The purpose of this research was to obtain information on the content of education within cardiac rehabilitation programs, methods of administering education, what the barriers are to providing education and which professionals administer education.To reach this goal, a questionnaire was modified from a previous study and a pilot study was undertaken to establish reliability of the questionnaire. The questionnaire was then sent to a sample of 100 directors of cardiac rehabilitation programs belonging to The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). The questionnaire focused on 13 established areas of education within cardiac rehabilitation programs.Once the questionnaires were completed, the information was transferred to a table format based upon the 13 content areas. The following conclusions were drawn from the research and the data gathered: 11 of the 13 content areas are offered at least 84% of the time, the major barriers for the 13 content areas were lack of time and lack of interest on the patient's behalf, the most frequent methods of education for all 13 content areas were individual education, print materials, and group education, and the primary educator overall for all 13 content areas was the nurse followed by the exercise physiologist and dietitian/nutritionist. / Department of Physiology and Health Science

Purpose: The primary purpose of the study was to assess if physical activity (PA) habits change between the first and final week in a phase II cardiac rehabilitation (CR) population and to determine if the PA habits differ on CR days versus non-CR days. The secondary purpose of the study was to determine if there were differences between the two PA assessment methods. Methods: There were 41 male subjects and 16 female subjects that volunteered for the study; however only 25 male subjects (age: 64.7 ± 11.4 years, BMI: 28.8 ± 4.5 kg/m2) and 11 female subjects (age: 65.2 ± 13.3 years, BMI: 31.6 ± 4.0 kg/m2) were included in the data analyses after accounting for dropouts and subject's whose data did not meet validation criteria. Subjects were required to wear both of the activity devices (pedometer and accelerometer) during both the first and final week assessments. Steps/day, activity counts/day, inactive minutes/day, light minutes/day and walking minutes/day were assessed by the Actigraph Accelerometer. Results: There was no significant difference in step counts from 5,290 ± 1,561 steps/day during the first week assessment to 5,730 ± 1,447 steps/day during the final week assessment. However, significant differences were seen between rehabilitation and nonrehabilitation days step counts/day (6,503 ± 1,663 steps/day vs. 4,517 ± 1517 steps/day, respectively). Furthermore, there was a significant increase between the first and final weeks activity counts/day (144,185 ± 56,399 counts/day vs. 165,220 ± 51,892 counts/day respectively) and a significant increase between rehabilitation and non-rehabilitation days activity counts/day (175,692 ± 58,239 counts/day vs. 133,712 ± 46,139 counts/day respectively). Conclusions: The results of the study suggest that patients are performing significantly more activity on days they attend rehabilitation versus days they do not attend rehabilitation. Furthermore, activity counts/day increased between the first and final weeks of rehabilitation and were higher on CR days vs. non-CR days, which may be due to the progressive exercise prescription associated with Phase II CR. Therefore, it was concluded that Phase II CR successfully increases the intensity of PA on CR days and between the first and final week of CR.Key Words: Cardiac Rehabilitation, Coronary Artery Disease, Pedometer, Accelerometer. / School of Physical Education, Sport, and Exercise Science

