Vous êtes sur la page 1sur 15

Heart Views. 2011 Apr-Jun; 12(2): 5157.

doi: 10.4103/1995-705X.86013
PMCID: PMC3221192

Effect of Exercise-Based Cardiac Rehabilitation on Ejection Fraction in


Coronary Artery Disease Patients: A Randomized Controlled Trial
Mohammad H. Haddadzadeh, Arun G. Maiya,1 R. Padmakumar,2 Bijan Shad,3 and Fardin
Mirbolouk3
Department of Physiotherapy, MCOAHS, Manipal University, Manipal, India and Golsar
Hospital, Rasht, Iran
1Department of Physiotherapy, MCOAHS, Manipal University, Manipal, India
2Department of Cardiology, Manipal University, Manipal, India
3Department of Cardiology, Guilan University of Health Sciences, Golsar Hospital, Iran
Address for correspondence: Dr. Mohammad H. Haddadzadeh, Department of Physiotherapy,
MCOAHS, Manipal University, Manipal - 576 104, Karnataka, India. E-mail:
moc.liamg@hedazdadahm
Author information Copyright and License information
Copyright : Heart Views
This is an open-access article distributed under the terms of the Creative Commons
Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Go to:
Abstract
Background:
Exercise training as a part of cardiac rehabilitation aims to restore patient with heart disease to
health. However, left ventricular ejection fraction (LVEF) is clinically used as a predictor of
long-term prognosis in coronary artery disease (CAD) patients, there is a scarcity of data on
the effectiveness of exercise-based cardiac rehabilitation on LVEF.
Objective:
To investigate the effectiveness of exercise-based cardiac rehabilitation on LVEF in early
post-event CAD patients.
Patients and Methods:
In a single blinded, randomized controlled trial, post-coronary event CAD patients from the
age group of 35-75 years, surgically (Coronary artery bypass graft or percutaneous coronary
angioplasty) or conservatively treated, were recruited from Golsar Hospital, Iran. Exclusion
criteria were high-risk group (AACVPR-99) patients and contraindications to exercise testing
and training. Forty-two patients were randomized either into Study or Control. The study
group underwent a 12-week structured individually tailored exercise program either in the
form of Center-based (CExs) or Home-based (HExs) according to the ACSM-2005

guidelines. The control group only received the usual cardiac care without any exercise
training. LVEF was measured before and after 12 weeks of exercise training for all three
groups. Differences between and within groups were analyzed using the general linear model,
two-way repeated measures at alfa=0.05.
Results:
Mean age of the subjects was 60.5 8.9 years. There was a significant increase in LVEF in
the study (46.9 5.9 to 61.5 5.3) group compared with the control (47.9 7.0 to 47.6 6.9)
group (P=0.001). There was no significant difference in changes in LVEF between the HExs
and CExs groups (P=1.0).
Conclusion:
A 12-week early (within 1 month post-discharge) structured individually tailored exercise
training could significantly improve LVEF in post-event CAD patients.
Keywords: Cardiac rehabilitation, coronary artery disease, ejection fraction, exercise training
INTRODUCTION
Middle Eastern countries, including Iran, are joining the global obesity pandemic and its
consequences such as coronary artery disease (CAD).[1] CAD is one of the most common
causes of morbidity and mortality in different communities worldwide.[24] Despite the lack
of accurate data, there is some evidence to indicate that CAD is increasing in magnitude in
Iran,[2] accounting for about 50% of all deaths per year.[5] While age-adjusted mortality from
CAD is gradually falling in developed countries,[3,6] the rate has increased by 2045% in
Iran.[7,8]
Left ventricular ejection fraction (LVEF) as a clinical index of myocardial contractility and its
pumping action[9,10] is a well-established predictor of mortality and long-term prognosis in
acute myocardial infarction.[10,11] However, exercise training is the core component of
cardiac rehabilitation and secondary prevention of CAD, there is a less body of evidence
regarding the effectiveness of exercise training on LVEF in CAD patients. Previous published
studies mainly studied this outcome in heart failure patients or they used a heterogeneous
subject group with respect to the time gap between coronary event and start of exercise
training or total duration of the program. The purpose of this study was to determine the effect
of early (within 1 month post-discharge) structured individually tailored exercise training on
LVEF in post-event CAD patients. This is a part of a larger multicenter study and, to our
knowledge, is the first of such in the country.
PATIENTS AND METHODS
Study design
The study procedure was designed in accordance with the Helsinki Declaration new revision
2000. This was a single blinded randomized (ratio 2:1) controlled trial in which the
effectiveness of early structured individually tailored exercise training on LVEF was studied.
Eligible patients who gave a written informed consent were allocated into study or control
groups by means of block randomization (block size of 6) using the concealed envelope
method. The assessor of main outcome, a cardiologist, was unaware of the allocation of

patients and, due to the nature of the study, authors were not able to mask more arms. A
flowchart of the study is summarized in Figure 1.

