invalidity) or a 67% loss of working capacity (partial invalidity). There are possibilities for vocational rehabilitation . Most of the patients prefer to choose to receive the invalidity pension, because besides this they can work on a part-time job in their original profession or in other sheltered work which provides them with a higher income. The age of retirement of the members of agricultural cooperatives used to be 65 years for men and 60 years for women. In the last three years a decrease of the retirement age of these categories has been introduced and within two years the retirement age will be the same for all citizens. Since 1975, the medical services have been available for each citizen free of charge by law. Israel Under the Ku pat Holim sickness fund of the Labour Federation and other non-statutory funds 85-90% of the population is insured for medical care . No cash or medical benefits exist under the national insurance programme. Most workers are , however, insured for medical care with a voluntary sickness fund. All residents over the age of 18 years are covered for old age, invalidity and death under the social insurance system. In addition, there is a special system for public employees. The old-age pension is payable at the age of 65 years for men and 60 years for women. The qualifying condition for invalidity pension is a reduction of earning capacity of at least 50%. Italy The social insurance system (cash and medical benefits) covers employed persons. There are special systems for seamen, the self-employed, journal- ists, public employees, self-employed artisans, merchants, and tenant farmers. Sickness benefit is payable after a three-day waiting period for up to 180 days and may be extended in special cases. Medical benefits include services generally provided by doctors and hospitals under contract with and paid directly by the National Sickness Insurance Institute. The social 141 insurance system covers all employed persons. In addition, there are special systems for seamen and some other occupational groups. The old-age pension is payable at the age of 60 years for men and 55 years for women . It is also payable at any age after 35 years of contribution. The qualifying medical condit ion for invalidity pension is a reducti on of earning capacity of 50% . Poland The social insurance system (cash and medical benefits) covers employees, apprentices, members of handicraft cooperati ves, se lf-employed art isans, lawyers , and home workers. In addition, there are special systems for miners , railway employees , the military , and the police. Sickness benefit is payable from the first day of incapacity for up to 26 weeks and may be extended to 39 weeks if a cure is probable . This may be followed by sickness pension for up to 12 months if recovery is likely. Medical services are provided directly to patients by establishments of the Public Health Service on behalf of the social insurance system . The coverage for old age, invalidity and death is about the same as under sickness benefits. The age of retirement is 65 years for men and 60 years for women. In some occupations it is five years earlier. Invalidity pension is paid when there is incapacity for any work (total invalidity) or when there is greatly impaired earning capacity or total incapacity for usual work (partial invalidity). A person with limited physical or mental capacity, classified in any of the invalidity groups, can take a job in sheltered circumstances. An establishment which had employed the dis- abled person before his illness is obliged to prepare for him a special work sta nd . If this is not possible, the invalid can be employed in a cooperative society for invalids which secures work in sheltered circumstances. It can be either work in an ordinary establishment, providing him with medical care and rehabilitation, or work at the invalid's home, so called home-work. Romania There are dual socia l insurance (cash benefits) and universal (medical care) sys tems. Employed persons and apprentices are covered for cash benefits. Medical care is provided to employees and to members of handicraft coop- eratives and collective farms. Cash sickness benefits are payable at half rate for the first three days of incapacity and then at full rate from the fourth day until recovery or the award of a n inval idity pension. Medica l services are provided directly to patients through faci lities of the Public Health Service. The socia l insurance system for old age, inva lidity and death covers employed persons. There are specia l systems fo r the se lf-employed and members of handicraft cooperatives and agri cu ltural cooperatives. The qualifying age for -old-age pension is 60 years fo r men and 55 years for women. There are lower requirements for those in arduous or dangerous work. The qualifying medical condition for inva lidity pension is incapacity fo r all work (total inva lidity) or for regular work (partial in validity). 