Clinical question: Does cardiac rehabilitation improve quality of life for a man with coronary artery disease who received percutaneous transluminal coronary angioplasty with insertion of a stent?

The purpose of "Evidence in Practice" is to illustrate how evidence is gathered and used to guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated.

A 48-year-old man developed severe anterior chest pressure with pain radiating to the left arm in the morning and was sent to the emergency department. Both his serum creatinine phosphokinase and creatinine phosphokinase-MB band levels were elevated significantly, and an elevated plasma troponin I level (14.1 IU) also was noted.

The electrocardiogram (ECG) confirmed the evolution of an extensive anteroseptal myocardial infarction (MI). He then was transferred to the intensive care unit where 100 mg of tissue plasminogen activator was administered, followed by a heparin drip; his chest pain subsided with only intermittent episodes thereafter. Monitoring with ECG revealed occasional episodes of ventricular tachycardia, and congestive heart failure was suspected. After medical treatment in the intensive care unit, the patient rarely experienced any chest pain and had a normal sinus rhythm.

Three days later, cardiac catheterization was performed, which revealed a 90% occlusion of the left anterior descending artery at the second diagonal, a 50% occlusion of the mid-right coronary artery, a 50% occlusion of a diagonal artery of the circumflex artery, and left ventricular dysfunction (left ventricular ejection fraction of 40%). His New York Heart Association classification was functional class I. A percutaneous transluminal coronary angioplasty (PTCA) with the insertion of a stent in the occluded left anterior descending artery was successfully performed on the same day. Two days later, the patient was discharged with the following medications prescribed: calcium channel blockers (diltiazem, 60 mg 3 times a day), antiplatelet agents (aspirin, 100 mg every day), and nitrates (sublingual nitroglycerin as required). His cardiologist did not prescribe a beta-blocker because of concern about his past history of bronchial asthma. The patient's condition significantly improved after PTCA; he could perform daily activities with no symptoms. He returned to work 1 month after the MI.

One month after the PTCA procedure, the patient was referred to the cardiac rehabilitation phase II program in our outpatient physical therapy department after a symptom-limited maximal exercise test. The exercise test using a cycle ergometer revealed a poor exercise tolerance with a maximal workload of 50 W and a peak work capacity of 3.6 metabolic equivalents, and the test ended with dyspnea and leg fatigue without angina or ST-segment changes.

** Examination and evaluation: Physical examination revealed that the patient had stable vital signs without any discomfort during daily activities. According to the patient, his health status was very good before his MI, and no dyspnea or any kind of cardiopulmonary discomfort occurred before this episode of MI. From his history, however, the patient had positive risk factor profiles for coronary artery disease (CAD): he had a family history of CAD (his father and mother both died from MIs at 53 years and 59 years of age, respectively), he had smoked 2.5 to 3 packs of cigarettes per day for more than 30 years, and he was obese (body mass index=30.4 kg/[m.sup.2]).

This patient worked as a counseling manager in a personal private business. Before the MI, he worked long hours each day (ie, 12 hours every day for 5 or 7 days a week). According to the patient, the psychological stress imposed by his work was greater than its physical demands. He also had to drive 5 km to work every day, and he resided in a 6-story building, which had an elevator available. For recreation, he occasionally went hiking if he did not have to work during the weekend. He, therefore, lived a relatively sedentary lifestyle with minimal physical demands. He lived with his wife who had her own career. They had no children; therefore, according to the patient, family life caused no stress.

Based on these findings, we concluded that the patient's major problem was insufficient cardiopulmonary capacity. We decided to implement a treatment program that we use routinely in our department for people with CAD who received PTCA and a stent. The patient immediately started an exercise training program on a cycle ergometer that consisted of a 5-minute warm-up period with workloads of 10 W, a 15-minute training period with workloads of 20 W, and a 5-minute cool-down of 10 W. The training frequency was three 30-minute sessions per week, with the training intensity gradually increasing according to the patient's tolerance, following the American College of Sports Medicine guidelines. (1)

The patient also received education regarding atherosclerotic heart disease, risk factors, and exercise precautions. During the initial training session, the patient's diastolic blood pressure remained consistently high (96 to 98 mm Hg) both at rest and during exercise. The primary physician thus decided to increase the dose of calcium channel blockers (diltiazem, 90 mg 3 times a day).

