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Three hundred and thirty patients with coronary artery disease (CAD) (288 men, 42 women, age of 55.5 +/- 10.0 years) participated in a 4-week ambulatory cardiac rehabilitation program (ACR) (Table 1). The cardiovascular indication for ACR was in 229 cases a myocardial infarction. In 101 patients a CAD with invasive revascularization but without a history of MI was present. In 92 patients with myocardial infarction additionally an invasive revascularization was performed. Eighty-three patients were included after a CABG-procedure (Tables 2 to 5). Six months after the ACR 290 (87.9%) patients presented for clinical reevaluation. In 235 (81.0%) of the 290 examined patients the cardiovascular diagnosis was unaltered. In the first 6 months after ACR in 76 (26.2%) patients a coronarography was performed, in 44 patients a restenosis was diagnosed. In 36 patients an additional invasive procedure (in 28 patients a PTCA, in 5 patients with additional stent-implantation, in 1 case with rotablation, in 8 patients CABG) was performed. In 1 patients a pace-maker was implanted. Since the ACR 1 patient experienced a myocardial infarction and 2 a recurrent myocardial infarction. In 1 patient myocardial fibrillation occurred. Totally, 70 patients (24.1%) required stationary-hospital treatment during the first 6 months after ACR (Table 6). In 11 cases an acute admission to hospital treatment because of cardiovascular reasons was documented. The majority of the hospital admission was elective, because of diagnostic or therapeutic procedures. In 6 patients a CABG-surgery was performed. In approximately 80% of the patients the cardiovascular status was stable during the first 6 months after ACR. Though 24.1% of the patients required stationary hospital treatment, the majority of the admissions was elective of interest, there was a high rate of hospital admissions in the PTCA-group in combination with recoronarographies and revascularization because of early reocclusion.

According to the guidelines and standards for a comprehensive phase II rehabilitation a new outpatient/part-time outpatient program was developed and started at an existing rehabilitation center in January 1997. All patients of the new program were included in a follow-up study and compared with patients of the same center, who met the inclusion and exclusion criteria for the outpatient mode, but wanted to perform their rehabilitation in the full-time residential mode. Both groups were examined before, at the end and 6 months after the program. Until December 1998 118 patients after an acute cardiac event such as myocardial infarction, PTCA or heart surgery were rehabilitated in the outpatient/part-time outpatient mode. The short- and medium-term results concerning somatic outcomes, e.g. the risk factor profile or the improvement of the maximum work capacity, were equal in both groups. Comparing the direct costs for a 4-week rehabilitation, the part-time outpatient program was 26%, the outpatient program even 52% cheaper than the standard full-time residential program. The new program is as effective as the residential rehabilitation, but it is cheaper. Because of the in- and exclusion criteria it is suitable for only a subgroup of cardiac patients, because of the demands and standards the new program it can be offered only in special rehabilitation centers.

From October 1994 to July 1996, 128 patients (30 women, 98 men) participated in an outpatient cardiac rehabilitation program (phase II). Our objectives were to demonstrate risk-factor modification and increased workload capacity resulting directly from the rehabilitation in terms of primary results and long-term effects 6 and 12 months (n = 118, Figure 1) respectively 1.5 and 2 years (n = 87) after termination of the program (Tables 9 to 12). We observed how many of the patients were able to be occupationally reintegrated after completion of phase-II rehabilitation. Workload capacity significantly increased from 1.2 W/kg upon entry to 1.5 W/kg (p < or = 0.05) upon completion of 4 weeks cardiac rehabilitation. Workload capacity remained consistently high at 6 months and 1 year (1.5 W/kg) and at 1.5 and 2 years (1.7 W/kg). Total cholesterol decreased significantly from 247 to 201 mg/dl (p < or = 0.05) during the 4-week program. Significant cholesterol (p < or = 0.01) reductions persisted at 6 months (216 mg/dl) and 1 year (215 mg/dl). After 1.5 and 2 years, the total cholesterol was less than 14% and 17% below the mean of cholesterol at the beginning of the program. Similarly, LDL cholesterol was 185 mg/dl before entering the program, 146 mg/dl after 4 weeks, 151 mg/dl after 6 months and 149 mg/dl after 1 year. Triglyceride levels showed a significant reduction (p < or = 0.01) with levels 189 mg/dl before entering the program, 148 mg/dl after 4 weeks, 151 mg/dl after 6 months and 154 mg/dl after 1 year. LDL cholesterol and triglyceride levels did not significantly increase after 1.5 and 2 years. The HDL cholesterol increased slightly as a long-term effect (from 51 mg/dl before entering the program to 55, 56 and 54 mg/dl after 1, 1.5 and 2 years, respectively). Seventy-three percent of the patients questioned (n = 73) found the program very good, 27% said it was good and no patient was dissatisfied. Fifty-one (81%) of the 63 patients who were actively employed before becoming ill and later entering our program were immediately able to be reintegrated into their previous occupation. In several cases reintegration took 7 weeks. Seven (11%) patients applied for pension, 5 (8%) patients remained unemployed on sick-leave.

