Increased Cardiovascular Disease Mortality Biology Essay

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Coronary artery disease is a condition in which plaque builds up inside the coronary arteries which supply blood to the heart muscles.

This disease is characterized by several symptoms like angina, reduced functional capacity etc. Approximately 1 in 20 subjects suffer from coronary artery disease according to the American Heart Association. Out of this, men are more prone to get this disease when compared to females.

The incidence of this disease is mainly found among individuals of age between 30 to 65. Out of this male to female ratio is 4:1 in India. Among this every 13 patients go for Coronary Artery Bypass Grafting for every 4 females.

By 2020, according to the WHO, the number of Indian citizens dying each year from heart disease will exceed 2.4 million, more than twice the number in 1990. One of every four cardiac patients in the world will be an Indian.

A high resting heart rate has been associated with increased cardiovascular disease mortality and increased risk of sudden death from uncomplicated myocardial infarction. It is projected that coronary artery disease mortality rates will double since 1990 -2020, with approximately 82% of the increase attributable to the developing world.

Regular physical exercise has both indirect and direct effects on the cardiovascular system, both of which can enhance functional capacity and reduce the resting heart rate in patients with uncomplicated myocardial infarction. Indirect benefits are reduction in cardiovascular risk factors, strengthening of the skeletal muscles, and life style modifications. This in turn gives the direct benefits such as slowing of resting heart rate, a reduction of blood pressure, and increase in peripheral vascular tone, an expansion of plasma volume, an increase of myocardial contractility, coronary blood flow, an increase in coronary vessels density and the threshold for myocardial fibrillation are obtained.

The risk factors for this disease include Tobacco Smoke, High blood pressure, Physical Inactivity, High blood cholesterol, Obesity and Overweight. The normal LDL level is considered to be in between 70 - 130 mg/dl of blood.

Patients with Coronary Artery Disease have relatively low levels of HDL and increased level of LDL. The increase of incidence to Coronary Artery Disease is found to be increasing with increase in Body Mass Index and also relate to Body fat distribution.

Several treatment procedures are available for treating Coronary Artery Disease such as Percutaneous Transluminal Coronary Angioplasty, medications, stent insertion etc. But Coronary Artery Bypass Grafting is the most followed procedure for multiple blocks. This is the bypass of blood by doing an Aortic-coronary bypass, thereby restoring the normal blood supply to the myocardium.

Obesity has a significant adverse effect on various Coronary Artery Disease. Cardiac rehabilitation is the Process of restoring psychological, social and physical functions in people with manifestations of a Heart disease. Cardiac Rehabilitation program includes the traditional Myocardial Infraction, Coronary Artery Bypass Grafting, Congestive Heart Failure, Heart Transplantation, Exercise induced Ischemia, Peripheral vascular disease, coronary angioplasty, valvular repairs and elderly patients.

Phase II cardiac rehabilitation is an out-patient phase of rehabilitation which consists of various rehabilitation protocols. Phase II Cardiac Rehabilitation is a medically monitored exercise program designed for those who have had a recent heart illness or surgery / procedure. This program mixes regular physical exercise with risk factor modification in order to help with recovery and strengthen the body. Phase II Cardiac Rehabilitation will usually begin anywhere between 1 and 4 weeks after being discharged from the hospital.

Those who have had heart attacks, angina, angioplasty, and stenting usually begin rehabilitation within 1 week. Those who have had open heart surgeries generally start anywhere between 1 and 4 weeks after discharge from the hospital. Usually, the mode is bicycle, treadmill, a rowing machine, a sitting bike (Nu-Step) or an upper extremity bicycle (Monarch). Mode is also determined by the level of monitoring the Phase II program uses.

1.1 NEED FOR THE STUDY

The phase II cardiac rehabilitation has been proven beneficial for both obese and non-obese patients in improving Body Mass Index, Body fat percentage and quality of life. Circuit Training has been a contemporary approach to enhance and promote an individual's functional capacity, especially in patients with cardiac disorders. This effect of Circuit training incorporated in phase 2 cardiac rehabilitation and its benefits on Body Mass Index, Body fat percentage and Quality of life has been proven. But, there is no study available to compare the effect of phase II cardiac rehabilitation between obese and non-obese patients. Thus the need for the study.

1.2STATEMENT OF PROBLEM

To analyze the effect of phase II cardiac rehabilitation on body mass index, body fat percentage and quality of life for obese and non-obese patients with coronary artery bypass grafting.