After the initial training session, this patient was asymptomatic at rest and exhibited normal blood pressure and heart rate responses during exercise training. He seemed to understand the benefits of the cardiac rehabilitation phase II program and was highly motivated to accomplish the program.

Six weeks after the PTCA procedure, however, he experienced an episode of chest tightness during his busy office hours that caused him to worry about his health. He went to his cardiologist, who told him that the thallium 201 imaging showed no evidence of restenosis of the coronary arteries and that the chest tightness might due to occasional vasospasm. His cardiologist prescribed dipyridamole (Persantine, * 75 mg 3 times a day) for dilation of the coronary arteries and for anticoagulation and recommended that he continue exercise training with regular follow-ups.

Since the episode of chest tightness, this patient continued to be anxious about his health. The patient's quality of life (QOL) was affected by these concerns, which included the possible recurrence of chest tightness, possible restenosis, and possible hospital readmission. He started to wonder if the cardiac rehabilitation program would be able to improve his cardiac dysfunction and accommodate his busy work schedule at the same time. Because the patient was in the prime of his life, he was much concerned about his future QOL.

Before answering his questions, we decided to search the literature to see if there was evidence demonstrating that the outpatient cardiac rehabilitation phase II program could improve his QOL by promoting physical well-being and reducing anxiety.

** Databases used for search: MEDLINE, CINAHL

Because we wanted to access literature from medical journals as well as journals dealing specifically with physical rehabilitation, we first used the MEDLINE database. We accessed MEDLINE through its online version, PubMed, at www.ncbi.nlm.nih. gov/PubMed. In addition, we wondered whether literature from another database such as CINAHL (Cumulative Index to Nursing and Allied Health Literature) might include journals dealing with physical activity and rehabilitation. We accessed CINAHL through Ovid ([dagger]) (gateway.ut.ovid.com/gw2/ovidweb. cgi). Unfortunately, the CINAHL database did not provide any pertinent information on this topic. Thus, we report only the search procedure from MEDLINE, which was performed on June 24, 2006.

** Initial Keywords: cardiac rehabilitation, exercise training, PTCA

We started the search using 3 keywords in the following search string: (cardiac rehabilitation OR exercise training) AND PTCA. The initial results listed 171 articles. Because the number of hits was somewhat large and might cover broader effects of cardiac rehabilitation or exercise training on patients after PTCA, we added another keyword "quality of life," our patient's major concern, to our search string. The final search string was (cardiac rehabilitation OR exercise training) AND PTCA AND quality of life. Thirty-one articles relevant to our question were retrieved.

We then added limits to our search. Because of recent advances in the PTCA procedure, especially the use of stents, we limited the search by entering the dates 1999 and 2006 in the Entry Date field in PubMed's Limits feature. We also restricted the search to articles that were published in English and that described studies on people rather than animals. The number of search results was reduced to 19.

A cursory look suggested that most of these articles dealt with the issues relevant to QOL after PTCA. It appeared that we were on the right track, and the total number of articles did not seem to be overwhelming. Rather than imposing further limits or using additional keywords, we began to examine each article. The citations from these articles are listed in Figure 1.

Figure 1. Citations retrieved by search using the search string
(cardiac rehabilitation OR exercise training) AND PTCA AND quality of
life.

1. Paquet M, Bolduc N, Xhignesse M, Vanasse A. Re-engineering
cardiac rehabilitation programmes: considering the patient's point
of view. J Adv Nuts. 2005;51:567-576.

2. Yu CM, Lau CP, Chau J, et al. A short course of cardiac
rehabilitation program is highly cost effective in improving long-term
quality of life in patients with recent myocardial infarction or
percutaneous coronary intervention. Arch Phys Med Rehabil. 2004;85:
1915-1922.

3. Evon DM, Burns JW. Process and outcome in cardiac rehabilitation:
an examination of cross-lagged effects. J Consult Clin Psychol.
2004;72:605-616.

4. Reddy. BK, Brewster PS, Walsh T, et al. Randomized comparison
of rapid ambulation using radial, 4 French femoral access, or
femoral access with AngioSeal closure. Catheter Cardiovasc Interv.
2004;62:143-149.

5. Muller-Nordhorn J, Roll S, Willich SN. Comparison of the short
form (SF)-12 health status instrument with the SF-36 in patients with
coronary heart disease. Heart. 2004;90:523-527.

