Cardiac Rehabilitation for the Treatment of Refractory Angina
Study Details
Study Description
Brief Summary
The purpose of this study is to determine whether cardiac rehabilitation is a successful treatment for refractory angina, in relation to improvements in cardiovascular risk factors, physical ability, symptomology, quality of life and psychological morbidity.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Phase 3 |
Detailed Description
The majority of patients presenting with angina pectoris resulting from coronary artery disease (CHD) are successfully treated with interventions including coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) and medical management. However, a growing number of patients experience persistent angina in spite of intervention and optimal medical treatment. Such patients are referred to as suffering from 'refractory angina'.
Currently, cardiac rehabilitation centres are reluctant to accept patients with ongoing angina or complicated cardiovascular history, in spite of the duration or stability of the symptoms. Indeed, angina and heart failure are often used to exclude patients from cardiac rehabilitation. However, in the recent updated American Heart Association (AHA) recommendations for exercise and training, cardiac rehabilitation and supervised exercise training is recommended for patients with ongoing angina, previous history of CABG, MI, PTCA and patients with existing cardiomyopathy in order to promote a reduction in myocardial ischaemia at rest and during sub-maximal exercise, while reducing the risk for the progression of CHD. Nevertheless, studies exploring the physiological and psychological impact of routinely available CR as a stand-alone intervention among refractory angina patients have not previously been undertaken. Until such studies are performed, CR practitioners will continue to refuse to accept refractory angina patients for participation in CR.
Research questions:
-
Is an eight-week cardiac rehabilitation exercise programme an appropriate treatment option for patients with refractory angina?
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Does an eight-week cardiac rehabilitation exercise programme improve the physical functioning and cardiovascular health of patients with refractory angina?
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Is symptom severity and frequency reduced following an eight-week cardiac rehabilitation exercise programme in patients with refractory angina?
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Does an eight-week cardiac rehabilitation exercise programme have any impact on anxiety, depression, cardiac anxiety and quality of life in patients with refractory angina?
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Are any physiological or psychological effects acquired by patients with refractory angina participating in a cardiac rehabilitation exercise programme maintained at an eight-week follow-up?
The study is conceived as a randomised intervention-control study of a standard, routinely available Phase III hospital-based CR program among patients with refractory angina. Patients will be randomly assigned to an eight-week CR programme based at Harefield Hospital or symptom diary monitoring control group.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: Cardiac rehabilitation 8-week cardiac rehabilitation programme |
Behavioral: Cardiac rehabilitation
Phase III cardiac rehabilitation programme
|
| No Intervention: Monitoring Carry on life as normal |
Outcome Measures
Primary Outcome Measures
- Health anxiety [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Health anxiety questionnaire (HAQ)
- Generalised anxiety and depression [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Hospital Anxiety and Depression scale (HADS)
Secondary Outcome Measures
- Systolic and diastolic blood pressure [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Measured after 10 minutes sitting, using automated machine (eg. Omron machine)
- Heart rate [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Heart rate measured using automated machine (eg. Omron blood pressure machine) or manually at the radial pulse
- Anthropomometry [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Weight, height, waist circumference (tape measure), hip circumference (tape measure), body mass index calculated from height and weight using the following website: http://www.nhlbisupport.com/bmi/bmi-m.htm
- Fasting lipids [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides. Measured in biochemistry departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques.
- Social support [Baseline]
Measured using the ENRICHED social support instrument (ESSI)
- Angina related health beliefs [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Measured using the York angina beliefs scale.
- Physical activity and exercise capacity [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Progressive shuttle walk test
- Angina frequency and severity [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
Subjects completed a daily symptom monitoring diary
- Quality of life [Base, week 8 (post intervention/monitoring), week 16 (8 weeks post intervention/monitoring)]
SF-36 quality of life scale
- Plasma glucose [Base, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the biochemistry departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques.
- Urea & electrolytes [Base, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the biochemistry departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques
- Liver function tests [Baseline, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the biochemistry departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques.
- Thyroid function tests [Baseline, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the biochemistry departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques.
- Hb [Baseline, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the haematology departments of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques.
