His postinfarct course was uncomplicated and
he entered the program 4 months later, at
which time his blood pressure was 110/75 mm
Hg and pulse rate 64 per minute. He has
participated for 15 months, during which time
he has been hospitalized twice, once for acute
renal colic and the second time for the removal
of a benign breast mass. His cardiovascular
status was stable.

Case 7. C. D., 48-year-old truck driver, had
an inferoseptal myocardial infarction while
repairing a flat tire. His course was compli-
cated by symptoms of congestive ‘heart failure,
following which he was digitalized. He was
referred to the program 3 months later. Initially
his blood pressure was 140/100 mm Hg and pulse
rate 76 per minute. He participated irregularly
for 1 year before discontinuing the program com-
pletely. Symptomatically, he did quite well. He
has not been rehospitalized, and he has returned
to work as a garage mechanic.

Case 8. H. B. was a 61-year-old postal em-
ployee who had an anteroseptal and anterolateral
myocardial infarction 5 years prior to initiating
physical conditioning. His clinical course had
been complicated by exertional dyspnea. During
the first evaluation, his blood pressure was 140/
90 mm Hg and pulse rate 76 per minute. He was
severely dyspneic at an oxygen demand three
times that of rest. Three months later he had
improved and performed the entire work-capacity
test satisfactorily. He discontinued the program
3 months later, however, when he became de-
pressed over the death of a friend.

Case 9. C. Y. was a 50-year-old insurance
salesman when he had a myocardial infarction.
Five months later, he had second myocardial in-
farction with extension anterolaterally. He re-
covered satisfactorily, and 7 months later he was
referred to the conditioning progrdm by his
physician. He has been a cautious, but regular
participant without any cardiovascular complica-
tions for 15 months.

Case 10. U. R., civil-service engineer, was 63
years old when he had a posterior myocardial
infarction. His therapy included 4 months of
almost total bedrest, anticoagulation, and digital-
ization. He volunteered for the conditioning
program 6 months postinfarct because he wanted
to regain his flying status. The initial evaluation
revealed a small, thin white man with a blood
pressure of 170/70 mm Hg and a pulse rate of

64 per minute. He had evidence of left-ventricu-
lar hypertrophy. He has participated in the

program regularly for 13 months even though he .

was retired from the civil-service job. His car-
diocascular status was uncomplicated.

Case 11. R. G. was a 87-year-old civil serv-
ice employee when he had an anteroseptal
and anterolateral myocardial infarction. His
postinfarct course was uncomplicated, and he was
referred to the program.3 months later, at which
time his blood pressure was 130/75 mm Hg and
pulse rate 68 per minute. He conditioned regu-
larly for 8 month periods, which were alternated
with 3 months of sedentary living. This regimen
was necessitated because he worked a swing-shift.
His clinical course was uneventful. :

Case 12. W. S., age 58 years, was referred to
the program after suffering an anterolateral and
a high lateral myocardial infarction 11 months
earlier. He was obese and had not performed
any formal exercise since adolescence. His at-
tendance was sporadic, and he often discontinued
exercise early complaining of muscular soreness.
He occasionally had episodes of left-shoulder
pain following pain following exercise that were
not relieved by nitroglycerin and during which
no electrocardiographic alterations were detected.
He was chronically depressed and was treated

with pharmacologic preparations for these symp- ~~
toms. He committed suicide 6 months after

entering the program.

Case 18. 1. G., a 48-year-old oil-company
executive, had been an outstanding college and
professional football player who assumed a
sedentary living pattern after retiring as a pro-
fessional athlete. He suffered his first posterior
myocardial infarction at 41 years of age. Eleven
months later he suffered a posteralaterol myocar-
dial infarction. His course following both epi-
sodes was uneventful. He entered the program 5
months after suffering the second myocardial in-
farction, at which time his blood pressure was
165/100 mm Hg and pulse rate 72 per minute.
He was an exacting, competitive, and vigorous
participant. The results of his second evaluation
indicated that he was improving physiologically ;
however, 12 months after suffering his second
infarction he died suddenly during a postexercise
recovery period. Post mortem examination was

not performed, and his death was attributed to-

an acute myocardial infarction.



Taste 4, Ten patients have discontinued their conditioning program for a variety of reasons.