Figure 1
Flow diagram of the study
Subjects
Post-coronary event, patients who were treated surgically (CABG or PTCA) or conservatively
were recruited between July and November 2009 at the Golsar Hospital, Rasht, Iran. The
Golsar Hospital is a general hospital and offers cardiac care, including angioplasty and CABG
as well as outpatient cardiac rehabilitation programs.
Inclusion criteria
Patients of both sexes were screened for eligibility criteria including age group of 3575 years
who were post-event (within 1 month post-discharge) CAD patients treated either surgically
(CABG or PTCA) or conservatively.
Exclusion criteria
High-risk group patients (AACVPR-99)[12] or any systemic, orthopedic or neurological
conditions that restrict participating in aerobic exercise and patients who were contraindicated
for exercise testing and training were excluded from the study.
Procedure
The ethical committee of Golsar Hospital approved the study. All eligible patients were
explained about the procedure and written informed consent was obtained from them before

allocating them into different groups. Eligible and consenting patients were randomly (ratio
2:1) assigned to exercise-based cardiac rehabilitation or control group by means of block
randomization (block size of 6) and concealed envelope method. Base line data included the
LVEF measured by echocardiography, and demographic and clinical evaluation was taken.
Patients in the study group underwent a 12-week structured individually tailored exercise
training either in the form of a Center-based program (CExs) or a Home-based program
(HExs). After 12 weeks of exercise training, subjects were reassessed clinically for the
primary outcome and results were compared pre- and post-intervention with the control
group. All patients underwent a graded exercise test (GXT) with Bruce protocol at baseline in
order to risk stratify the patients (AACVPR-99), and the results of the test included MET and
achieved HRPeak were used as baseline for exercise prescription according to the Karvonen
formula.
Exercise training group
Authors used the ACSM-2005[13] guidelines as principle for exercise prescription for the
study group. The intensity of the prescribed exercise was calculated based on heart rate
reserve achieved during the graded exercise test (Bruce protocol) as well as the rating of
perceived exertion (RPE). Target heart rate range (THRR) using the Karvonen formula was
applied to prescribe exercise intensity. All recruited subjects were given orientation to the
program. A session of informal health education about their condition was given by the
physiotherapist to the patients and to their family members. Risk factor modifications advice
according to the risk factors of each patient, life style modification and smoking cessation
advice were given prior to the start of the rehabilitation program. Awareness about cardiac
rehabilitation, exercise program, adherence to the program and its benefits, which they attend,
was explained to the study group to increase the rate of attendance and compliance.
Patients in the study group allocated to either a CExs training program or a HExs training
program according to the convenience and preference of patients but same guidelines
(ACSM-2005),[13] were used for both subgroups for prescribing the intensity of the exercise.
Group IA. Center-based group
This group underwent a structured, supervised exercise training program for a period of 12
weeks. They attended a minimum of 3 days exercise-based cardiac rehabilitation in the
hospital set-up. The exercise program consisted of 510 min warm up (breathing exercise,
stretching exercise and walking on treadmill) followed by graded aerobic training and 510
min cool down. Graded aerobic training was mainly treadmill walk three to five times per
week, with an intensity of 4070% of HRR achieved in the exercise test applying the
Karvonen formula, and RPE of 1114 for a duration of 2040 min (ACSM guidelines).[13]
Group IB. Home-based group
Exercise component of cardiac rehabilitation program for the home-based group was an
individualized tailored program of aerobic exercises; preferably, brisk walking, as it is shown
in the literature that brisk walking provides an activity intense enough to increase aerobic
capacity in healthy sedentary as well as cardiac patients.[14] Initial sessions of exercise
prescription and training were given in the department under physiotherapist supervision, and
then the program protocol was given to the patient to do at home for 12 weeks. Intensity of
exercise converted to a safe range of speed of walk that the patient achieved on a treadmill to
use as a base for brisk walking.