Purpose: The primary purpose of this study was to determine if a pedometer-driven physical activity (PA) intervention with individualized stepcount goals would be more efficacious in yielding greater amounts of PA than the usual time-based PA recommendations given to maintenance CR patients. Additionally, the secondary purpose of this study was to assess differences in stepcount activity on days attending maintenance CR and on non-rehab days. Methods: Subjects entering maintenance CR for the first referral were recruited for study participation and stratified into pedometer feedback (PF) and usual care (UC) groups. All subjects wore a New Lifestyles NL-1000 pedometer. PF subjects wore the pedometer for the duration of the 8-week study. For comparison, UC subjects wore the pedometer at baseline, week 4, and week 8.Both groups were encouraged to accumulate a minimum of 40 - 50 min/d at moderate intensity when attending maintenance CR. UC subjects were encouraged to follow-up with at least 30 min/d PA outside maintenance CR, while PF subjects were given daily stepcount goals. Stepcount goals were calculated as 10% of baseline stepcounts and added weekly to increase daily goal. All subjects completed a 6- minute walk test at baseline and week 8, and behavioral change questionnaires were completed at baseline, week 4, and week 8. Results: A total of 18 subjects (PF, n = 9, 53.7±8.0; UC, n = 9, 60.2±9.6 yrs) completed the 8-week study. There were no differences between groups at baseline. PF group increased daily stepcounts by week 4 (19%, 1,080±649 steps/d) and 8 (44%, 2,468±846 steps/d) in addition to days attending rehab by week 4 (14%, 1064±45 steps/d) and 8 (36%, 2,711±423 steps/d) and non-rehab days by week 8 (42%, 1,747±759 steps/d). PF subjects accumulated greater daily stepcounts compared to UC subjects at weeks 4 (26%, 1,405±393 steps/d) and 8 (48%, 2,612±284 steps/d). UC subjects accumulated greater stepcounts on rehab compared to non-rehab days, but no changes were found from baseline for daily stepcounts, rehab, or non-rehab days. There was a time effect for responses to social support from friends for all subjects (baseline to week 4) and a time by group effect for decision balance pro-questions by week 4 where PF significantly increased, UC significantly decreased, and both groups where significantly different. Conclusions: The results of this study suggest that a pedometer-driven PA intervention yields significantly greater stepcounts compared to time-based PA recommendations among maintenance CR patients. / School of Physical Education, Sport, and Exercise Science

Physical inactivity is a significant health concern for individuals in the United States, and is especially an issue for those with a history of coronary artery disease. Increased physical activity is encouraged for those who are participants in Phase III cardiac rehabilitation to promote a healthy lifestyle after a cardiac event. The purpose of the study was to assess and characterize the physical activity levels of Phase III cardiac patients. Other objectives of this study were to compare various forms of physical activity assessment and compare the activity levels of the cardiac rehabilitation participants with other populations. Comparisons of three physical activity devices were analyzed as well as activity levels on rehab and non-rehab days. Those who participated in home exercise vs. those who did not do home exercise were compared as well as those who were retired vs. those who were employed. Subject inclusion criteria included Phase III cardiac patients who were 40-69 years of age and who attended rehab a minimum of two days per week. The subjects were required to wear a pedometer and accelerometer for at least 12 days and complete a questionnaire following the trial. The mean ± S. D. for age, height, weight and BMI of the subjects was 59.4±8.2 years, 69.1±3.1 inches, 200.9±41.8 lbs., and 29.4±4.8 kg/m2 respectively. The Lifecorder, ActiGraph and International Physical Activity Questionnaire (IPAQ) were used to measure physical activity levels of the Phase III cardiac patients. The IPAQ did not correlate well with the Lifecorder or ActiGraph in assessing physical activity in Phase III cardiac patients (R=0.251, P=0.226-ActiGraph and R=0.280, P=0.175-Lifecorder), however, the Lifecorder and the ActiGraph had a significant correlation coefficient with one another (R=0.83, P<0.001). Rehab vs. non-rehab day data as well as rehab session and non-rehab session physical activity levels were compared among the subjects. On a rehab day, subjects took 9,770±3132 steps/day, which was significantly higher than what they took on a non-rehab day, 5,404±2843 steps/day. Those who did not exercise at home accumulated on average 8,194±2912 steps/day on a rehab day, while on a non-rehab day they accumulated 3,475±1579 steps/day (P<0.001). Those who did exercise at home, took 10,883±2856 steps/day on a rehab day, while on a non rehab day they took 6,767±2768 steps/day (P<0.001). Those who were employed were more active than those who were retired. In conclusion, Phase III cardiac rehabilitation is an effective way to increase physical activity levels of those with a history of coronary artery disease. All participants in Phase III cardiac rehabilitation should be encouraged to come into the center-based facility at least 4-5 days per week or implement a home exercise program into their weekly regimen. / School of Physical Education, Sport, and Exercise Science