Patient

re]
we

Haperghors
ny Olnwyra

cause he was depressed. The first death occurred
suddenly in T. B, 7 weeks after he discontinued
the program; the second was a suicide (W. 8S.) ;
and the third patient (L. G.) died suddenly
while he was still an active participant. The
two sudden deaths were attributed to acute myo-
cardial infarctions. Unfortunately, post mortem
examinations were not performed.

The attendance varied from 38% by W. S. to
98% for R. C. The average attendance was 76%.

Three of the patients have been rehospital-
ized five times. R. C. was hospitalized for 1
week following his syncopal episode, during
which his ECG and serum enzyme determina-
tions were normal. L. P. was hospitalized twice
for short intervals for treatment of acute peptic
esophagitis, A. B. was hospitalized once for
acute renal colic and once for surgical excision
of a benign breast mass.

Nineteen of the twenty patients returned to
full-time employment. One patient T. B., was
an unskiled laborer who could not find new
employment. U. R. was eventually retired from
the civil service because of age and service. At
least two of the subjects have returned to jobs
that were more physically demanding than those
they held prior to the onset of the illness.

V. Discussion.
This study was designed so that cardiac pa-

tients could be evaluated over an extended.

period of time under relatively controlled con-
ditions in an attempt to assess the effects of
regular physical conditioning on their clinical
courses. These patients have been matched for
age with another group of sedentary cardiacs
so that their long-term clinical courses can be
compared, The approach used in this study has
several advantages. The oxygen requirements
for the work-capacity test can be quantitated

Reasons for discontinuing
program
Moved
Job conflict
Moved
Job conflict
Depression
Suicide
Sudden death
Joint pain
Moved
Supervisor's request

enabling the investigator to compare the
intraindividual and interindividual observations
over time. The amount of energy expenditure re-
quired in performing the activity program can
be estimated. or quantitated, and an assessment
can be made of the minimal amount of condi-
tioning necessary to produce a desired physio-
logic response. The program serves as a source
of motivation and initiative for the patients to
condition themselves.

Even though it is too early to arrive at any
definite conclusions concerning the role of physi-
cal conditioning for the nonsyptomatic cardiac
patient, several interesting observations have
been recorded. Many patients who recover from
myocardial infarctions are sufficiently motivated
to enter a long-term physical-conditioning pro-
gram. The incidence of complications has been
relatively low during the first 2 years. Although
all the patients reported a subjective feeling of
improvement and benefit, it is likely that physical
conditioning may not benefit every nonsympto-
matic cardiac patient. The ability to develop
improved cardiopulmonary efficiency through
conditioning is probably limited by the severity
of the underlying atherosclerotic process and by
the ability to develop interarterial coronary
anastamoses and collateral circulation. It is
anticipated that with further experience the pat-
tern of the physiologic response recorded during
the work-capacity test will make it possible to
distinguish between subjects who might be, versus
those who might not be, physically conditioned.

VI. Summary.

Twenty men who have recovered from well-
documented episodes of myocardial infarction
have participated in a physical conditioning
program for 8 months or longer. Their


fering an anteroseptal myocardial infarction.
His initial blood pressure was 145/100 mm Hg
and pulse rate 88 per minute. His clinical course
has been uncomplicated, and he has participated
regularly for 8 months,

IV. Results.
The patients ranged from 37 to 68 years of

age with a mean age of 47.2 (Table 1). Their
weight varied from 61.7 to’100.0 kg with a mean
myocardial ‘infarctions; three had histories of
of 75.3 kg. ‘Two patients had’ suffered two
angina pectoris;and three had been digitalized
(Table 2). Thirteen patients were on long-term
anticoagulant therapy. .

‘Taste 2. Two patients had two documented episodes of myocardial infarction. Three meh had histories of angina
pectoris, while one patient’s history was equivocal. Three were on a digitalis preparation and thirteen were

anticoagulated.
No.
documented

Patient infarcts

R. CG.

PRN aPp rang raororpgron
PRB wyorna,SPNHRUN ona
HEE EER DH RRR

History of
angina pectoris

Digitalis Anticoagulated

ll+t

| i
petet abbr tee tet rr di

SEL bee etree tei tts

[++

‘Taste 8, All patients had electrocardiographic evidenceof myocardial infarction, Additional abnormalities during
exercise testing were recorded in three patients.