Patients were also trained in palpating the pulse and calculating the heart rate, and to rate the
RPE of 1114. The exercise program consisted of 510 min warm up, including breathing
exercise, stretching exercise and gentle active exercise, to larger muscle groups like the lower
limb and trunk muscles followed by graded aerobic training and cool down. Graded aerobic
training was mainly brisk walking for three to five times per week with an intensity of 40
70% of HRR achieved in the exercise test applying the Karvonen formula, converted to a
speed of walk and RPE of 1114 for a duration of 2040 min (according to the ACSM
guidelines).[13]
Patients in the HExs group were regularly contacted by phone every 2 weeks to find out their
adherence to the program and advice or changes in program if necessary and to monitor the
progress. The exercise log was reviewed every 15 days. Subjects were also advised to contact
the physiotherapist if any advice or help was needed. A trained physiotherapist gave them
detailed awareness of the signs and symptoms to be monitored while doing the exercise
program, dos and donts and the criteria for the termination of exercise were well explained to
them.
Exercise intensity progression
As the conditioning effect of exercise training, progression of the exercise intensity was done
as needed. As the RPE falls with improving fitness, the intensity of exercise was increased at
510% of the maximum heart rate and by maintaining RPE of 1114 throughout the 12 weeks
duration. For the first 4 weeks, patients performed the exercise training for 1520 mins, from
the 5th to 8th week increased to 2030 mins and the final 9th to 12th week duration was
increased to 3040 mins.
Monitoring
RPE
RPE provides a subjective means of monitoring exercise intensity. HR-VO2 relationship
could be evaluated further in relation to individual RPE, which is helpful in monitoring the
exercise intensity. This method is appropriate for setting exercise intensity in persons with
low fitness, cardiac patients and those who are under medication that affect HR response to
exercise, taking into account personal fitness level, environmental conditions and general
fatigue level.[14] Light to moderate intensity (RPE of 1114) is suitable for cardiac patients.
It is important to use standardized instruction to reduce problems of misinterpretation of RPE.
The following instruction is recommended by the ACSM guidelines:[13]
During the exercise we want you to pay close attention to how hard you feel the exercise
work rate is. This feeling should reflect your total amount of exertion and fatigue, combining
all sensations and feeling of physical stress, effort and fatigue. Do not concern yourself with
any one factor such as leg pain, shortness of breath or exercise intensity, but try to concern
on your total inner feeling of exertion. Try not to underestimate or overestimate your feeling
of exertion. Be as accurate as you can.
Other symptomatic complaints such as degree of chest pain, angina, burning sensation
discomfort and dyspnea are collected from the patients routinely.[13]

Indications for termination of exercise


Detailed awareness of signs and symptoms to be monitored while doing the exercise program
and subjective symptoms and criteria for the termination of exercise were well explained to
the subjects.
Group II: Control group
In the control group, subjects underwent baseline assessment and these patients were
instructed to follow medical treatment advised by their physician and only education program
were given to them. They were not advised any extra formal exercise training program.
Reassessment
After 12 weeks, post-intervention re-evaluation was done by echocardiography in both the
study as well as the control group.
Data analysis
Sample size was determined using a pilot study of 10 patients. Within-group improvement of
5% in LVEF was considered as clinically significant. At alfa=0.05 and power of 90%, authors
determined a sample size of 42 subjects. Analyses were performed by using an intention to
treat approach. Statistical software SPSS v17 was used to infer the data. The General Linear
Model, including repeated measures, was used to analyze the results.
RESULTS
A total of 42 (32 male, 10 female) subjects with mean age of 60.5 8.9 years enrolled in the
study. All subjects completed their course of exercise training with a minimum of 70%
attendance in the exercise sessions. Both groups had similar demographic and clinical
characteristics at baseline with respect to the LVEF, risk stratification, number of diseased
vessels, life style, educational level and diet habits, but there was a significant difference
between the groups with respect to age [Tables [Tables11 and and22].

