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Heart foundations in Europe fulfill many roles in their work to prevent cardiovascular diseases. They fund a great deal of research, they provide information to the general public on healthy lifestyles, and they undertake educational programs in specific settings targeting selected audiences. An important role for many heart foundations is to lend support to cardiovascular patients and their families. [ABSTRACT FROM AUTHOR]

Cognitive behavioral (CB) disease management programs were developed to help people with chronic back pain and have an extensive evidence base in that role. The same methods are now being adapted for use in other chronic illnesses.1 Using the example of angina, this chapter will explain how these techniques can be applied in cardiac rehabilitation (CR) and concludes with a brief description of such a program. [ABSTRACT FROM AUTHOR]

It is often expected that among seriously ill patients sexuality is not important. However, satisfaction with sexual functioning is recognized as a component that influences quality of life. Studies show that patients who are chronically or critically ill are concerned about sexual dysfunction. Sexual function has been studied in some chronic disease states, especially in diabetes, cancer, spinal cord injury, and some cardiac diseases. For example, sexual function in patients after myocardial infarction (MI) or after coronary artery bypass grafting (CABG) has been studied since the 1970s and 1980s. More recently sexual function in patients with heart transplantation or heart failure has been studied. It is known that there are many important links between sexual activity and heart disease: Heart disease can result in both reduced sexual activity and increase sexual dysfunction, for example due to fear or symptoms.Heart disease and erectile dysfunction share important risk factors such as diabetes and hypertension.Sexual activity, like all forms of exertion and/or stress, may trigger cardiac symptoms.Medications used to treat heart disease may impair sexual function.Drugs that are used to treat sexual dysfunction may have serious interactions with medications used to treat heart disease. [ABSTRACT FROM AUTHOR]

Is healthcare service "A"more cost-effective than the alternative service "B" which, most frequently, is usual care?What is the cost impact for the healthcare system if service "A" is substituted for service "B"? [ABSTRACT FROM AUTHOR]

Comprehensive cardiac rehabilitation (CR) is defined as: "The sum of activities required to ensure the best possible physical, mental and social conditions, so that the cardiac patient may resume as normal a place as possible in the life of the community."1 This implies the use of an individually tailored combination of physiological, clinical, psychological and social methods. Measuring the outcome of a multifaceted intervention is a methodological and logistical challenge. At present quality assurance of CR is relatively uncommon even though guidelines recommend that data are routinely collected and presented.2 Thus, as CR programs must compete for resources with other healthcare modalities, caregivers will increasingly demand auditing of the service. [ABSTRACT FROM AUTHOR]

Comprehensive cardiac rehabilitation (CR) is beneficial for a wide variety of coronary patients: after a myocardial infarction (MI), following percutaneous transluminal coronary angioplasty (PCI), coronary artery bypass grafting (CABG), implantable cardiac defibrillators, cardiac rhythm surgery and ablation techniques, stable angina pectoris, and chronic heart failure.1,2 Yet in several countries CR is underused due to multiple factors, not least the unsatisfactory referral practices. [ABSTRACT FROM AUTHOR]

Although there is substantial scientific evidence that professional lifestyle intervention on smoking, diet and physical activity, together with control of blood pressure, cholesterol and glycemia, and selective use of cardioprotective drug therapies can reduce cardiovascular morbidity and mortality, the translation of that evidence into everyday clinical practice remains a challenge. The joint European Societies guidelines on prevention of cardiovascular disease (CVD) define priorities for preventive cardiology in clinical practice, thresholds for treatment, and treatment goals.1 The priorities are firstly patients with established atherosclerotic cardiovascular disease; coronary disease, and all other manifestations of atherosclerosis. The second priority is apparently healthy individuals in the general population who are at high risk of developing CVD because of hypertension, dyslipidemia, diabetes, or a combination of these and other risk factors. [ABSTRACT FROM AUTHOR]