Area of infarction

by eléctrocardiogram
Inferoseptal and lateral
Inferoseptal
Anteroseptal and anterolateral
with peri-infarction block
Posterior ;
Inferoseptal
Inferoseptal
Inferoseptal
Anteroseptal and anterolateral
Anteroseptal and anterolateral
Posterior
Anteroseptal
Anterolateral and high lateral
Posterior and posterolateral
Anteroseptal and anterolateral
Inferoseptal
Anteroseptal and anterolateral
Anteroseptal
Anteroseptal and anterolateral
Inferoseptal
Anteroseptal

Be
os

gH
ar

Piwaprorapconop gs
OnByoOhRPnont aoa

Additional ECG changes
during exercise or recovery
Ventricular extrasystoles
None
None
None
None
None
Intermittent
complete LBBB
None
None
None
None
None .
“Infarct PVC”
None
None
None
None
None
None
None



Case 14. G. H. was a 47-year old Army re-
serve employee with diabetes mellitus when he
suffured an anteroseptal myocardial infarction.
His hospital course was uneventful. Upon enter-
ing the program 8 months later, his blood pres-
sure was 130/85 mm Hg and pulse rate 96 per
minute. He participated regularly for 7 months
without complications before taking a leave of
absence for the summer months.

Case 15. 1. J., an aircraft inspector, had an
inferoseptal myocardial infarction at age 39
years. He entered the program 5-14 months
later, at which time his blood pressure was 150/
100 mm Hg and pulse rate 80 per minute. He
has participated regularly for 8 months without
any further complications or hospitalizations.

Case 16. A. O. was 47 when he entered the
program. He had episodes of myocardial in-
ferction at 41 and 43 years of age from which
he recovered uneventfully. He was a large man
with blood pressure of 130/90 mm Hg and a
pulse rate of 72 per minute when evaluated
initially. His standard electrocardiogram re-
vealed evidence of an old anteroseptal and
anterolateral myocardial infarction. He partici-
pated in the program for 3 months before dis-
continuing, complaining of severe aching ankles
and knees. He has continued to golf and to
hunt since that time.

Case 17, W. E. was a 48-year old electric
company employee who volunteered for the pro-
gram 4 months after suffering an anterolateral
myocardial infarction. He left the program
after 8 months of conditioning because he was
transferred to another plant.

Case 18. P, E, was 44 years old when he
entered the program. He had an anteroseptal,
anterolateral myocardial infarction at age 42
years. Before initiating the conditioning pro-
gram, his blood pressure was 170/120 mm Hg
and pulse rate 64 per minute. He had a history
of frequent bouts of chest pain that were relieved
by nitroglycerin. Similar episodes did not occur,
however, either during the exercise test or dur-
ing the regular exercise sessions. He has par-
ticipated regularly for 4 months.

Case 19. H.S., a 51-year-old civil-service elec-
trician with a 25-year history of high blood
pressure, had an inferosptal myocardial infare-
tion 3 years prior to initiating physical condi-
tioning. He participated vigorously each day for
6 months before his supervisor made him dis-
continue the program. The patient has had no
further cariovascular complications and has re-
sumed his sedentary living habits.

Case 20. 1. C. was a 41-year-old office worker
who entered the program 13 months after suf-

Taste. 1, The patients ranged in age from 87 to 68 years with a mean age of 47.2 years. The time interval
from suffering the myocardial infarction to beginning of conditioning varied from 2 to 48 months with a
mean of 12.6 months. The mean duration of conditioning was 8.8 months.

Patient Age (yr) Weight (Kg)
RC. 54 86.3
T. B 48 69.0
D.C. 43 83.6
LP. 44 64.1
Ww. G 41 70.0
A. B. 48 64.1
C.D. 43 81.8
HB. 61 72.0
©. ¥. 50 68.6
U. R. 63 61.7
R. G. 387 90.9
w. Ss. 58 86.3
L. G. 43 86.5,
G. A 4T 66.8
LJ. 39 76.8
ALO. aT 100.0
W. EL 43 5.9
Pp. EL 44 78.2
HS. 51 78.6
Lc 41 65.9

Interval (months) from Months

infact to onset of in
Height (cm) conditioning program
178.5 2 24
172.5 3 4
182.9 44 6
180.3 7 5
172.0 3 16
172.7 4 15
170.2 4 2
177.8 48 7
162.5 6 14
167.6 8 13
172.7 4 12
172.7 i 6
190.5 5 6
167.6 4 7
180.3 6 7
187.9 35 3
172.7 3 3
175.8 17 4
169.2 26 6
177.8 13 7