142 Spain The social insurance system (cash and medical benefits) covers employees in industry and commerce. There are special systems for agricultural em- ployees, as for farmers and some other occupational groups. Sickness benefits are payable after a three-day waiting period (during which benefit is payable by the employer) for up to 12 months and may be extended to 18 months or to 72 months if the invalidity is temporary. Medical services are provided to patients directly through facilities of the National Insurance Institute or by doctors or hospitals under contract to it. The social insurance system for old age, invalidity and death covers the same groups mentioned under sickness benefits. The age of retirement is 65 years in general and lower for difficult , dangerous or unhealthy work . The qualifying medical condition for invalidity pension (non-occupational) is loss of normal earn- ing capacity. The National Social Security Institute, belonging to the Minis- try of Health and Consumer Affairs, covers the rehabilitation of disabled patients in the field of traumatological and neurological problems. Patients with cardiovascular diseases do not, however, have any legal protection as regards rehabilitation services. Special systems for agricultural workers and for some other occupational groups (e.g. seamen and non-agricultural self-employed workers) have been included in the general system of social insurance. Concerning the rehabilitation of myocardial infarction patients, no major developments have taken place during the last few years. Several hospitals and cardiological departments have, however, started active reha- bilitation programmes. Plans are being made to cover the prevention of and rehabilitation from some major diseases, including cardiac diseases, within the framework of a new Act of Public Health. Sweden The social insurance system includes cash benefits to all gainfully occupied persons and most housewives and dependent husbands. Medical benefits are paid to all residents. Sickness benefits are payable from the second day of incapacity for seven days a week for the duration of illness. Medical benefits include doctors' consultations and other services refunded partially or completely by the National Social Insurance system. There is a universal pension system covering all residents, and an earnings-related pension which covers all employees and self-employed persons earning over a "base amount" . The qualifying age for old-age pension in both systems is 65 years (or 60-64 years with a 0.5% reduction per month or full pension if unable to cope with a job or if unemployed with no prospect of a job). The qualifying medical condition for invalidity pension is a five-sixths loss of working capacity; a reduced pension is paid for a half loss of working capacity. USSR There are dual social insurance (cash benefits) and universal (medical care) systems. Cash benefits are paid to employed persons, students and 143 workers on state farms. Medical care is available for all residents. Sickness benefits are payable from the first day of incapacity until recovery or pension . Medical services are provided directly to patients by governmental health agencies. There are three groups of invalidity determined according to the degree of invalidity, the need for care , and working capacity. The patient is classified in one of these groups by a special board of physicians. The first group of invalidity includes the most disabled patients receiving the highest amount of sickness benefits . The social insurance system for old age, invalidity and death covers employed persons and persons disabled in public duties and workers on state farm s. Special provisions are available for some occupational groups, such as teachers , scientists, etc. The age of retirement is 60 years for men and 55 years for women. These requirements are reduced for difficult or dangerous work, for mothers of five children, for the blind, etc. The qualifying medical conditions for invalidity pension are incapacity for any work (total invalidity) or usual work (partial invalidity). Since 1977, the rehabilitation of acute myocardial infarction patients has been tightly organized to include programmes during the three phases of recovery , i.e. the clinical phase carried out in cardiological departments, the convalesc- ent phase in sanatoria where accommodation is free of charge and where sickness benefits are payable during the stay and the maintenance phase carried out under the supervision of the district doctor. From January 1968, the age of retirement was lowered by five years for some groups of workers, especially those who have been working at least 15 years in unfavourable climatic conditions. Since 1974, both the old-age pension and the pension paid to families that have lost bread-winners have been substantially increased. United Kingdom Sickness benefit is paid if sufficient National Health Service contributions were paid during the relevant tax year. This benefit will be paid for up to 28 weeks. After 28 weeks an invalidity benefit will be paid. A flat-rate benefit is paid, plus, if relevant, an earnings-related supplement. The National Health Service covers all citizens. The old-age pension is payable at the age of 65 years for men and 60 years for women, although this can be deferred thereby earning extra pension. The amount of pension is dependent on length of working life and National Health Service contributions paid. Old-age benefit is treated as part of income for income tax purposes. Invalidity benefit is payable when there has been a total inability to work because of illness or disability for at least 168 days . Invalidity benefit is not taxable . 