The provision of multifactorial cardiac rehabilitation and secondary prevention strategies requires a range of skills and knowledge which, while understood by cardiologists, are delivered only in part by them. The role of the cardiologist in the initiation of cardiac rehabilitation programs is self-evident. As patient advisors, cardiologists are in an ideal position to recommend the benefits of cardiac rehabilitation to the individual patient. They are also in a prime position within the health services and individual medical institutions to espouse the establishment and appropriate financial support of such services. [ABSTRACT FROM AUTHOR]

In a comprehensive cardiac rehabilitation program, the different forms of physical training may put patients at risk, although a review of the literature has shown that cardiac or orthopedic events rarely occur. This may be further limited through adequate safety precautions. The risk is fully outweighed by the benefits of participation, independent of the indication for enrollment: after myocardial infarction (MI), percutaneous coronary intervention, coronary artery bypass grafting, in patients with chronic heart failure or in patients with implantable cardioversion devices (ICD).1-3 [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation (CR) programs were first developed in the 1960s when the benefits of ambulation during prolonged hospitalization for coronary events had been documented. Exercise was the primary component of these programs. They were predominantly offered to survivors of uncomplicated myocardial infarction and initiated at a time remote from the acute event. Concern about the safety of unsupervised exercise after discharge led to the development of highly structured rehabilitation programs that were supervised by physicians and included electrocardiographic monitoring. The safety and benefits of moderate-intensity exercise training programs were intensively investigated in supervised programs. More recent data clearly indicate that unsupervised or home-based programs are also safe and effective in appropriately selected patients.1-11 [ABSTRACT FROM AUTHOR]

Recent European guidelines for cardiovascular disease (CVD) prevention in clinical practice recommend the use of preventive strategies based on the identification of individuals at high absolute risk for CVD.1 To identify high-risk individuals these guidelines have chosen the Systematic Coronary Risk Evaluation (SCORE) risk model as a tool in clinical practice.2 Lipidlowering drugs are recommended in individuals with a 10-year risk of fatal CVD of ≥5%. These guidelines should be adapted to reflect practical, economic, and medical circumstances in each country. [ABSTRACT FROM AUTHOR]

Healthcare systems throughout Europe are feeling the strain due to the ever increasing demands made upon them to provide treatments and solutions for many cardiovascular related diseases (CV). The corporate setting provides an ideal location for delivering both cardiac rehabilitation and preventative strategies that can help combat the ever increasing burden that cardiovascular illness is placing upon society.1 [ABSTRACT FROM AUTHOR]

The term claudication is derived from the Latin word claudicatio, translated as "to limp." In vascular disease nomenclature, claudication describes the symptom of exercise-induced muscle ischemia, most commonly due to peripheral artery disease (PAD). The patient with intermittent claudication typically describes leg pain that is caused and reliably reproduced by a certain degree of exertion. The pain is sufficiently intense to stop the activity and is promptly relieved by rest, usually within minutes. A given degree of exercise, commonly measured in pain-free distance able to walk, consistently reproduces symptoms. The Fontaine stages are commonly used to rate symptom severity (Table 51-1). [ABSTRACT FROM AUTHOR]

Implantable devices were introduced as life-saving equipment for millions of people suffering from coronary heart disease. Nowadays, not only traditional antiarrhythmic pharmacological therapy has been shown to decrease sudden cardiac death, but also pacemakers and cardioverter defibrillators have proved their value in the treatment of life-threatening rhythm disorders. In heart failure, cardiac resynchronisation therapy (CRT) and assist devices have recently demonstrated their importance,but no published data regarding physical exercise or training are available yet. This chapter will mainly deal with physical exercise and rehabilitation in patients who have received an implantable cardioverter defibrillator. Cardiac rehabilitation in patients with assist devices or pacemakers will be discussed only briefly. [ABSTRACT FROM AUTHOR]