Baseline demographic characteristics of patients assigned to the exercises and control groups

Table 2

Baseline clinical characteristics of patients assigned to the exercises and control groups
Baseline LVEF in the study group was 46.9 5.9 and in the control group was 47.9 7.0.
There was a significant improvement in LVEF after 12 weeks of exercise training in the study
group (46.9 5.9 to 61.5 5.3) compared with the control (47.9 7.0 to 47.6 6.9) group
(P=0.001) [Figure 2].

Figure 2
Changes in left ventricular ejection fraction (pre-post) exercise training

Because there was a significant difference between the study and control groups with respect
to age, a second analysis after adjusting for the age variable still showed a significant
improvement in LVEF in the study group compared with the control group (P=0.008) [Table
3].

Changes in LVEF in the study and control groups following 12 weeks exercise training
A subgroup analysis of the results between HExs and CExs showed that there was no
significant difference in changes of LVEF between the two protocols [Table 3].
DISCUSSION
Although decreased left ventricular systolic function is a well-established independent
predictor of mortality in CAD patients, little information is available regarding the effect of
exercise training on LVEF.[11] The existing literature either focuses more on heart failure
patients or lacks methodological uniformity regarding the type of patients, time gap between
post-discharge to start of exercise training in post-event patients or the intensity and type of
exercise given to the patients. Koch, Duard and Broustet (1992) in a randomized clinical trial
studied the effect of graded physical exercise on EF and found no significant effect. But, their
study was conducted on chronic heart failure patients.[15]
Adachi, Koiket and Obayshi (1996) reported improvement in cardiac function (such as stroke
volume) both at rest and during exercise only with high-intensity exercise training.[16]
The present study demonstrated two important findings. First, an early (within 1 month postdischarge) 12 weeks structured exercise training program in post-event coronary artery
disease patients could significantly improve the myocardial contractility in terms of LVEF.
Second, a structured individually tailored HExs training could be as effective as center-based
programs and safely used not only in low-risk but also in moderate-risk (AACVPR-99) CAD
patients. These programs could be started as early as 2 weeks post-discharge in uncomplicated
patients. These findings are in consistent with results from Haddadzadeh, Maiya et al. in their
recent study in India, which found a similar effect in a RCT.[17] Giallauria et al. also found a
favorable remodeling from 6 months exercise training program in patients with moderate left
ventricular dysfunction.[18] As evidence shows, there are many difficulties and barriers to
long term-center-based exercise training, and only 2530% of the eligible patients attend
exercise-based cardiac rehabilitation programs. Individually tailored HExs training programs
could be an alternative method in improving myocardial contractility without affecting the
efficacy of the programs.

To the best of our knowledge, this was the first RCT in Iran to investigate the effectiveness of
structured exercise training program on LVEF. Applying the finding into practice amplifies
the importance of secondary prevention and effectiveness of early exercise-based cardiac
rehabilitation programs on the overall cardiac condition of the patients. Keeping in mind the
increasing number of cardiovascular diseases in the Middle East, including Iran, forwarding
the message to the policy makers, insurance companies for covering the cardiac rehabilitation
expenses, hospital administrative for necessity of such programs and adjusting the need of the
common people with the available resources in the form of home-based programs without
losing the efficacy is a must.
Limitation of the study
One of the limitations of this study, like many other rehabilitation programs, was the inability
to randomize the patients in center-based or home-based groups due to the universal barriers
of cardiac rehabilitation, e.g. transportation, economical aspect and far distances of centers to
rural areas and reaching the center three to five times per week. It can be an interest of
consideration for future studies.
In conclusion, a 12-week early (within 1 month post-discharge) structured individually
tailored exercise training could significantly improve the LVEF in post-event coronary artery
disease patients. However, a structured individually tailored HExs program could be as
effective as a center-based program in improving LVEF.
ACKNOWLEDGMENT
The authors would like to thank the reviewers in the International Conference on MultiDisciplinary Approach in Healthy & Participatory Aging (MAHPA), Mumbai, in which a
preliminary report of the pilot study was presented and comments were considered in the
paper. The authors would also like to thank the primary funding agency, Armaghan
Educational Institute, through the Ministry of Education of Iran, as a part of a larger
multicenter study. Thanks are also due to the physiotherapists S. Alidoust and M. Monfaredi
and the head nurse M. Pourgholi from the Department of Physiotherapy, for their minute to
minute help during the study conduct. The authors would especially like to thank Prof.
Anoush Barzigar, Head of Cardiology Department, Heshmat Heart Center, Dr. AzizollahZadeh, Chief Manager of Golsar Hospital, Rasht, Iran and Dr. A. Ershadi, Department of
Angioplasty and Exercise Test Unit of Golsar Hospital for their complete support and
cooperation.
Footnotes
Source of Support: Armaghan Educational Institute, Ministry of Education, Iran
Conflict of Interest: Authors agreed that there was no source of conflict of interest.
REFERENCES
1. Bahrami H, SadatSafavi M, Pourshams A, Kamangar F, Nouraei M, Semnani S, et al.
Obesity and hypertension in an Iranian cohort study; Iranian women experience higher
rates of obesity and hypertension than American women. BMC Public Health.
2006;6:15866. [PMC free article] [PubMed]