6. Eisenberg MJ, Blankenship JC, Huynh T, et al; ADORE Investigators.
Evaluation of routine functional testing after percutaneous
coronary intervention. Am J Cardiol. 2004;93:744-747.

7. Gardner JK, McConnell TR, Klinger TA, et al. Quality of life and
self-efficacy: gender and diagnoses considerations for management
during cardiac rehabilitation. J Cardiopulm Rehabil. 2003;23:
299-306.

8. Stewart KJ, Badenhop D, Brubaker PH et al. cardiac rehabilitation
following perculaneous revascularization, heart transplant,
heart valve surgery, and for chronic heart failure. Chest.
2003;123:2104-2111.

9. Pasquali SK, Alexander KP, Coombs LP, et al. Effect of cardiac
rehabilitation on functional outcomes after coronary revascularization.
Am Heart J. 2003; 145:445-451.

10. Hevey D, Brown A, Cahill A et al. Four-week multidisciplinary
cardiac rehabilitation produces similar improvements in exercise
capacity and quality of life to a 10-week program. J Cardiopulm
Rehabil. 2003;23:17-21.

11. Raine RA, Black NA, Bowker TJ, Wood DA. Gender differences in
the management and outcome of patients with acute coronary
artery disease. J Epidemiol Community Health. 2002;56:
791-797.

12. Jamieson M, Wilcox S, Webster W, et al. Factors influencing
health-related quality of life in cardiac rehabilitation patients. Prog
Cardiavasc Nuts. 2002; 17:124-131, 154.

13. Pilote L, Lauzon C, Huynh T, et al. Quality of life after acute
myocardial infarction among patients treated at sites with and
without on-site availability of angiography. Arch Intern Med.
2002; 162:553-559.

14. Bengtsson I, Hagman M, Wedel H. Age and angina as predictors
of quality of life after myocardial infarction: a prospective
comparative study. Scand Cardiavasc J. 2001;35:252-258.

15. Belardinelli R, Paolini I, Cianci G, el al. Exercise training
intervention after coronary angioplasty: the ETICA trial. J Am Coll
Cardiol. 2001;37:1891-1900.

16. Pocock SJ, Henderson RA, Clayton T, et al. Quality of life after
coronary angioplasty or continued medical treatment for angina:
three-year follow up in the RITA-2 trial, Randomized Intervention
Treatment of Angina. J Am Call Cardiol. 2000;35:907-914.

17. Hofman-Bang C, Lisspers J, Nordlander R, et al. Two-year results
of a controlled study of residential rehabilitation for patients
treated with percutaneous transluminal coronary angiography:
randomized study of a multifactorial programme. Eur Heart J.
1999;20: 1465-1474.

18. Moser DJ, Cohen RA, Clark MM et al. Neuropsychological functioning
among cardiac rehabilitation patients. J Cardiopulm
Rehabil. 1999; 19:91-97.

19. Lisspers J, Sundin O, Hofman-Bang C, el al. Behavioral effects
of a comprehensive multifaceted program for lifestyle change
after percutaneous transluminal coronary angioplasty: a prospective,
randomized, controlled study. J Psychosom Res. 1999;46:
143-154.

* Selection of articles for review: After examining the titles of these articles, we determined that 7 research articles (Paquet et al, Reddy et al, Eisenberg et al, Raine et al, Pilote et al, Bengtsson et al, Pocock et al) and 1 review paper (Stewart et al) did not focus on the effect of cardiac rehabilitation on QOL for patients after PTCA, and we excluded them from further discussion. Another 6 articles addressed issues that were not relevant to our patient's concern, such as physical functioning (Pasquali et al), neuropsychological functioning (Moser et al), factors influencing health-related QOL in cardiac rehabilitation (Jamieson et al and Gardner et al), comparison of different QOL evaluation tools (Muller-Nordhorn et al), and self-efficacy (Evon et al) and were excluded from further review. Although one article with a randomized controlled trial (RCT) design (Hevey et al) addressed our topic, we excluded it from further examination because the participants in that study either had an MI or underwent coronary artery bypass grafting and were different from our patient.

In addition, we found that 2 articles (Lisspers et al and Hofman-Bang et al) were based on the same group of subjects but reported the outcomes in different follow-up periods. The article by Hofman-Bang et al, however, placed more emphasis on the long-term maintenance of achieved behavior and risk factor-related changes rather than the time frame that concerned our patient and we excluded it from further review. We, therefore, deemed the remaining 3 articles (Yu et al, Belardinelli et al, Lisspers et al) to be the best evidence because they used an RCT design and the content pertained to our patient's concern. These articles are discussed below, and the relevance of each article to our clinical question is addressed.