Heart transplantation has been performed as definitive therapy for endstage heart failure since the early 1980s. According to the international registry the annual number of patients is probably well over 4000 worldwide. Any special rehabilitation program for this group will depend on sufficient local concentration of heart transplant recipients (HTRs). Since 60% of all patients are reported from centers with less than 30 patients per year, going without any formal rehabilitation is a reality for many. 1 On the other hand, one can hardly imagine a group of patients that is so obviously in need of rehabilitation because of the multifaceted physical and mental problems to be encountered pre- and postoperatively. [ABSTRACT FROM AUTHOR]

Chronic conditions are now the leading reason why people seek medical care.1 The syndrome of heart failure (HF) is the final pathway for myriad diseases that affect the heart, and is a salient example of the challenge posed by chronic disease. Although the understanding of chronic HF pathophysiology has changed and therapeutic paradigms have been revolutionized, 2 a considerable burden of disability and unrelieved symptoms remains in optimally treated patients, with corresponding low quality of life, and poor prognosis which is worse than for many forms of cancer.3 In addition, the existence of multiple medical co-morbid conditions, an aging population, potential interaction among multiple medications and psychological impact combine to aggravate the complexity of HF management. Thus, HF is a chronic, costly, and life-threatening disorder, and the need for adequate management strategies is clear. [ABSTRACT FROM AUTHOR]

The number of older people is growing rapidly worldwide. Today, more than 580 million people are older than 60 years and the number is projected to rise to 1000 million by 2020. The proportion of the population over 80 years, the so-called "old-old," is increasing most rapidly. Life expectancy at all ages is also increasing. At 65 years, life expectancy ranges from 14.9 to 18.9 years and at 80 years from 6.9 to 9.1 years for men and women, respectively.With the increase in life expectancy, the leading causes of death have shifted dramatically from infectious diseases to non-communicable diseases. Cardiovascular disease is the most frequent single cause of death in persons over 65 years of age, and most importantly it is responsible for considerable morbidity and a large burden of disease, particularly in the community.1 [ABSTRACT FROM AUTHOR]

Congenital malformations of the heart and vessels occur in 5-8 per 1000 live births, resulting in an incidence of approximately 0.7%.1, 2 Some of these malformations (10-15%) do not require correction. Between 70% and 80% of defects can be corrected, and an increasing number of therapeutic procedures can be performed by interventional catheterization techniques, avoiding the need for open heart surgery.3 Definitive therapeutic procedures are increasingly carried out in early infancy, to avoid long-term complications resulting from the hemodynamic burden, or from chronic cyanosis. With improved techniques and experience, procedure-related mortality has been substantially lowered.4 In 2002, a total of 27,772 operations for the treatment of CHD were performed in Europe. Germany leads this statistic with 5868 operations for congenital heart defects in 2003; 4415 of those were performed using a heart-lung machine. [ABSTRACT FROM AUTHOR]

This is the story of a 37-year-old woman in her own words. She had no other cardiovascular risk factors than a history of smoking and being 3 months in the postpartum period. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a common disease in the population and it is clearly recognized that patients with diabetes have an increased risk for coronary heart disease. Indeed, several studies have shown that diabetic subjects have a two to four times greater risk of developing and dying from coronary heart disease than non-diabetic persons.1-3 [ABSTRACT FROM AUTHOR]

In many industrialized countries, the percentage of the population that is elderly is rising;more people are surviving with conditions that in the past were fatal, and obesity and a sedentary lifestyle are still increasing.As a result, the number of people living with a chronic illness is also rising rapidly. For example, in the UK the proportion of people living with a chronic condition has risen from 21% in 1972 to 35% in 2002; 17% of those with a chronic condition have a cardiovascular illness or hypertension. Approximately 25% have three or more chronic health problems. The healthcare systems designed over the 20th century faced different challenges, initially to eradicate and then to control infectious disease and also to manage acute events. There was less attention given to prevention and rehabilitation, and services are not well suited to caring for a large number of people living, often for decades, with a high level of disability or complex disease management regimes. [ABSTRACT FROM AUTHOR]