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L.G. 43 wm

PVC

Frevre 2. The oblique-lead ECG was compatible with a moderately recent inferoseptal myocardial infarction.
In the June 2, 1964, evaluation, the patient maintained a similar ECG complex without any alterations in the
rhythm during the test. Immediately after exercise, he developed a widened QRS interval with depression of
the ST-junction and inversion of the T-wave. This was interpreted as a complete left-bundle branch block
and as representing a possible ischemic response. The abnormality persisted for 47 seconds before his normal
ECG pattern returned. In February, 1965, the QRS interval was normal at rest. On standing, a complete
LBBB configuration developed and persisted throughout exercise and during the first 2 minutes of recovery.
Later, the normal QRS configuration returned, and it was observed that the complete LBBB complex could
be induced by the patient tilting his head forward while he was supine. .

The time interval from the date of myocardial
infarction to the onset of physical conditioning
varied widely (Table 1). One patient (R. C.)
began a program of gradually increased daily
activity 9 weeks postinfarct, while there was an
interval of at least 3 years in three of the
patients (D. C., A. O., and H. B.). The re-
maining 16 patients entered the program from
3 to 13 months after infarction.

All the subjects performed the exercise test
without experiencing angina pectoris. The most
common reasons for terminating testing were
dyspnea and fatigue. In addition, nnoe of these
men have experienced angina while participat-
ing in the exercising sessions. One patient:
(R. C.) once ingested three nitroglycerin tablets
during the hour prior to exercising. He had a
syncopal episode following exercise. This episode
was attributed to vasodilatation with pooling of
blood that was potentiated by a combination of
drug therapy and exercise.

Very few additional clectrocariographic ab-
normalities were recorded during exercise in the
group (Table 3). Two subjects did have ventri-
cular extrasystoles, one of which was character-
istic of an “infarct ventricular extrasystole” 9

(Figure 1). One patient had anepisode of in-
termittent complete left-bundle branch block that
followed exercise on one occasion and that was
associated with postural changes on another o¢-
casion (Figure 2).

The anticoagulated patients did not experience
any episodes of hemorrhage or bruising during
participation in the program.- One patient
(L. G.) did sprain his ankles easily but he. did
not have any hemarthroses. .

All the patients performed work-capacity tests
without complications. The mean exercise time
before physical conditioning was 12 minutes at
an energy demand approximately 5 times the
work of rest. Two patients did not. complete
the entire 18-minute test after 3 months of condi-
tioning while the remaining 18 did.

The original volunteer has participated for
2 years. Ten patients remained in the pro-
gram in excess of 4 months. Of those pati-
ents who have discontinued physical condition-
ing (Table 4), four moved to other communities;
one discontinued at the request of his super-
visor; one took a 3-month leave of absence be-
cause of family committments; and three have
died. One patient terminated conditioning be-

\-l



_AM 66-21 |

CLINICAL AVIATION MEDICINE:

A Physical-Conditioning Program for Cardiac Patients—A Progress Report

John Naughton, M.D.
Michael T. Lategola, Ph.D.
Kamal Shanbour, B.S.

Released by Approved by
Bld Pith [USdge 0
J. Ropert Drute, M.D. P.V. Srmcex, M.D.
Cuer, Civin, AEROMEDICAL Fenrrat Arr Surceon

InstiTUTE

June 1966

FEDERAL AVIATION AGENCY
Office of Aviation Medicine





physiologic adjustments were evaluated with a
work-capacity test before and periodically dur-
ing the program. One patient has’ participated
regularly for 2 years and has been demonstrated
to have a higher peak-oxygen intake after con-
ditioning than he possessed before suffering a

myocardial infarction. Three patients have been
rehospitalized a total of five times for minor
problems. Nineteen patients returned to full-
time employment. Three patients have died,
two of recurrent myocardial infarctions and one
of suicide.

REFERENCES

1, Morris, J. N., Heapy, J. A., Rorrte, P.A.B., Roserrs,
©. G., and Parks, S. W.: Coronary Heath Disease and
Physical Activity of Work Lancet 2:1058, 1111, 1953.