2. Hadaegh F, Harati H, Ghanbarian A, Azizi F. Prevalence of coronary heart disease


among Tehran adults: Tehran Lipid and Glucose Study. East Mediterr Health J.
2009;15:15766. [PubMed]
3. Castelli WP. Epidemiology of coronary heart disease: The Framingham study. Am J
Med. 1984;76:412. [PubMed]
4. Keil U. [The worldwide WHO MONICA Project: results and perspectives]
Gesundheitswesen. 2005;67(Suppl 1):S3845. [PubMed]
5. Hatmi ZN, Tahvildari S, Gafarzadeh Motlag A, Sabouri Kashani A. Prevalence of
coronary artery disease risk factors in Iran: A population based survey. BMC
Cardiovasc Disord. 2007;7:32. [PMC free article] [PubMed]
6. Sytkowski PA, DAgostino RB, Belanger A, Kannel WB. Sex and time trends in
cardiovascular disease incidence and mortality: The Framingham heart study, 19501989. Am J Epidemiol. 1996;143:33850. [PubMed]
7. Prevention and control of cardiovascular disease. Alexandria, World Health Organization Regional Office for the Eastern Mediterranean. 1995;24
8. Zali M, Kazem M, Masjedi MR. [Health and disease in Iran]. Tehran, Islamic
Republic of Iran, Deputy of Research, Ministry of Health. 1993 (Bulletin No 10)
9. Ratchford AM, Hamman RF, Regensteiner JG, Magid DJ, Gallagher SB, Merenich JA.
Attendance and graduation patterns in a group model health maintenance
organization.Alternative cardiac rehabilitation program. J Cardiopulm Rehabil.
2004;24:1506. [PubMed]
10. Johnson N, Fisher J, Nagle A, Inder K, Wiggers J. Factors associated with referral to
outpatient cardiac rehabilitation services. J Cardiopulm Rehabil. 2004;24:16570.
[PubMed]
11. Dutcher JR, Kahn J, Grines C, Franklin B. Comparison of left ventricular ejection
fraction and exercise capacity as predictors of two and five-year mortality following
acute myocardial infarction. Am J Cardiol. 2007;99:43641. [PubMed]
12. Guidelines for Cardiac Rehabilitation and Secondary Prevention Program. 3rd ed.
Champaign, IL: Human kinetics; 1999. American Association of Cardiovascular and
Pulmonary Rehabilitation.
13. 7th ed. Philadelphia: Lippincott, Williams and Wilkines; 2006. American College Of
Sports Medicine (ACSM) Guidelines for exercise testing and prescription.
14. Machionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, et al.
Improved exercise tolerance and quality of life with cardiac rehabilitation of older
patients after myocardial infarction: results of a randomized controlled trial.
Circulation. 2003;107:22016. [PubMed]
15. Koch M, Douard H, Broustet JP. The benefit of graded physical exercise in chronic
heart failure. Chest. 1992;101(5 Suppl):231S235S. [PubMed]
16. Adachi H, Koike A, Obayashi T, Umezawa S, Aonuma K, Inada M, et al. Does
appropriate endurance exercise training improve cardiac function in patients with prior
myocardial infarction? Eur Heart J. 1996;17:151121. [PubMed]
17. Haddadzadeh MH, Maiya AG, Padmakumar R, Devasia T, Kansal N, Borkar S.
Effectiveness of cardiac rehabilitation on myocardial contractility in post-event
coronary artery disease patients: A randomized controlled trial. Physiotherapy.
2010;8:512.
18. Giallauria F, Cirillo P, Lucci R, Pacileo M, De Lorenzo A, DAgostino M, et al. Left
ventricular remodelling in patients with moderate systolic dysfunction after
myocardial infarction: Favourable effects of exercise training and predictive role of Nterminal pro-brain natriuretic peptide. Eur J Cardiovasc Prev Rehabil. 2008;15:1138.
[PubMed]