144 There are the following special allowances. Attendance allowance is paid to people who are so severely disabled, physically or mentally, that they need frequent attention or continual supervision from another person . Mobility allowance is paid to people below retirement age who are unable or virtually unable to walk . Motability is intended to help disabled people get the maximum benefit from the mobility allowance by enabling them to lease new cars. This is a new scheme which is being phased in gradually. Employment rehabilitation allowance is paid to people who are attending an employment rehabilitation course. They normally will have been sick or unemployed or will be disabled. Assistance with fares to work is given to severely disabled people who are registered as disabled under the Disabled Persons (Employment) Act, 1944. Because of their disability they must be unable to use public transport for all or part of their journey to and from work; and they must be paying extra travelling costs as a result. Employment Rehabilitation Centres and Training Centres have been set up to help the disabled to readjust to or retrain for suitable employment. Yugoslavia The social insurance system includes cash and medical benefits. It covers employed persons in industry, commerce, agriculture and some other groups. There is a special system for self-employed farmers. Sickness bene- fits are payable from the first day of incapacity until recovery or the award of an invalidity pension. Medical services are provided directly to patients through facilities of the governmental health service on the basis of con- tracts with local health insurance associations. The social insurance system covers the same groups as mentioned under sickness benefits. The qualifying age for old-age pension is 60 years for men and 55 years for women. There are lower requirements for those in arduous or unhealthy work. The qualify- ing medical conditions for invalidity pension are incapacity for all work (total disability) or greatly reduced capacity for regular or equivalent work (partial disability). 145 Annex 2 WHO study on the effects of rehabilitation and comprehensive secondary prevention after myocardial infarction Code Centre 01 Brussels (Belgium) Principal investigator: Professor H. Denolin 02 Ghent (Belgium) Principal investigator: Dr G . De Backer 03 Bucharest (Romania) Principal investigator: Dr I. Orha 04 Budapest (Hungary) Principal investigator: Dr P. Szabolcs 05 Rome (Italy) Principal investigator: Dr V. Rulli 08 Helsinki (Finland) Principal investigator: Dr J . Hakkila 146 Participating centres and principal investigators Affiliation Centre de Cardiologie du Travail, St Pierre Uni- versity Hospital , Brussels Cardiac Rehabilitation Centre, University Hospi- tal, Ghent Department of Preventive Cardiology and Reha- bilitation, National Centre of Cardiology, Hospi- tal Fundeni, Bucharest Hungarian Institute of Cardiology, Budapest Centre for Cardiovascular Diseases, San Camillo Hospital , Rome Second Department of Medicine, University Central Hospital , Helsinki Code Centre 09 Turku (Finland) Principal investigator: Dr V. Kallio II Bratislava (Czechoslovakia) Principal investigator: Dr J . Kolesar 12 Bordeaux (France) Principal investigator: Professor J.-P. Broustet 13 Tbilisi (USSR) Principal investigator: Professor N .N. Kipsidze 14 Opatija (Yugoslavia) Principal investigator: Dr C. Plav~ic 15 Kaunas (USSR) Principal investigator: Dr N.B. Misiunene 17 Stockholm (Sweden) Principal investigator: Dr L.G . Ekelund 18 Sofia (Bulgaria) Principal investigator: Professor J . Belov 19 Balatonfiired (Hungary) Principal investigator: Dr F. Endersz 20 Moscow (USSR) Principal investigator: Dr L.F. Nikolaieva 21 Prague (Czechoslovakia) Principal investigator: Professor J . Widimsky Affiliation The Rehabilitation Research Centre of the Social Insurance Institution, Turku Human Bioclimatology Research Institute, Komensky University, Bratislava Haut Leveque Hospital of Cardiology, Pessac Georgian Institute of Experimental and Clinical Therapy, Tbilisi Institute for Treatment and Rehabilitation for Patients with Heart and Lung Diseases, Thalasso- therapia Opatija, Opatija Therapeutic Hospital of the Medical and Cardio- logical Institutes, Kaunas Department of Clinical Physiology, Karolinska Hospital, Stockholm Scientific Institute of Cardiovascular Diseases, Medical Academy, Sofia State Hospital of Cardiology, Balatonfiired Department of Rehabilitation, Miasnikov Insti- tute of Cardiology, Moscow Department of Medicine II, Institute for Clinical and Experimental Medicine, Prague 147 Code Centre 22 Warsaw (Poland) Principal investigator: Dr S. Rudnicki 23 Valencia (Spain) Principal investiga1or: Dr V. Tormo Alfonso 25 Nantes ( France) Principal investigator: Professor G. Nicolas 31 Tel Aviv (Israel) Principal investigator: 51 53 54 Professor D. Brunner Erfurt (German Democratic Republic) Cottbus (German Democratic Republic Dessau (German Democratic Republic) Principal investigator: Professor W. Geissler Affiliation National Institute of Cardiology, Medical Academy, Warsaw Cardiac Rehabilitation Centre, Provincial Hospi- tal, Valencia Clinic of Cardiology and Cardiovascular Dis- eases, University Hospital Centre of Nantes Sackler Medical School, Tel Aviv University University Clinic of Internal Medicine , Humboldt-University Medical School (Charite), Berlin IIIIIII IIIII IIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 148 .. 0007855'-t ..