2, Moris, J. N., and Crawrorp, M. C.: Coronary Heart
Disease and Physical Activity of Work. Brit. Med. J.
211485, 1958,

3. Hetiersrern, H. K., Hirsu, BE. Q, ALLEN, W.C.L.,
Paster, S., and ZackEr, N.: Reconditioning of the
Coronary Patient: A Preliminary Report. In: Coro-
nary Heart Disease, p. 448. Edited by Tikoff, W., and
Moyer, J. H. New York. Grune and Stratton, 1963.

4, Hexierstern, H. K., and Forp, A. B.: Comprehensive
Care of the Coronary Patient Cymposium on Coronary
Heart Disease. American Heart Association Mono-
graph No, 2, 1961.

5. Hexterstein, H. K., and Forp, A, B.: Rehabilitation
of the Cardiac Patient. JAMA, 164:225, 1957.

6. NaveHton, J., Severrus, G., and Batxe, B.: Physio-
logical Responses of Normal and Pathological Subjects
to a Modified Work Capacity Test. J. Spts. Med.
3:201, 1963.

a

, Linpeman, R., Kyrtacorouros, J,, and Conran, L,:
Evaluation of a New Single, dblique Lead for the
Detection of Electrocardiographic Abnormalities.
Amer. Heart J. 64:24, 1962.

8. NauaHton, J., BALKE, B., and Nacte, F.: Refinements
in Method of Evaluation and Physical Conditioning
Before and After Myocardial Infraction. Amer. J.
Cardology 14 :837, 1964.

9. Leouer, J. F., and Bencu’or, A.; The Significance
of Extrasystoles in Coronary Artery Disease. Geria-
trics 19 :468, 1964.

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range one with no time limit placed on participa-
tion.

The remainder of each patient’s therapeutic
regimen was left intact, and he was encouraged
to continue consulting his personnal physician
just as he had before entering the program. A
periodic progress report was sent to the referring
physician,

The work-capacity test was repeated after 3
months of physical conditioning and at 6-month
intervals thereafter.

III. Case Reports.

Case 1. R. C. was a 54-year-old, obese air traffic
controller with a 1-year history of hypertension
and an elevated serum cholesterol. He initiated
physical conditioning 6 weeks before suffering an
inferoseptal and lateral myocardial infarction.
His hospital course was unevertful, and 2 months
later he entered the conditioning program. His
initial progress was the subject of an earlier re-
port. During his 2 years of participation, he
had two vacations that lasted 3 weeks each and
was hospitalized once for 7 days. The latter
was occasioned by a syncopal episode that oc-
curred following exercise. The physician learned
from the patient, upon regaining consciousness,
that he had ingested three nitroglycerin tablets
for “chest tightness” during a 30- to 45-minute
period prior to exercising. A combination of
vasodilator drugs and exercise probably precipi-
tated this syncope. The electrocardiographic
findings were unchanged following this episode
and three SGOT determinations were within nor-
mal limits. He had no other rehospitalizations
or cardiovascular complications.

Case 2. T. B. was a 48-year-old intermittent
laborer when he had an inferoseptal myocardial
infarction. He was referred to the program 8
months later after an uneventful postinfarct
course. His initial evaluation revealed a blood
pressure of 100/70 mm Hg and a pulse rate of
72 per minute. He was a thin, wiry man with
arcus senilis who appeared much older than his
stated age. He had an atrial gallop. He par-
ticipated in the program for 4 months before
moving to a new location. On two occasions he

complained of transient episodes of lightheaded- _

ness, following which his blood pressure was
within normal limits and not additional electro-
cardiographic abnormalities were detected. After
leaving the program, he stopped training and he

did not return to work. Some weeks later he
died suddenly while sitting in a chair. Post
mortem examination was not performed. Death
was attributed to an acute myocardial infraction.

Case 3. D.C., a 48-year-old electric-company
executive volunteered for the program 4 years
after suffering an anteroseptal and antero-lateral
myocardial infarction. His blood pressure was
150/90 mm Hg and pulse rate 80 per minute upon
‘entering the study. He had electrocardiographic
evidence of an old anteroseptal and anterolateral
myocardial infarction with peri-infarction block.
He participated irregularly and without compli-
cations for 6 months before discontinuing the
program because of job pressures. His clinical
course has remained uncomplicated.