Transmyocardial laser revascularization (TMLR) is a new technique for patients with CAD or heart attack to revascularize ischemic areas of the myocardium in which the localisation or the condition of the vessels does not allow bypass grafting. This study shows the results in observation of patients before and during the first 3 months after TMLR. Of 110 patients operated on from 1994 to 1996, 86 were evaluated for well being (quality of life), using NYHA- and CCS-classification, stress test and nitril-scintigraphy at rest and under stress conditions. 51 patients, of whom 11 were females, underwent TMLR combined with coronary artery bypass graft (CABG). 35 male patients were treated singularly with TMLR. The average age in both groups was 59 years (+/- 23). All patients were subject to phase I rehabilitation in specialised institutions after being mobilised in the operating hospital. The evaluations took place on the day of admission to the hospital prior to surgery, within 10 days after surgery and 3 months following. The average stay in the rehabilitation-institution was between 4 and 6 weeks. Our findings demonstrate that both groups profited from the procedures, while the TMLR/CABG group showed a faster recovery and a better outcome. In comparison to 57% of the TMLR group, 85% of the patients in the TMLR/CABG group reported an improvement ranging from good to significant in quality of life assessments. The TMLR/CABG rated from an average of initially 3.4 (+/- 0.6) to 2.1 (+/- 0.8) after 3 months at NYHA- and 3.3 (+/- 0.7) to 1.7 (+/- 0.8) at CCS-classification. The TMLR group rated from 3.6 (+/- 0.5) to 2.4 (+/- 0.8) in NHYA- and from 3.4 (+/- 0.5) to 1.9 (+/- 0.7) on the CSS-scales. A remarkable improvement was noted in the stress test with an increase in power and endurance from 21 to 89 watts for the combined group and 8 to 81 watts for the TMLR treated patients, who generally recovered more slowly. The perfusion scan showed the same tendencies as previously reported but in some cases the results were not congruent with other findings. Overall, our findings indicate that there is a benefit for terminally symptomatic CAD patients after TMLR, but an observation period of 3 months does not allow for final conclusions on this matter. Rehabilitation seems to be of value for TMLR-patients since they have shown a markedly better performance following 3-month treatment, but further data from clinical randomised trials are needed to determine the influence of TMLR with short- and long-term rehabilitation on the prognosis of the disease.

Between 1975 and 1979 15 patients under 35 underwent aorto-coronary bypass-grafting. The youngest was 24 years old. Out of 1188 revascularized patients over the same period, only 1.26% of surgically treated patients with coronary artery disease were under 35, whereas 4.79% were under 40. The main risk factors were smoking, overweight and hyperlipidemia, and every patient had several risk factors. 12 of 15 patients had preoperative infarctions. 3 patients had single vessel disease, 3 had double vessel disease and 9 had triple vessel disease, the latter two groups with massive and diffuse disease down to the peripheral vessels. By the usual criteria some of them had been refused for revascularization and only their youth and disabling angina without hope of improvement through medical therapy prompted us to operate on them. At operation 2.73 grafts per patient were performed, three of which were internal mammary artery anastomosis. Operative mortality was nil. Only one patient had a perioperative myocardial infarction, without complications or hemodynamic impairment. Another patient sustained a re-infarction four months postoperatively. However, this patient did not reduce any of his risk factors. At postoperative angiography 32 out of 40 grafts performed, i.e. 2.13 grafts per patient, were patent. In 9 patients all grafts were patent, in 4 over 51% of the grafts performed were patent, in 1 two out of four were patent and one single-bypass was subtotally occluded. The angina-free working tolerance increased postoperatively by 70 Watts, i.e, by 100%. These preliminary results with 15 patients under age 35 show that satisfactory medical and professional rehabilitation can be achieved with coronary artery surgery. All but one returned to work as they would otherwise have been unable to do because of disabling angina under maximal medical therapy.