- HbA1C (if diabetic) [Baseline, post intervention/monitoring, 8 weeks post intervention/monitoring]
Measured in the haematology department of the Royal Brompton & Harefield NHS Foundation Trust using standard techniques
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Clinically diagnosed with refractory angina > 6 months
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Two or more episodes of angina per week
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Males and females aged 30 - 80
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Previous history of single or multiple myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA) or any combination of the above
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Prescribed optimal medical therapy
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AHA exercise and training guidelines classification B and C
-
Willing to give written informed consent
Exclusion Criteria:
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History of any other chronic illness
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AHA exercise and training guidelines classification class D
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Suffer any physical condition for which exercise is a contra-indication
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Participation in two or more periods of planned moderate intensity exercise per week during the past 6 months
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Participation in another research study within the previous 60 days
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History of psychiatric illness
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Unwilling to give written informed consent
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | National Heart and Lung Institute, Imperial College London | London | United Kingdom | SW3 6LY |
Sponsors and Collaborators
- National Heart and Lung Institute
- British Heart Foundation
- Royal Brompton & Harefield NHS Foundation Trust
Investigators
- Principal Investigator: Peter Collins, MA, MD, FRCP, National Heart and Lung Institute, Imperial College London
- Principal Investigator: Kim Fox, MD, FRCP, Royal Brompton & Harefield NHS Foundation Trust
- Principal Investigator: Mahmud Barbir, FRCP, Royal Brompton & Harefield NHS Foundation Trust
Study Documents (Full-Text)
None provided.More Information
Publications
- Asbury EA, Creed F, Collins P. Distinct psychosocial differences between women with coronary heart disease and cardiac syndrome X. Eur Heart J. 2004 Oct;25(19):1695-701.
- Chester M, Hammond C, Leach A. Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain. 2000 Jul;87(1):103-105. doi: 10.1016/S0304-3959(00)00270-0.
- DeJongste MJ, Tio RA, Foreman RD. Chronic therapeutically refractory angina pectoris. Heart. 2004 Feb;90(2):225-30. Review.
- Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Piña IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001 Oct 2;104(14):1694-740.
- Gowda RM, Khan IA, Punukollu G, Vasavada BC, Nair CK. Treatment of refractory angina pectoris. Int J Cardiol. 2005 May 11;101(1):1-7. Review.
- Grace SL, Abbey SE, Shnek ZM, Irvine J, Franche RL, Stewart DE. Cardiac rehabilitation I: review of psychosocial factors. Gen Hosp Psychiatry. 2002 May-Jun;24(3):121-6. Review.
- Grace SL, Abbey SE, Shnek ZM, Irvine J, Franche RL, Stewart DE. Cardiac rehabilitation II: referral and participation. Gen Hosp Psychiatry. 2002 May-Jun;24(3):127-34.
- Hevey D, Brown A, Cahill A, Newton H, Kierns M, Horgan JH. Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program. J Cardiopulm Rehabil. 2003 Jan-Feb;23(1):17-21.
- Johnston M, Foulkes J, Johnston DW, Pollard B, Gudmundsdottir H. Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial. Psychosom Med. 1999 Mar-Apr;61(2):225-33.
- Lear SA, Ignaszewski A. Cardiac rehabilitation: a comprehensive review. Curr Control Trials Cardiovasc Med. 2001;2(5):221-232.
- Mannheimer C, Camici P, Chester MR, Collins A, DeJongste M, Eliasson T, Follath F, Hellemans I, Herlitz J, Lüscher T, Pasic M, Thelle D. The problem of chronic refractory angina; report from the ESC Joint Study Group on the Treatment of Refractory Angina. Eur Heart J. 2002 Mar;23(5):355-70. Review.
- Moore RK, Groves D, Bateson S, Barlow P, Hammond C, Leach AA, Chester MR. Health related quality of life of patients with refractory angina before and one year after enrolment onto a refractory angina program. Eur J Pain. 2005 Jun;9(3):305-10.
- Stewart S. Refractory to medical treatment but not to nursing care: can we do more for patients with chronic angina pectoris? Eur J Cardiovasc Nurs. 2003 Sep;2(3):169-70. Review.
- Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682-92. Review.
- Yoshida T, Kohzuki M, Yoshida K, Hiwatari M, Kamimoto M, Yamamoto C, Meguro S, Endo N, Kato A, Kanazawa M, Sato T. Physical and psychological improvements after phase II cardiac rehabilitation in patients with myocardial infarction. Nurs Health Sci. 1999 Sep;1(3):163-70.
- 06/Q0404/77
- PG/06/087/21239