Case 4. L. P. was a 45-year-old flight-line
mechanic when he had posterior myocardial in-
farction. His clinical course was complicated
by severe left-sided chest pain and the develop-
ment of the “Shoulder-Hand Syndrome.” These
events precipitated an early retirement from
civil-service employment. When evaluated 7
months after suffering the myocardial infarction,
he was totally invalided despite the fact that his
cardiovascular status was satisfactory. His blood
pressure was 130/90 mm Hg and pulse rate 100
per minute. He appeared tense and depressed.
There was exquisite tenderness over the entire
left chest. anteriorly. His left shoulder was
frozen, and there was edema with cyanosis of the
left hand. He developed moderately severe
dyspnea after a few minutes of walking on a
level grade. Daily physical therapy was insti-
tuted for the shoulder, and the patient entered
the conditioning program. Six months later, he
had recovered complete function of the left upper
extremity and had regained much of his physical
working capacity. He left the program after he
returned to a new job. His course was compli-
cated by two short-term rehospitalizations for
treatment of acute peptic esophagitis.

Case 5. W. G. was a 41-year-old pilot when he
suffered an inferoseptal myocardial infarction.
He entered the program 3 months later, at which
time his blood pressure was 130/80 mm Hg and
pulse rate 72 per minute. He has participated
in the program 16 months without any known
cardiovascular complications or rehospitaliza-
tions,

Case 6. A. B., a civil-service attorney, had an
inferoseptal infarction at the age of 48 years.


CLINICAL AVIATION MEDICINE: :

A Physical-Conditioning Program for Cardiac Patients—A Progress Report

I, Introduction.

The high incidence of coronary atheroscle-
rosis among middle-aged men has prompted
many investigations of the possible etiologies,
pathogenesies, and therapies of this malady.
One of the least-explored factors that might
have a relationship to the development of this
disease process has been physical activity.
Morris? indicated that life-long physical activ-
ity might protect men from clinically manifest
coronary artery disease. ‘These findings, coupled
with the clinical experience that many patients
recover from myocardial infarction and return to
their jobs, have led investigators such as Heller-
stein ** to advocate that cardiac patients should
participate in physical-conditioning programs.
Although it is his impression that the patients
benefit. emotionally and physiologically during
participation in these programs, there is still
very little data available that document the
clinical course of these patients. It is the purpose
of this report to review the growth of a physical-
conditioning program for cardiac patients and
to present a progress report of the clinical course
to the patients during its first 2 years.

II. Methods and Materials.

Twenty men who have recovered from well-
documented episodes of myocardial infarction
comprise this study. All subjects were referred
by their physicians to the study.

A pertinent history, physical examination, and
standard electrocardiogram were done on each
patient prior to entering the program. In addi-
tion, each man performed an exercise test that,
was designed to induce an energy demand no
greater than seven times that of the resting
metabolic state. The patient began walking on
a treadmill at a speed of 2.0 mph on a level
grade. The speed was held constant while the
slope of the treadmill bed was elevated 3.5%
every 3 minutes. Each energy requirement ap-

proximated an additional increment of the rest-
ing metabolic state; ie. 2, 8, 4 times, etc, the

work of rest. Blood pressure and pulse rate ,

were monitored by the auscultatory method while
a single-lead oblique electrocardiogram’ was re-
corded during the last half of each minute.

Respiratory gas exchange was determined every”

3 minutes. The test was terminated either after
the 18th minute on a 17.5% grade, or earlier, if
the patient developed severe dyspnea, angina
pectoris, or intermittent claudication.

The first five subjects were seen in the labo-
ratory daily for 1 month, during which they
walked on the treadmill for 30- to 45-second
periods alternating with 30 seconds of rest. The
speed and grade were varied each day. Blood
pressure and pulse rate were monitored so that
the energy demands were within each patjent’s
physical working capacity.

The physical-conditioning program was con-
ducted in a gymnasium. Each patient was en-

couraged to attend three times a week, The -

exercises were conducted in the late morning for
1 hour. An attendance record was kept. The
activities were varied slightly from day to day
and included calisthenics, competitive games such
as volley ball, and intermittent jogging. Each
patient began very slowly and was encouraged to
increase his energy output gradually during each
session.

The purposes of the study were explained to
each patient following his initial evaluation. He
was taught how to recognize an acute cardiac
emergency, to administer mouth-to-mouth resus-
citation, and to apply closed-chest cardiac mas-
sage. He was familiarized with the principles
of operation of an external defibrillator and pace-
maker. He was instructed to notify the attend-
ing physician imediately if he noticed any un-
usual symptoms before, during, or after the ac-
tivity. The program was presented as a long-



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