Abstract
INTRODUCTION
PATIENTS AND METHODS
RESULTS
DISCUSSION
ACKNOWLEDGMENT
Footnotes
REFERENCES
Articles from Heart Views : The Official Journal of the Gulf Heart Association are provided
here courtesy of Medknow Publications

Bottom of Form
Similar articles in PubMed
The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based
compared with hospital-based cardiac rehabilitation in a multi-ethnic population: costeffectiveness and patient adherence.[Health Technol Assess. 2007]
Jolly K, Taylor R, Lip GY, Greenfield S, Raftery J, Mant J, Lane D, Jones M, Lee KW,
Stevens A. Health Technol Assess. 2007 Sep; 11(35):1-118.
Prognostication in 3-vessel coronary artery disease based on left ventricular ejection fraction
during exercise : influence of coronary artery bypass grafting.[Circulation. 1999]
Supino PG, Borer JS, Herrold EM, Hochreiter C. Circulation. 1999 Aug 31; 100(9):924-32.
Single photon emission computed tomography for the diagnosis of coronary artery disease: an
evidence-based analysis.[Ont Health Technol Assess Ser....]
Health Quality Ontario. Ont Health Technol Assess Ser. 2010; 10(8):1-64. Epub 2010 Jun 1.
The impacts of cardiac rehabilitation program on echocardiographic parameters in coronary
artery disease patients with left ventricular dysfunction.[Cardiol Res Pract. 2013]
Sadeghi M, Garakyaraghi M, Khosravi M, Taghavi M, Sarrafzadegan N, Roohafza H. Cardiol
Res Pract. 2013; 2013:201713. Epub 2013 Dec 29.
Feasibility of physical training after myocardial infarction and its effect on return to work,
morbidity and mortality.[Acta Med Scand Suppl. 1976]
Palatsi I. Acta Med Scand Suppl. 1976; 599:7-84.
See reviews...See all...
Links
MedGen
MedGen
Related information in MedGen
PubMed
PubMed
PubMed citations for these articles
Recent Activity
ClearTurn OffTurn On
Effect of Exercise-Based Cardiac Rehabilitation on Ejection Fraction in Coronary...
Effect of Exercise-Based Cardiac Rehabilitation on Ejection Fraction in Coronary Artery
Disease Patients: A Randomized Controlled Trial
Heart Views : The Official Journal of the Gulf Heart Association. Apr-Jun 2011; 12(2)51

Effect of age on left ventricular function during exercise in patients with coro...
Effect of age on left ventricular function during exercise in patients with coronary artery
disease.
J Am Coll Cardiol. 1983 Oct ;2(4):645-51.
PubMed
Value of left ventricular ejection fraction during exercise in predicting the ex...
Value of left ventricular ejection fraction during exercise in predicting the extent of coronary
artery disease.
J Am Coll Cardiol. 1983 Apr ;1(4):1002-10.
PubMed
Relative risk, relative and absolute risk reduction, number needed to treat and ...
Relative risk, relative and absolute risk reduction, number needed to treat and confidence
intervals - Smart Health Choices
Diagnosis of iron-deficiency anemia in the elderly.
Diagnosis of iron-deficiency anemia in the elderly.
Am J Med. 1990 Mar ;88(3):205-9.
PubMed
Your browsing activity is empty.
Activity recording is turned off.
Turn recording back on
See more...
Obesity and hypertension in an Iranian cohort study; Iranian women experience higher rates
of obesity and hypertension than American women.[BMC Public Health. 2006]
Bahrami H, Sadatsafavi M, Pourshams A, Kamangar F, Nouraei M, Semnani S, Brennan P,
Boffetta P, Malekzadeh R
BMC Public Health. 2006 Jun 20; 6():158.
Prevalence of coronary heart disease among Tehran adults: Tehran Lipid and Glucose Study.
[East Mediterr Health J. 2009]
Hadaegh F, Harati H, Ghanbarian A, Azizi F
East Mediterr Health J. 2009 Jan-Feb; 15(1):157-66.
[The Worldwide WHO MONICA Project: results and perspectives].[Gesundheitswesen. 2005]
Keil U
Gesundheitswesen. 2005 Aug; 67 Suppl 1():S38-45.
Prevalence of coronary artery disease risk factors in Iran: a population based survey.[BMC
Cardiovasc Disord. 2007]
Hatmi ZN, Tahvildari S, Gafarzadeh Motlag A, Sabouri Kashani A
BMC Cardiovasc Disord. 2007 Oct 30; 7():32.
Epidemiology of coronary heart disease: the Framingham study.[Am J Med. 1984]
Castelli WP
Am J Med. 1984 Feb 27; 76(2A):4-12.
Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart
Study, 1950-1989.[Am J Epidemiol. 1996]
Sytkowski PA, D'Agostino RB, Belanger A, Kannel WB
Am J Epidemiol. 1996 Feb 15; 143(4):338-50.
See more ...
Attendance and graduation patterns in a group-model health maintenance organization
alternative cardiac rehabilitation program.[J Cardiopulm Rehabil. 2004]
Ratchford AM, Hamman RF, Regensteiner JG, Magid DJ, Gallagher SB, Merenich JA
J Cardiopulm Rehabil. 2004 May-Jun; 24(3):150-6.
Factors associated with referral to outpatient cardiac rehabilitation services.[J Cardiopulm
Rehabil. 2004]
Johnson N, Fisher J, Nagle A, Inder K, Wiggers J

