Rehabilitation of the patient with acute myocardial infarction

Abstract A program for comprehensive rehabilitation for the patient with coronary heart disease and acute myocardial infarction has been presented with particular emphasis on the psychic, social and physiological factors thereof. An outline of integrated rehabilitation activities in the form of varied and progressive exercise programs has been set forth as have certain aspects of clinical management. There has been a discussion of the initial observations of the program as it has affected the recovery of 10 patients from acute myocardial infarctions. The utilization of uninvolved and inexpensive equipment in a method of assessing exercise tolerance has been described essentially as promulgated by the original authors. A few additional electrocardiographic indications for terminating an Exercise Tolerance Test were mentioned. The Single Step and Treadmill Test are felt to be valuable procedures for the discernment of specific exercise responses of patients recovering from acute myocardial infarctions. It is felt that their use should be basic to the development of any comprehensive cardiac rehabilitation program. The following observations and concepts are derived from the study: 1. 1. The implementation and conduct of a comprehensive cardiac rehabilitation program is possible with minimal equipment and the availability of certain personnel. 2. 2. The commencement of an integrated exercise program early in the course of a patient's convalescence from an acute myocardial infarction seems to have a salutary effect on psychic factors and early ambulation. Its purpose is to enhance revascularization of the myocardium. 3. 3. Patients with acute myocardial infarctions assigned to a Cardiac Rehabilitation Ward seem to accept readily the disciplines of the Program and to develop a strong in-group feeling which is felt to be a vital factor in deriving optimal benefit from the Program. 4. 4. Exercise Tolerance Tests and the computation of Physical Fitness Indexes are valuable adjuncts to clinical factors in the intelligent assessment of the exertional limitations of a patient recovering from an acute myocardial infarction. They document increases in exercise tolerance. One is then better able to prepare future work and physical activity prescriptions for the patient. The tests, used and supervised as described, did not cause increased morbidity in the patients. 5. 5. Serum cholesterol levels were significantly reduced on a restricted fat diet. With the accomplishment of certain educative efforts during hospitalization these reduced levels can be sustained after the patient's discharge from the hospital. In the same manner weight reduction can be achieved and sustained. 6. 6. An active exercise program (i.e. corrective therapy program) is well tolerated by the patients and seems to effect significant increases in cardiac tone and efficiency in relatively short periods of total exercise time. A majority of patients are continuing such an exercise program at home. 7. 7. The use of vasodilators can be minimized for most patients who achieve a certain degree of increased exercise tolerance (presumably because of increased cardiac tone and increased coronary blood flow) by participation in an integrated exercise program. 8. 8. It is planned, on the basis of the observations discussed in ¶'s 6 and 7 to broaden the criteria for admission to the Program in order that patients with only the anginal syndrome or congestive failure may also be included. 9. 9. Useful information for the management of cardiac patients can be derived from the results of psychological testing and the compilation of certain social data. It is contemplated that such testing will eventually include a comprehensive evaluation of the patient's family and a complete psychiatric diagnostic evaluation of the patient. There is a definite hiatus in the current treatment of patients with myocardial infarction. It is caused by the lack of data regarding the individual cardiac patient's exercise tolerance, motivation and the relative importance of various life stresses (particularly those of the home environment) on his cardiac status. These data must be obtained and utilized before rehabilitation of the coronary heart disease patient can be truly comprehensive. The Research Project of which this Rehabilitation Program is an integral part provides for the future study of selected patients on the job and at home, to further assess the impact of these environments on the patient's cardiac status. This will involve the collection of certain types of physiological data on the job, at home, and possibly during transit to and from home. At home this will involve a type of remote (radio) equipment with a write-out recorder. One measurement which could be recorded would be an electrocardiogram (RKG-100). Others would include pulse rate, urinary epinephrine and norepinephrine levels. Definitive measures of psychological and psychiatric data will also be obtained in these environments. The Program as outlined is not the final answer to cardiac rehabilitation, but it provides a working model which can be used as an approach and point of departure for the development of more comprehensive plans which will culminate eventually in truly comprehensive rehabilitation of the patient with coronary heart disease and acute myocardial infarction.