In the meta-analysis on cardiac rehabilitation (CR) after myocardial infarction published by Oldridge and coworkers,1 a reduction rate of 24% in all-cause death was found for CR as a whole. The rate was larger for programs with a duration of 36 or more months, where a 38% all-cause death reduction was found, higher than the reduction by programs below 12 weeks (8%) or between 12 and 52 weeks (24%). 52 weeks (24%). [ABSTRACT FROM AUTHOR]

One of the objectives of coronary interventions is to enable patients to return to work. This is also one of the aims of the cardiac rehabilitation programs offered to these patients. The inability to resume professional activities after coronary interventions may constitute a stress (and therefore a risk factor) for the patient due to a loss of self-esteem and earnings. [ABSTRACT FROM AUTHOR]

One of the main goals of a cardiac rehabilitation (CR) program is to support the patient in returning to work: strong economic and quality of life arguments exist. It has been stated that patients after an acute myocardial infarction (MI) without complications such as left ventricular dysfunction or exercise-induced myocardial ischemia may safely resume their previous work: for light office work 2 weeks of sickness absence are recommended, for average manual work 3 weeks, and for strenuous physical work 6 weeks. Thus, a majority of MI patients may well return to work (RTW) within the first month after discharge from hospital, as almost all industrial and other jobs require significantly less effort than the average maximum work capacity of a healthy population: only 25% is generally demanded for the modern workplace. [ABSTRACT FROM AUTHOR]

There are a large number of studies demonstrating that physical activity reduces cardiovascular morbidity and mortality. Some studies are on physical activity during work, some on leisure-time activity and some on a combination of the two. [ABSTRACT FROM AUTHOR]

Heart failure is a serious condition. More than two-thirds of individuals with moderate to severe systolic dysfunction are hospitalized yearly and one out of three die within one year after hospitalization. The heart failure group consumes >2% of the total healthcare costs and the main costs are due to hospitalizations.1,2 [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation services have developed worldwide over the last few decades. The World Health Organization definitions of cardiac rehabilitation of 1969 and 1993 outlined what was required of a cardiac rehabilitation service for patients with coronary heart disease. However, as might be expected, different countries and health provision services developed different styles of programs in response to local funding, available staff, and patient profiles. As a result of this, many international bodies developed their own guidelines and policies for the provision of cardiac rehabilitation.1-4 The CARINEX survey of current guidelines and practices within the European Union5 identified 20 professional guidelines since 1990, in nine languages across Europe alone. Twelve separate countries had national guidelines. [ABSTRACT FROM AUTHOR]

The WHO1 defines adherence as "the extent to which a person's behaviour — taking medication, following a diet, and/o r executing lifestyle changes, corresponds with agreed recommendations from a health care provider" (p. 3). There are numerous ways in which behavior may not correspond with recommendations: non-adherence comprises behaviors such as not commencing performance of a recommended behavior (e.g. not exercising), cessation of a behavior too soon (e.g. stopping medication prematurely), no t performing enough of the behavior (e.g. taking insufficient exercise to gain a benefit), and inconsistently performing the behavior (e.g. taking some medications some of the time). A distinction is made between intentional and unintentional nonadherent behaviors. [ABSTRACT FROM AUTHOR]

Early models of stress considered it to arise from our environment, and to impact on us all equally. Holmes and Rahe1 established a hierarchy of severity for various stressors. They also attempted to provide a link between stress and health, suggesting that the more stressful life events an individual experiences, the more their risk of ill-health. Unfortunately, this hypothesis was rarely substantiated. What has emerged from subsequent research is that the impact of potentially stressful events is mediated by our psychological responses to those events. The meaning attributed to events, and the coping responses we use, profoundly influence our emotional and behavioral responses to them. Accordingly, more recent models of stress consider stress to have a number of components: a cognitive response ("I am worried I won't cope with this problem"), a physiological component usually involving increased autonomic arousal, a behavioral element involving more or less useful coping responses, and an emotional experience involving a variety of negative emotional states such as anger or anxiety (Figure 34-1). [ABSTRACT FROM AUTHOR]