J Cardiopulm Rehabil. 2004 May-Jun; 24(3):165-70.


Comparison of left ventricular ejection fraction and exercise capacity as predictors of twoand five-year mortality following acute myocardial infarction.[Am J Cardiol. 2007]
Dutcher JR, Kahn J, Grines C, Franklin B
Am J Cardiol. 2007 Feb 15; 99(4):436-41.
Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients
after myocardial infarction: results of a randomized, controlled trial.[Circulation. 2003]
Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, Burgisser C,
Masotti G
Circulation. 2003 May 6; 107(17):2201-6.
Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients
after myocardial infarction: results of a randomized, controlled trial.[Circulation. 2003]
Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, Burgisser C,
Masotti G
Circulation. 2003 May 6; 107(17):2201-6.
Comparison of left ventricular ejection fraction and exercise capacity as predictors of twoand five-year mortality following acute myocardial infarction.[Am J Cardiol. 2007]
Dutcher JR, Kahn J, Grines C, Franklin B
Am J Cardiol. 2007 Feb 15; 99(4):436-41.
The benefit of graded physical exercise in chronic heart failure.[Chest. 1992]
Koch M, Douard H, Broustet JP
Chest. 1992 May; 101(5 Suppl):231S-235S.
Does appropriate endurance exercise training improve cardiac function in patients with prior
myocardial infarction?[Eur Heart J. 1996]
Adachi H, Koike A, Obayashi T, Umezawa S, Aonuma K, Inada M, Korenaga M, Niwa A,
Marumo F, Hiroe M
Eur Heart J. 1996 Oct; 17(10):1511-21.
Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial
infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain
natriuretic peptide.[Eur J Cardiovasc Prev Rehabil. 2008]
Giallauria F, Cirillo P, Lucci R, Pacileo M, De Lorenzo A, D'Agostino M, Moschella S,
Psaroudaki M, Del Forno D, Orio F, Vitale DF, Chiariello M, Vigorito C
Eur J Cardiovasc Prev Rehabil. 2008 Feb; 15(1):113-8.
Obesity and hypertension in an Iranian cohort study; Iranian women experience higher
rates of obesity and hypertension than American women.
Bahrami H, Sadatsafavi M, Pourshams A, Kamangar F, Nouraei M, Semnani S, Brennan P,
Boffetta P, Malekzadeh R
BMC Public Health. 2006 Jun 20; 6():158.
[PubMed] [Ref list]
Prevalence of coronary heart disease among Tehran adults: Tehran Lipid and Glucose Study.
Hadaegh F, Harati H, Ghanbarian A, Azizi F
East Mediterr Health J. 2009 Jan-Feb; 15(1):157-66.
[PubMed] [Ref list]
[The Worldwide WHO MONICA Project: results and perspectives].
Keil U
Gesundheitswesen. 2005 Aug; 67 Suppl 1():S38-45.
[PubMed] [Ref list]
Prevalence of coronary artery disease risk factors in Iran: a population based survey.
Hatmi ZN, Tahvildari S, Gafarzadeh Motlag A, Sabouri Kashani A
BMC Cardiovasc Disord. 2007 Oct 30; 7():32.
[PubMed] [Ref list]
Epidemiology of coronary heart disease: the Framingham study.