Yu CM, Lau CP, Chau J, et al. A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Arch Phys Med Rehabil. 2004;85:1915-1922.

This article described a prospective RCT. The researchers evaluated the long-term effect of a cardiac rehabilitation and prevention program (CRPP) on QOL and its cost-effectiveness in a total of 269 patients (76% were men; mean age [[+ or -]SD]=64[+ or -]11 years) with a recent MI (n=193) or after an elective percutaneous coronary intervention (n=76). All the subjects were randomized in a ratio of 2 to 1 into either the CRPP group (which received an 8-week exercise and education class in phase II) or the control group (which received "conventional" therapy without an exercise program). They were followed until all 4 phases of the program were completed (about 2 years). The main outcomes were assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and Symptoms Questionnaire.

The results showed that, in the CRPP group, 6 of the 8 SF-36 dimensions improved significantly by phase II and were maintained throughout the study period. In terms of their psychology, patients in the CRPP group were less anxious and depressed and felt more relaxed and contented after training. In addition to the conventionally known effect of exercise training on physical capacity for subjects receiving PTCA, this study showed significant benefits of exercise training on mental health, social functioning, emotional role, and vitality. These were all major outcomes that our patient lacked.

The authors concluded that a short-course CRPP was highly cost-effective in providing better QOL to patients with a recent MI or after an elective percutaneous coronary intervention. In addition, the improvement in QOL took effect quickly and was sustained for at least 2 years after CRPP.

A primary strength of this study was that it used an RCT design; furthermore, most of the major outcomes were comparable at baseline between the 2 groups, and the study provided both point measures and measures of variability with statistical analysis. Most articles address the effects of exercise training on cardiopulmonary capacity; this paper investigated the effect of cardiac rehabilitation on QOL, especially the mental health and psychosocial functioning aspects that are affecting our middle-aged patient.

From our perspective, a primary weakness of the study was the lack of blinding, and this potential bias might affect the outcomes of exercise training shown in this study. Another potential weakness was the relatively low follow-up rate (75.8%), which is below the suggested level of many literature appraisal tools (such as the PEDro Scale). (2) The Table lists our critical appraisal of the Yu et al article, as well as the other articles retrieved by our literature search, using the PEDro Scale.

Although there were some weaknesses in the study, the characteristics of the subjects recruited in this study were similar to our patient and the exercise protocol was similar to the one he was receiving. We concluded that this study provided moderate evidence that would help us make a clinical decision about whether exercise training could increase the QOL in our patient.

Belardinelli R, Paolini I, Cianci G, et al. Exercise training intervention after coronary angioplasty: the ETICA trial. J Am Coil Cardiol. 2001;37:1891-1900.

This RCT seemed highly relevant to our clinical question because the subjects had a mean age ([+ or -]SD) of 57[+ or -]10 years, and most of the subjects were male and had characteristics comparable to our patient. In this study, patients exercised 3 times a week for 6 months, at an intensity of 60% of peak oxygen uptake; and this protocol was similar to ours. They originally recruited 130 patients with CAD who underwent PTCA with or without a stent to determine the effects of exercise training on functional capacity, QOL, the restenosis rate, and the readmission rate. Subjects were randomized into 2 matched groups after baseline examination. The examination--which was carried out at baseline, 6 months after the cardiac rehabilitation program, and at the 12-month follow-up--included: a symptom-limited cardiopulmonary exercise test for measuring hemodynamic and metabolic variables, echocardiography for left ventricular volume and diameter measures, thallium scintigraphy for myocardial perfusion, and coronary angiography for restenosis and progression of CAD. Quality of life was assessed using 2 questionnaires: the Duke Activity Status Index and the SF-36, with a higher score indicating better QOL.

Compared with the patients in the control group, patients in the training group experienced significant improvements in peak oxygen uptake (26%, P<.001), QOL (26.8%, P=.001), lower residual stenosis diameter (-29.7%, P=.045), fewer new lesions in coronary arteries (7.6% vs 25%, P=.038), a lower event rate (11.9% vs 32.2%, risk ratio=0.71, P=.008), and a lower rate of rehospitalization (18.6% vs 46%, risk ratio=0.69, P<.001). The authors suggested that exercise training of moderate intensity was safe and could improve functional capacity and QOL, especially in health perception and the mental health domain after PTCA or stent, despite an unchanged restenosis rate.