With the aging population on the rise, the prevalence of heart failure is expected to increase in the coming years. Heart failure is independently correlated with cognitive decline and has a negative impact on quality of life, morbidity and mortality. Reduced cardiac output (Q) and cerebral blood flow (CBF) are proposed mechanistic links between heart failure and cognitive decline; however, reports are limited to the supine position and the response to an everyday upright posture is unknown. The purpose of this thesis was to primarily investigate the CBF response to a common upright seated position encountered in daily life in heart failure patients compared to healthy age- and sex-matched controls. Furthermore, we sought to determine whether cognitive performance or cognitive-activated hemodynamics were posture-dependent in the heart failure group. The secondary objective of this thesis was to be inclusive to patients that represent those encountered in clinical practice???specifically to include patients with higher left ventricular ejection fractions (LVEF) and atrial fibrillation with co-existing heart failure. Our findings confirmed greater cognitive impairments and a low supine CBF and Q in heart failure compared to controls and importantly, for the first time, a greater reduction in CBF with an upright seated position compared to healthy age- and sex- matched controls. When a cognitive task was performed supine and seated, performance outcomes were independent of posture in heart failure patients. However, mean flow velocity through the middle cerebral artery (MFV_MCA) increased less in response to the cognitive task seated. With regard to our secondary objectives, the results suggest that those with higher LVEF are equally at risk for cognitive decline and cerebral hypoperfusion due to a low Q. Furthermore, high variability in Q and MFV_MCA were detected in association with the beat-to-beat variation inherent to atrial fibrillation and suggest that this may be an underappreciated pathway to cognitive impairments in this sub-group. Together, these results suggest that upright cerebral hypoperfusion throughout the day may contribute to cognitive decline in heart failure and create a basis for further work to be done with larger sample sizes. Moreover, cerebral hypoperfusion with higher LVEF and the blood flow variation in atrial fibrillation represent important pathways contributing to cognitive decline in these under investigated sub-groups.

Previous research has suggested that emotional expression is important for psychological adjustment to disease (e.g., Stanton et al., 2000). Indeed, experimentally prescribed emotional disclosure (traditionally, expressive writing) in the context of illness has been shown to provide benefits for mental and physical health (Pennebaker, 1993). However, the experimentally prescribed disclosure in previous research has typically been asocial, akin to writing in a diary. In contrast, the present research, by experimentally manipulating the intended audience of one’s disclosure, examined the effect of addressing one’s emotional disclosure to specific types of listener, namely a therapist or one’s spouse. Cardiac couples in which one partner had a recent cardiac event took part in the current study. First, partners completed pre-study characteristics questionnaires. Next, in a lab session, partners (in separate rooms) were randomly assigned to one of three conditions: (1) they disclosed their thoughts and feelings about the cardiac event as though speaking to their partner; (2) they disclosed their thoughts and feelings about the event as though speaking to a therapist; or (3) in a non-disclosure, control condition, they spoke about a neutral topic. Partners then engaged in a dyadic discussion about each partner’s experiences, thoughts and feelings about the cardiac event. Finally, a one-month follow-up measure assessed their relational outcomes since participation. It was hypothesized that the partner-oriented condition would lead to better outcomes than the therapist-oriented condition, and that disclosing overall would be more beneficial than non-disclosure. The study also examined the influence of pre-study characteristics on in-lab and follow-up outcomes, with the hypothesis being that participants doing less well initially (i.e., higher on psychological distress, Type D personality, emotional suppression, and lower on mindfulness, cognitive reappraisal, relationship satisfaction, and perceived social support) would experience relatively more benefits from participation than those initially doing well. In addition, the study investigated whether type of event (unexpected and sudden vs. planned and more gradual) would differentially influence measures throughout the study, with the hypothesis being that couples who experienced a sudden event (MI) would be more distressed and therefore benefit more from participation than those who went through a planned procedure. Hypotheses were partially supported. Although the manipulation of disclosing to one’s partner vs. a therapist did not elicit many differences, one important and novel finding emerged regarding the orientation of disclosures: partner-disclosures yielded a more communal orientation whereas therapist-disclosures yielded a more self-focused orientation. The importance of patients’ disclosure orientation (me vs. we) was revealed when it emerged that greater communal focus led to better outcomes for both partners, but greater self-focus led to less positive outcomes for spouses. Compared to non-disclosure, disclosure generally was found to provide greater benefits for relational communication as well as marital satisfaction at follow-up. Consistent with predictions, participants who seemed most in need at pre-study (i.e., greater distress, Type D personality, emotional suppression, and less marital satisfaction and perceived support) experienced better outcomes than those who were initially well. Finally, couples who went through a sudden event were found to be more in need and benefited more than those whose event was planned, and this was especially pronounced in the effects on the spouses. Directions for future research and implications for clinical practice were discussed. For example, in addition to highlighting the value of emotional disclosure in the context of serious illness, the findings identified characteristics of cardiac couples who may be more in need of communication interventions and drew attention to important, relatively unmet needs in the patients’ spouses.