Castelli WP
Am J Med. 1984 Feb 27; 76(2A):4-12.
[PubMed] [Ref list]
Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart
Study, 1950-1989.
Sytkowski PA, D'Agostino RB, Belanger A, Kannel WB
Am J Epidemiol. 1996 Feb 15; 143(4):338-50.
[PubMed] [Ref list]
7. Prevention and control of cardiovascular disease. Alexandria, World Health Or-ganization
Regional Office for the Eastern Mediterranean. 1995;24 [Ref list]
8. Zali M, Kazem M, Masjedi MR. [Health and disease in Iran]. Tehran, Islamic Republic of
Iran, Deputy of Research, Ministry of Health. 1993 (Bulletin No 10) [Ref list]
Attendance and graduation patterns in a group-model health maintenance organization
alternative cardiac rehabilitation program.
Ratchford AM, Hamman RF, Regensteiner JG, Magid DJ, Gallagher SB, Merenich JA
J Cardiopulm Rehabil. 2004 May-Jun; 24(3):150-6.
[PubMed] [Ref list]
Factors associated with referral to outpatient cardiac rehabilitation services.
Johnson N, Fisher J, Nagle A, Inder K, Wiggers J
J Cardiopulm Rehabil. 2004 May-Jun; 24(3):165-70.
[PubMed] [Ref list]
Comparison of left ventricular ejection fraction and exercise capacity as predictors of twoand five-year mortality following acute myocardial infarction.
Dutcher JR, Kahn J, Grines C, Franklin B
Am J Cardiol. 2007 Feb 15; 99(4):436-41.
[PubMed] [Ref list]
12. Guidelines for Cardiac Rehabilitation and Secondary Prevention Program. 3rd ed.
Champaign, IL: Human kinetics; 1999. American Association of Cardiovascular and
Pulmonary Rehabilitation. [Ref list]
13. 7th ed. Philadelphia: Lippincott, Williams and Wilkines; 2006. American College Of
Sports Medicine (ACSM) Guidelines for exercise testing and prescription. [Ref list]
Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients
after myocardial infarction: results of a randomized, controlled trial.
Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, Burgisser C,
Masotti G
Circulation. 2003 May 6; 107(17):2201-6.
[PubMed] [Ref list]
The benefit of graded physical exercise in chronic heart failure.
Koch M, Douard H, Broustet JP
Chest. 1992 May; 101(5 Suppl):231S-235S.
[PubMed] [Ref list]
Does appropriate endurance exercise training improve cardiac function in patients with prior
myocardial infarction?
Adachi H, Koike A, Obayashi T, Umezawa S, Aonuma K, Inada M, Korenaga M, Niwa A,
Marumo F, Hiroe M
Eur Heart J. 1996 Oct; 17(10):1511-21.
[PubMed] [Ref list]
17. Haddadzadeh MH, Maiya AG, Padmakumar R, Devasia T, Kansal N, Borkar S.
Effectiveness of cardiac rehabilitation on myocardial contractility in post-event coronary
artery disease patients: A randomized controlled trial. Physiotherapy. 2010;8:512. [Ref list]

Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial
infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain
natriuretic peptide.
Giallauria F, Cirillo P, Lucci R, Pacileo M, De Lorenzo A, D'Agostino M, Moschella S,
Psaroudaki M, Del Forno D, Orio F, Vitale DF, Chiariello M, Vigorito C
Eur J Cardiovasc Prev Rehabil. 2008 Feb; 15(1):113-8.
[PubMed] [Ref list]
You are here: NCBI > Literature > PubMed Central (PMC)
Write to the Help Desk
External link. Please review our privacy policy.
NLM
NIH
DHHS
USA.gov
Copyright | Disclaimer | Privacy | Browsers | Accessibility | Contact
National Center for Biotechnology Information, U.S. National Library of Medicine 8600
Rockville Pike, Bethesda MD, 20894 USA
External link. Please review our privacy policy.
PreferencesTurn off