European Journal of Physical Education and Sport Science
ISSN: 2501 - 1235
ISSN-L: 2501 - 1235
Available on-line at: www.oapub.org/edu
10.5281/zenodo.56130
Volume 2│Issue 1│2016
REHABILITATION IN PATIENTS WITH MYOCARDIAL
INFARCTION - A HISTORICAL REVIEW AND REFLECTION ON THE
TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
Tanya Megova1i, Ivan Maznev2
Department of Kinesitherapy, Medical University, Pleven, Bulgaria
1
National Sports Academy "Vasil Levski", Sofia, Bulgaria
2
Abstract:
The aim of this study was to review the literature regarding the impact of rehabilitation
on prognosis in patients with acute myocardial infarction. Cardio-rehabilitation is
administered routinely in practice over the last two centuries. It underwent significant
development in our times and is characterized by an accelerated rate and by the
application of very intense exercise. Numerous studies in recent decades prove beyond
doubt the benefits of cardio-rehabilitation in patients with acute myocardial infarction.
It reflects favourably on the quality of life of patients and on their forecast. In
confirmation of this statement are clear evidence of reduced total mortality,
cardiovascular mortality and recurrent myocardial infarction in patients conducted
cardio-rehabilitation.
Keywords: myocardial infarction, rehabilitation, historical review, total mortality,
cardiovascular mortality
Introduction
According to the European Society of Cardiology the cardio-rehabilitation is defined as
"…a set of interventions aimed at achieving the best physical, psychological and social
opportunities so that patients with chronic or after acute heart disease, maintain or occupy their
inherent in society". Generally, rehabilitation represents a return to an active and
Address for correspondence: Tanya Megova, Ph.D., , Department of Kinesitherapy, Medical University,
Pleven. e-mail: tmegova@abv.bg
i
Copyright © The Author(s). All Rights Reserved
Published by Open Access Publishing Group ©2015.
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Tanya Megova, Ivan Maznev REHABILITATION IN PATIENTS WITH MYOCARDIAL INFARCTION - A HISTORICAL REVIEW AND
REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
fulfilling lifestyle. The relative importance of physical activity in patients with coronary
artery disease is described further in the eighteenth century. In 1772, a doctor named
Heberden published a report describing the six-month training program consisting of
30 minutes of daily physical activity of one of his male patients who had a diagnosed
problem localized in chest [Heberden W]. Parry, in 1799 noted the beneficial effects of
exercise in patients suffering from chest pains [Parry CH]. Although these messages
appear long before the disease of the coronary arteries can be described in scientific
literature, no doubt some of these patients suffered from heart failure or myocardial
infarction. Herrich in 1912 gives the original clinical description of acute myocardial
infarction [Mallory GK]. He expressed concern about the relationship between physical
exercise and increased risk of ventricular rupture or provoking ischemia in these
patients. This promotes the adoption of a conservative approach in the treatment of
myocardial infarction in patients who were kept at rest for six to eight weeks after onset
of illness. This approach to the patients was confirmed by Mallory and White in the
thirties of the nineteenth century based on the fact that the necrotic area of the
myocardium is transformed into connective tissue, for a period of about 6 weeks
[Mallory GK,]. Limited physical activity is recommended after hospital discharge. In
some cases even prohibited and climbing stairs for up to one year. Often, patients do
not return to work, and consequently treated as unproductive members of society.
In the sixties of the twentieth century, inpatient cardiac rehabilitation is widely
used thanks to the efforts and the efforts of new approaches and practices Wenger,
Zohman, Tobis and Bruce. They are of the opinion that cardio-rehabilitation leads to
faster recovery of patients and reduce hospital stays; improve the functional status and
allows earlier return to work. Adopted programs include early rehabilitation and
recovery during the acute phase after myocardial infarction [Wenger N] [Zohman L]
[Bruce RA].
At the end of 1960 Hellerstein, encouraged by the results of his hospital program
includes bold exercise in patients after hospital discharge. Hellerstein is seriously
criticized by his colleagues for his innovative and risky approach. His research clearly
showed that patients with heart disease can safely benefit from regular exercise and
enjoy improved physical and psychological state without negative effect [Hellerstein
H]. The success of this medically supervised program offers a new dimension in the
outpatient cardiac rehabilitation program. As a result of the work of Hellerstein and coauthors, the concept of progressive controlled activity in patients who have myocardial
infarction received a major role in the therapeutic approach [Zohman L329-335]
[Hellerstein H]. Rehabilitation of patients with myocardial infarction developed
European Journal of Physical Education and Sport Science - Volume 2 │ Issue 1 │ 2016
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Tanya Megova, Ivan Maznev REHABILITATION IN PATIENTS WITH MYOCARDIAL INFARCTION - A HISTORICAL REVIEW AND
REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
significantly in recent years and is an established practice in most countries. Numerous
studies have shown that inpatient and outpatient rehabilitation programs are safe and
effective methods to improve the physical and mental well-being of the patients; they
are associated with significant improvement in prognosis and quality of life. So cardiorehabilitation established itself as a mandatory element of effective clinical management
of myocardial infarction.