The critical appraisal of this article showed the presence of 9 out of 11 items in the PEDro Scale (Table), (2) with the exceptions being the concealment of randomization and blinding of patients. These weak points, however, are common among this type of study. The evidence provided by the article seemed fairly strong because of its RCT design and its large sample size. Another potential strength was that some of the outcomes were analyzed by "intention to treat," which provided information on those subjects who withdrew during the training period. In addition, this study provided both point measures and measures of variability of most key outcomes and reported between-group comparisons using an appropriate statistical method. According to the results, the follow-up rate of this study was about 80%, somewhat below the recommended 85%, but we believed that this was still an acceptable level.

From our perspective, this was a highly valid study that provided strong evidence that exercise training was beneficial for patients after PTCA, not only in exercise capacity and physiological improvement, but also for mental and psychosocial health.

Lisspers J, Sundin O, Harmon-Bang C, et al. Behavioral effects of a comprehensive, multifactorial program for lifestyle change after percutaneous transluminal coronary angioplasty: a prospective, randomized, controlled study. J Psychosom Res. 1999;46:143-154.

The participants recruited in this study were similar to our patient. The authors stated that they were especially interested in using a behavioral intervention with patients treated with PTCA because these patients had low morbidity and mortality and a higher percentage of these patients returned to work than those who had an acute MI and underwent coronary artery bypass grafting. Therefore, the authors believed that patients treated with PTCA would achieve long-term preventive effects from changes in lifestyle.

This prospective RCT recruited 93 patients with coronary conditions who received the PTCA (mean age=53 years) and randomly assigned them into either an intervention or a control group. Subjects in the intervention group participated in a 4-week comprehensive, behaviorally oriented program focused on stress management, diet, exercise, and smoking cessation, as well as practical skills training in physical exercise, food preparation, biofeedback, and applied relaxation. These participants were not given a well-constructed exercise training program, however. The authors carried out assessments of lifestyle behaviors using a self-developed questionnaire, psychological factors using the Heart and Lifestyle Type A Measure (HALTAM) questionnaire, and exercise capacity using symptom-limited maximal exercise tests at baseline and after 12 months. They also gathered data on endpoints such as numbers of clinical events, readmissions, or days in hospital.

The results showed that the patients in the intervention group improved significantly in measures of smoking cessation, exercise, and dietary habits. These self-rated changes were confirmed by weight reductions and improved exercise capacity as well as by between-group differences in subclinical chest pain during an exercise test. Few effects, however, were found on the different psychological variables, as well as on morbidity or return-to-work rate.

A primary strength of this study lies in its RCT design and high follow-up rate of more than 90%. Another potential strength was that the 2 groups were comparable at baseline regarding the most important prognostic indicators. The study also provided point measures and measures of variability for the major outcomes. However, the potential weakness of the study was the fact that the authors did not give a clear account of whether the subjects, the therapist who administered the therapy, and the evaluators who measured outcomes were blinded to the group assignment. In addition, none of the major outcomes were analyzed by "intention to treat"; therefore, we could not know the characteristics of the subjects who dropped out. This RCT with high follow-up rate showed no significant effect of a 4-week "individual" behavior-oriented program on stress, and only a few psychological variables were shown to be different between the groups.

From our perspective, this study provided moderate evidence because of its uncertain blinding procedure and lack of "intention to treat" analysis. Moreover, this study investigated the effect of a behavior-oriented program that did not include a conventional cardiac rehabilitation component such as aerobic exercise training. This intervention was different from our protocol; therefore, the results might not be applicable to our patient.