ABSTRACT To understand the mechanisms underlying cardiac dysfunction during ischemia reperfusion (I/R) injury, we tested the hypothesis that oxidative stress and defects in endothelium play a critical role in the activation of calpain and matrix metalloproteinases (MMP), inhibition of sarcolemmal (SL) Na+-K+-ATPase, and induction of cardiac dysfunction during I/R injury. It was observed that I/R induced depression in cardiac function and SL Na+-K+-ATPase activity was greater in hearts perfused at constant flow than in hearts perfused at constant pressure. Such a difference was associated with increased calpain activity as well as decreased endothelial nitric oxide synthase protein content and in nitric oxide production. The depression in Na+-K+-ATPase activity and decrease in protein content of Na+-K+-ATPase isoforms in I/R hearts were associated with an increase in calpain activity and translocation of calpain isoforms (I and II) from the cytosol to SL membrane as well as changes in the distribution of calpastatin. I/R induced alterations were Ca2+-dependent and were prevented by treatment with calpain inhibitors, MDL28170 and Leupeptin (Leu). These results suggest that depressions in cardiac function and SL Na+-K+-ATPase activity in the I/R hearts may be due to endothelial dysfunction as well as changes in the activity and translocation of calpain. In another set of experiments, we examined the role of oxidative stress in activation of calpain during I/R and its association with changes in the activity of MMP. Our results show depression of cardiac function and Na+-K+-ATPase activity in I/R hearts were associated with increased calpain and MMP activities. These alterations due to I/R were attenuated by ischemic preconditioning as well as treatment with antioxidant, N-acetylcysteine (NAC) and mercaptopropionylglycine (MPG). Treatment of I/R hearts with MMP inhibitor doxycycline (Dox) improved I/R-induced changes in cardiac function and Na+-K+-ATPase activity without affecting the calpain activation while treatment with calpain inhibitors, Leu and MDL 28170, reduced the MMP activity significantly in addition to attenuating the I/R-induced depression in Na+-K+-ATPase activity. These results suggests that alterations in Na+-K+-ATPase activity in I/R hearts are associated with oxidative stress and intracellular Ca2+ overload induced activation of calpain and MMP.

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A decrease in the apparent diffusion coefficient (ADC) of water is becoming an important tool for the detection of acute and chronic brain disorders, yet it is not known whether changes in myocardial ADCs hold similar potential. Consequently, this work determined whether the ADCs of water or intracellular metabolites could be used to show ischaemia or cell swelling in the isolated rat heart. A modified STEAM pulse sequence was designed to measure the ADCs of the ¹H-NMR detectable metabolites, taurine and creatine, with 4 min time resolution in a 3 mm myocardial slice. Experiments included the measurement of: a) metabolite diffusion coefficients and diffusion tensors in solutions, and ADCs and diffusion tensors in the isolated, KCl-arrested rat heart; b) taurine and creatine content during 32 min total, global ischaemia in the isolated rat heart; c) metabolite and water ADCs before, during and after ischaemia; and d) changes in average cardiomyocyte diameter during perfusion and ischaemia using the taurine ADC measurements. At a diffusion time of 50 ms, the myocardial ADCs were 1.06 x 10^-3 mm²/s for water, 0.29 x 10^-3 mm²/s for taurine and 0.26 x 10"3 mm 2 /s for creatine. Neither taurine nor creatine was lost from the heart during ischaemia, making either suitable for ischaemic diffusion measurements. Contrary to changes in the brain, myocardial water and taurine ADCs remained constant during ischaemia; however, the total creatine ADC increased by 35% which was shown to result from hydrolysis of PCr to creatine. Using the taurine ADC measurements at diffusion times between 50 ms and 1510 ms, the average myocyte diameter was calculated to be 40 μm during perfusion and 27 μm by the end of ischaemia. The decrease in myocyte diameter indicates that the buffer perfused heart is highly oedematous. This is the first time that: 1) metabolite ADCs have been measured in isolated heart, and 2) NMR spectroscopy has been used to determine the myocyte diameter. Thus ADC changes may not have potential for detecting ischaemia in the heart, although the measurement of myocyte diameter using taurine ADCs could indicate myocardial oedema.