Which conclusions can be drawn from these clinical observations? One key message is that educating patients and spouses with the purpose of optimizing rehabilitation and secondary prevention is not just a matter of informing about facts. It is a process where professional caregivers must be sensitive to the social and emotional reality of the patient and spouse. Caregivers must also be very aware of the communicative interplay and the fact that both patient and spouse cognitions and interpretations may be very different from those of the professional. To health professionals, cardiological and surgical procedures are relatively routine aspects of their daily work. However, these procedures are not routine to the patient and his or her family — to them, it is a profoundly life-changing experience, and emotionally and spiritually a brush with death. [ABSTRACT FROM AUTHOR]

The search for psychological factors involved in the development and/or progression of coronary heart disease (CHD) has been a fairly persistent, although not always fruitful, activity over the last few decades. Both the clinical observation that CHD patients seem to exhibit certain psychological profiles and the apparent failure of traditional risk factors, such as smoking, high blood pressure and cholesterol, and low levels of physical exertion, to predict anywhere near all new instances of CHD have helped fuel an expectation that there may be other, psychological, predisposing factors at work. [ABSTRACT FROM AUTHOR]

Increased longevity and the development of sophisticated healthcare technologies and treatments mean that many people now live with chronic health conditions such as cardiovascular disease over extended periods of their lives. In this context, health-related quality of life (HRQoL) has become an important endpoint in evaluations of health interventions. Its use reflects an increasingly biopsychosocial perspective in modern healthcare. HRQoL research first developed in cancer settings where the balance of quality and duration of life became a key concern in decisions to use novel treatments with very serious side-effects and only partial efficacy. However, over the past 20 years there has been a burgeoning of research activity in every major chronic illness category. In cancer, the European Organisation for Research on the Treatment of Cancer (EORTC) has been established by interested professionals.1 [ABSTRACT FROM AUTHOR]

According to popular opinion, stress is one of the most important risk factors for coronary heart disease (CHD). This view has not, however, so far been altogether accepted by the medical profession. However, accumulating evidence does demonstrate that it is likely that stress and other psychosocial factors are causally related to CHD, and possibly to stroke. Other than stress, some of the psychosocial factors that have been investigated in relation to CHD include socioeconomic factors, social support, adverse life events, personality factors, perceived control, anxiety, and depression. [ABSTRACT FROM AUTHOR]

When stopping smoking, the patient deals on the one hand with physical and on the other hand with psychosocial withdrawal, in other words getting out of smoking behavior. The patient has to learn how to deal with smoking needs and has to change habit patterns and to replace the function of smoking by, for example, learning to relax and deal with stress without cigarettes. [ABSTRACT FROM AUTHOR]

Most smokers do want to quit smoking. That this is not always an easy task can be attributed to the fact that dependence plays an important role. Nicotine dependence meets all criteria of addiction. The use is compulsive, it is hard to quit even when there is clear damage, withdrawal symptoms appear when stopping, and there is always a risk of falling back when trying to quit a chronic behavior. Smoking dependence fits the criteria given in the Diagnostic and Statistical Manual of Mental Disorders system, version IV (DSM IV),1 grading dependence and addiction to a substance (Table 28-1). [ABSTRACT FROM AUTHOR]

According to the World Health Organization (WHO) the number of smokers in the world was estimated to be 1. 1 billion in the year 2000. Of those, 300 million lived in the developed world, while 800 million lived in developing countries. [ABSTRACT FROM AUTHOR]