* Extended search: Because anxiety was our patient's most serious health concern after the episode of chest tightness, we decided to repeat the search using the same database (MED-LINE), but using a somewhat broader term for the intervention. We selected "well-being" to make sure that we did not miss any articles that used QOL as an outcome measure for patients who underwent PTCA, and we also searched directly by the keyword "anxiety." We also used the abbreviations "PTCA" and "CAD" rather than spelling them out. We decided to restrict our other keywords to the primary problem. Our searches used the following search strings: (1) cardiac rehabilitation AND PTCA AND well-being and (2) cardiac rehabilitation AND CAD AND anxiety. After setting the same limits as our original search, these searches retrieved 3 and 7 articles, respectively (Figs. 2 and 3). We reviewed the tides of each citation, and excluded 3 studies (Lichtenberger et al, Michalsen et al, Sheps et al) from further discussion because they did not include the cardiac rehabilitation intervention. Another 5 articles addressed issues that were not relevant to our patient (Hevey et al, Marcuccio et al, Seki et al) or were not his primary concern, such as heart rate variability (Lavoie et al) or the impact of aging on hostility (Lavie and Miliani, Am J Geriatr Cardiol, 2004). However, 2 citations (Higgins et al and Lavie and Milani, Am J Geriatr Cardiol, 2004) did suggest that cardiac rehabilitation could improve well-being and reduce the prevalence of anxiety. These articles are discussed below.

Figure 2. Citations retrieved by search using the keywords "cardiac
rehabilitation" and "PTCA" and "well-being."

1. Lichtenberger CM, Martin Ginis KA, MacKenzie CL, McCartney N.
Body image and depressive symptoms as correlates of self-reported
versus clinician-reported physiologic function. J Cardiopulm
Rehabil. 2003;23:53-59.

2. Hevey D, Brown A, Cahill A, et al. Four-week multidisciplinary
cardiac rehabilitation produces similar improvements in exercise
capacity and quality of life to a 10-week program. J Cardiopulm
Rehabil. 2003;23:17-21.

3. Higgins HC, Hayes RL, McKenna KT. Rehabilitation outcomes
following percutaneous coronary interventions (PCI). Patient Educ
Couns. 2001;43:219-230.

Figure 3. Citations retrieved by search using the keywords "cardiac
rehabilitation" and "CAD" and "anxiety."

1. Michalsen A, Grossman P, Lehmann N, et al. Psychological and
quality-of-life outcomes from a comprehensive stress reduction
and lifestyle program in patients with coronary artery
disease: results of a randomized trial. Psychother Psychosom.
2005;74:344-352.

2. Lavoie KL, Fleet RP, Laurin C, et al. Heart rate variability in
coronary artery disease patients with and without panic disorder.
Psychiatry Res. 2004;128:289-299.

3. Lavie CV, Milani RV. Impact of aging on hostility in coronary
patients and effects of cardiac rehabilitation and exercise training
in elderly persons. Am J Geriatr Cardiol. 2004; 13:125-130.

4. Lavie C J, Milani RV. Prevalence of anxiety in coronary patients
with improvement following cardiac rehabilitation and exercise
training. Am J Cardiol. 2004;93:336-339.

5. Marcuccio E, Loving N, Bennett SK, Hayes SN. A survey of
attitudes and experiences of women with heart disease.
Women's Health Issues. 2003; 13:23-31.

6. Seki E, Watanabe Y, Sunayama S, et al. Effects of phase III
cardiac rehabilitation programs on health-related quality of life
in elderly patients with coronary artery disease: Juntendo Cardiac
Rehabilitation Program (J-CARP). Circ J. 2003;67:73-77.

7. Sheps DS, Kaufmann PG, et al. Sex differences in chest pain
in patients with documented coronary artery disease and exercise-induced
ischemia: Results from the PIMI study. Am Heart J.
2001;142:864-871.

Higgins HC, Hayes RL, McKenna KT. Rehabilitation outcomes following percutaneous coronary intervention (PCI). Patient Educ Couns. 2001;43:21-30.

Patients who have undergone PTCA have been reported to have higher levels of uncertainty and psychological distress 3 months after the procedure than patients who have had coronary artery bypass grafting. Patients receiving PTCA, however, do not routinely participate in cardiac rehabilitation because PTCA involves a shorter hospital stay and because some clinicians believe that the psychological well-being and physical status of patients receiving PTCA improve spontaneously.

This prospective study evaluated the effect of an individualized, comprehensive, home-based cardiac rehabilitation program in 99 patients who received percutaneous coronary interventions (PCI). The participants were randomized to a control group (n=49, which received "standard care" plus telephone follow-up) or intervention (n=50) groups. The intervention consisted of an "individualized" moderate-intensity walking program with a graded increase in the frequency and duration of exercise, risk factor modification, and psychosocial counseling on risk factors, psychological well-being, functional capacity, and work resumption.

Psychological well-being was measured using the Psychological Adjustment to Illness Scale, self-report version, and functional capacity was determined by the Canadian Cardiovascular Society functional classification