Benefits and possible risks of rehabilitation in patients with myocardial
infarction, determination of its impact on total, cardiovascular mortality and the risk of
recurrent myocardial infarction, have been the subject of several studies. They cover
different number of persons as follow-up period ranged widely - from several months
to 10 years or more. The larger randomized studies prove that held inpatient and
outpatient rehabilitation significantly reduced total and cardiovascular death, but also
the risk of fatal and nonfatal recurrent myocardial infarction [Kallio V., Carson P.,
Fridlund B., Hamalainen H., Specchia G., Naughton J., La Rovere M., Lee B.].
In confirmation of these allegations is the latest big a randomized study
conducted in the United States covering 2991 patients with myocardial infarction
[Dunlay S.]. In 52,5% thereof is carried out rehabilitation after being discharged from
hospital within 90 days. Patients were followed for an average of 7.6 years. The authors
found a drastic reduction in the risk of death by 42% in patients conducted
rehabilitation. Most probative value have several meta-analyzes involving a
randomized studies. Taylor R. et al conducted a meta-analysis of 48 studies involving a
total of 8940 patients with myocardial infarction, published by 2004. [Taylor R.]. The
follow-up was over 6 months. The authors found that the conduct of cardiorehabilitation is associated with a credible reduction of total mortality (OR = 0,80 [0.68 0.93]) and cardiac mortality (OR = 0,74 [0,61 - 0.96]). The newest meta-analysis of studies
conducted by 2011 regarding the prognostic significance of cardio-rehabilitation in
patients with acute myocardial infarction is represented by Lawler et al [Lawler P.].
Inclusion criteria are very well chosen; with 147 publications were selected 34. The total
number of patients in these studies was 6111, the minimum duration of rehabilitation
was conducted one month and duration of follow-up from 3 months to 5 years. The
authors found fairly lower total mortality (OR = 0,74 [0.58-0.95]), cardiovascular
mortality (OR = 0,64 [0,46 - 0.88]) and risk of re-infarction (OR = 0,53 [0 38 - 0.76]) in
patients rehabilitated. A very important point in this analysis is that the benefits of
rehabilitation are observed regardless of the duration of the applied program
(minimum 1 month) and continue years after its termination. With the introduction of
reperfusion therapy in the treatment of acute myocardial infarction, particularly
European Journal of Physical Education and Sport Science - Volume 2 │ Issue 1 │ 2016
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Tanya Megova, Ivan Maznev REHABILITATION IN PATIENTS WITH MYOCARDIAL INFARCTION - A HISTORICAL REVIEW AND
REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
percutaneous interventions, the question arises whether in these patients conducting
cardio-rehabilitation a significant prognostic importance. This issue is discussed in
relatively small studies. The biggest and targeted study published by K. Goel et al in
2011 [Goel K.]. It is based on a retrospective analysis, and included 2395 patients with
acute myocardial infarction undergoing percutaneous coronary intervention. The study
analyzed indicators total mortality, cardiovascular mortality, recurrent myocardial
infarction and repeat percutaneous intervention. Tracking patients averaged 6.3 years.
In this period were recorded 503 deaths for any reason, 199 cases of death, myocardial
infarctions and 394 755 cases of revascularization. Cardio-rehabilitation has conducted
964 patients (40%). The authors reported a significant reduction in overall mortality
rehabilitated patients (ratio of 0.53 to 0,55; P <0.001). Also, there is a tendency to lower
cardiovascular mortality, recurrent myocardial infarction, and repeat revascularization.
The difference between rehabilitated and the other patients independent of age and
gender.
Conclusion
Rehabilitation of patients with acute myocardial infarction underwent development
over the past two centuries. The principles that changed and fluctuated dramatically,
prolonged immobilization of patients in the past, the application of relatively intense
exercise regimen in our time. Numerous studies in recent decades prove beyond doubt
the benefits of cardio-rehabilitation in patients with acute myocardial infarction. It
reflects favorably on the quality of life of patients and on their forecast. In confirmation
of this statement are clear evidence of reduced total mortality, cardiovascular mortality
and recurrent myocardial infarction in patients conducted cardio-rehabilitation.
These findings concern for patients treated conservatively and patients with
reperfusion therapy applied (percutaneous coronary intervention and bypass surgery).
It is worrying that a small proportion of patients with acute myocardial infarction are
included in rehabilitation programs. This is particularly true for economically
developed countries with stable health system. In even more relevant is that for our
country. This requires taking measures by the state and society for accessibility for all
patients with myocardial infarction to contemporary rehabilitation programs.
European Journal of Physical Education and Sport Science - Volume 2 │ Issue 1 │ 2016
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Tanya Megova, Ivan Maznev REHABILITATION IN PATIENTS WITH MYOCARDIAL INFARCTION - A HISTORICAL REVIEW AND
REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
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REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
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Tanya Megova, Ivan Maznev REHABILITATION IN PATIENTS WITH MYOCARDIAL INFARCTION - A HISTORICAL REVIEW AND
REFLECTION ON THE TOTAL, CARDIOVASCULAR MORTALITY AND
THE RISK OF RECURRENT MYOCARDIAL INFARCTION
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