Purpose: This study was initiated to compare the effectiveness of a traditional cardiac rehabilitation protocol (TP) to a lower cost modified cardiac rehabilitation protocol (MP) designed to promote off-site exercise adherence. Methods: Effectiveness was based on supervised and independent exercise adherence and selected physiological outcomes. Fifty one moderate and low risk patients (41 men, 10 women) completed maximal graded metabolic exercise tests upon entry and at three months. Rehabilitation based and off-site exercise adherence was documented weekly over three months. The first month, all subjects followed identical protocols; three ECG monitored exercise sessions per week with encouragement to exercise off-site to achieve≥ 5 times per week for ≥ 30 minutes a session. In the third week, patients were randomized to either the TP (n=25) or the MP (n=26). The TP involved three continuous ECG monitored exercise sessions per week for 12 weeks. The MP included the following: in week five ECG monitoring was discontinued, in week six, patients were weaned to two on-site exercise sessions per week and asked to attend a weekly education/ discussion group. In week 11, patients were weaned to one on-site exercise session per week.Results: The three month evaluation revealed the TP average billing cost per patient of $1,961 was $784 more than the MP ($1,177). This was primarily due to additional on-site ECG monitoring. The MP completed 16.5% less on-site exercise sessions (MP -22, TP- 26) however, overall they completed 12.5% more exercise due to more off-site sessions (MP- 37, TP- 27). Both protocols elicited significant increases in anaerobic threshold and peak VO2, and decreases in body mass index (P<.05), while the MP also showed greater reductions in submaximal RPP (p<.05). Conclusion: A well designed low cost program for cardiac rehabilitation can facilitate improved offsite exercise adherence and equal or superior physiological outcomes compared to a traditional protocol.

Given the usefulness of gas exchange measurements in risk stratifying patients with cardiovascular events, the safety of graded exercise testing utilizing gas exchange less than 1 month after a cardiovascular procedure was studied by reviewing complication rates and number of abnormal responses in our exercise laboratory over eighteen months. A total of 348 patients, 131(38%) post myocardial infarction, 178 (51%) post bypass and 39 (11%) post angioplasty, were tested using an individually prescribed ramping treadmill protocol with on line measurement of gas exchange. All subjects were tested between 3 and 4 weeks post procedure. Treadmill complications were defined as sustained ventricular tachycardia (VT), ventricular fibrillation (VF), acute myocardial infarction (AMI) and exercise induced hypotension. Abnormal responses were identified as abnormal ST segment depression or elevation, and exercise induced angina. There were a total of 70 treadmill tests (20%) with either abnormal responses or complications. Of these, 25 (7%) were exercise induced angina, 25 (7%) were ST segment depression, 4 (1%) were ST elevation, 13 (4%) were exercise induced hypotension, and 3 (<1%) were sustained VT. No VF, AMI or mortality was associated with the treadmill testing. These data suggest that complications and abnormal responses observed acutely following a procedure are similar to those found in larger populations not tested as early. Therefore, we conclude that exercise testing with gas exchange is a relatively safe procedure and can be initiated soon after a cardiovascular procedure.