Hippocrates' famous aphorism "we are what we eat" is more than ever pertinent at the present time. Indeed, strong scientific evidence has demonstrated that dietary patterns are important determinants of health status, especially concerning the cardiovascular system. However, nutrition must be considered not only as an energetic source, but must be integrated with its other components: culture, beliefs, tradition, and pleasure. This complexity explains why behavioral modifications in nutrition are so difficult to promote and sustain in subjects, often needing deep changes in the ways of being and thinking. Moreover, as cardiovascular prevention is multifactorial, healthy food choices must often be associated with other behavioral modifications, such as smoking cessation or physical exercise, so our main task will be to help patients to cope with all these recommendations. [ABSTRACT FROM AUTHOR]

An alarming rise in overweight and obesity is occurring worldwide.1,2 Obesity is more common than cardiovascular disease, diabetes, and cancer combined, and may be a leading cause of these three disorders and numerous other morbid states. Despite some advances in research into genetic, metabolic, behavioral, psychological, and environmental factors, children, adolescents, and adults are continuing to become overweight and obese in increasing numbers. In the United States, the Centers for Disease Control and Prevention report a doubling of the obese population in the period between 1976-1980 and 2001-2003. Currently, in this country, nearly two-thirds of adults are overweight, nearly onethird are obese, and almost 5% are extremely obese. Especially impressive is the progression of overweight and obesity in children and adolescents. [ABSTRACT FROM AUTHOR]

Active prevention of coronary heart disease (CHD) is usually started immediately after the first clinical manifestation of CHD. Secondary prevention should primarily focus on the risk of death. The two main causes of death in these patients are sudden cardiac death (SCD) and heart failure (HF), often resulting from myocardial ischemia and subsequent necrosis. In that context, it is crucial to understand that our populations are chronically and severely deficient in some major nutrients, in particular omega-3 fatty acids (n-3 PUFA). Actually, consumption of n-3 PUFA is inversely correlated with the risk of SCD, the main cause of death in CHD patients. On the other hand, the main mechanism underlying recurrent cardiac events is myocardial ischemia resulting from atherosclerotic plaque rupture or ulceration. [ABSTRACT FROM AUTHOR]

Exercise training is the core component of cardiac rehabilitation in patients with coronary artery disease (CAD) and the positive effects have been studied extensively (see Chapter 17).1-5 Markedly less information is available concerning the results of exercise training in patients with valvular heart disease (VHD). This is mainly due to the fact that patients with native VHD have rarely been considered candidates for exercise training. In the guidelines on the management of patients with VHD no comments are made on this topic in patients with native VHD or after valve surgery.6 In the new recommendation by the working group on valvular heart disease of the European Society of Cardiology suggestions for exercise training after valve surgery are outlined.7 [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation increases fitness and quality of life and should therefore be offered to all patients after acute cardiac events and interventions. After a rehabilitation program of 4-8 weeks further physical activity is important, and usually previous sports can be taken up at some level. In most cases this will be recreational sports, but sometimes also recommendations for competitive sports are needed after a cardiac event or diagnosis of a cardiac disorder. [ABSTRACT FROM AUTHOR]

We are all on a trajectory to heart disease. It's called age. (J. N. Cohn, University of Minneapolis, at the Annual Scientific Meeting of the Heart Failure Society of America, Toronto, Canada, 2004) [ABSTRACT FROM AUTHOR]

Diabetes mellitus type 2 is one of the most common diseases in industrialized countries and is one of the main risk factors for the development of micro- and macrovascular diseases. Vascular complications are causes of death in up to 80% of these patients and 75% of deaths are due to coronary artery disease.1,2 [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is a chronic disorder with a natural history that spans multiple decades. In each affected individual, the disease can go over to a number of well-defined clinical phases: asymptomatic, stable angina, progressive angina, unstable angina, and acute myocardial infarction. Therefore, the approach to diagnosis and risk stratification of the coronary disease patient varies according to the phase of the disease in which the patient presents. [ABSTRACT FROM AUTHOR]