1.3 KEYWORDS

Cardiac rehabilitation

Coronary artery bypass grafting

Circuit training

Obesity

1.4OBJECTIVES

1. To find the effect of phase II cardiac rehabilitation on Body Mass Index, Body Fat Percentage and Quality of life for obese patients with Coronary Artery Bypass Grafting.

2. To find the effect of phase II cardiac rehabilitation on Body Mass Index, Body Fat Percentage and Quality of life for non-obese patients Coronary Artery Bypass Grafting.

3. To find the effect of phase II cardiac rehabilitation on Body Mass Index, Body Fat Percentage and Quality of life between obese and non-obese patients Coronary Artery Bypass Grafting.

1.5HYPOTHESIS

NULL HYPOTHESIS

There is no significant difference in BMI, Body fat percentage and Quality Of Life between obese and non-obese patients with Coronary Artery Bypass Grafting after phase II cardiac rehabilitation.

ALTERNATE HYPOTHESIS

There is a significant difference in Body Mass Index, Body fat percentage and Quality Of Life between obese and non-obese patients with Coronary Artery Bypass Grafting after phase II cardiac rehabilitation.

II. REVIEW OF LITERATURE

CARL J LAVIE,MD,FCCP, RICHARD V MILANI,MD (1996)

Modest reductions in BMI, obesity and severe obesity occur after cardiac rehabilitation.

ORNISH JOHN 1990, SCHULER (1992)

Increasing evidence suggest that combining a low fat diet and intense exercise training improve myocardial perfusion by regression of coronary arteriosclerosis.

HARTUNG GH, SQUAIRES WG, GOTTO AM (1990)

Greater effects of exercise training on plasma high- intensity lipoprotein cholesterol is seen in coronary disease patients

ANDREW JS COAST et al (2000)

Home based exercise training results in improving exercise capacity and in Quality of life.

FLETCHER GF et al (2001)

Aerobic exercise is clearly beneficial on lowering mortality compared to a sedentary life style in myocardial infarction patients.

WENGER NK et al (1995)

Aerobic exercises after myocardial infarction improves exercise tolerance, coronary risk factors, psychological well being and health related Quality of life

HAENNEL RG (1991)

Suggested that well being structured, properly supervised circuit training programs can be safe and beneficial for patients after coronary artery bypass grafting.

JIM MERILL (1997)

Phase 2, out- patient training with light dumbbells and elastic bands, has been successfully initiated as early as 3 to 8 weeks after a myocardial infarction or coronary artery bypass grafting

DENDALE P et al (1992)

The incidence of major adverse cardiac events and rest enosis were significantly lowered when coronary artery bypass grafting patients are included in the cardiac rehabilitation program.

MICHEAL D KENNEDY (1983)

Concluded that there is a significant improvement in Quality of life after participating in cardiac rehabilitation program.

ELLRAALZ AD (1986)

Concluded that there is an improvement of left ventricular contractile function in patients with coronary artery bypass grafting after phase 2 cardiac rehabilitation.

MARTIN MORENO V et al (2001)

Concluded that OMRON HBF 306 monitor satisfies the precision criteria and validation and is a valid alternative to cutaneous folds as a method of assessing the patient

G SUN, C FRENCH et al (2005)

Concluded that DXA and BIA is valid for determining body fat mass

C J LAVIE, MILANI MD (1996)

Concluded that phase 2 cardiac rehabilitation and exercise training is effective in obese patients with coronary artery disease.

WOOD PD (1988)

Concluded that there is a significant change in plasma lipids and lipoproteins in overweight men during weight loss through exercise.

YAGESH BHAMBHAMI, GRAY ROWLAND (2005)

Significant changes were seen in BMI, after circuit training in patients with moderate obesity.

MARK A ANSHEL (2006)

Concluded that there is significant changes in BMI and body fat percentage after circuit training in college students

ERIC T, PHILIP A ACHS (2000)

Stated that there is a significant change in non-obese patients after resisted type circuit training.

WILLIAMS P T, KRAURS R M (1990)

Concluded that exercise induced weight loss is effective in reducing lipoprotein level

JOLLIFFE T A , R EESK, TAYLOR R S (2005)

Concluded that exercise based cardiac rehabilitation is very effective in reducing lipoprotein levels

MASKIN C S et al(1986)

Circuit training usually lower the heart rate, blood pressure and lipid level in cardiac patients

LAVIE C J et al (1996)

Concluded that phase 2 cardiac rehabilitation is effective in patients who are overweight.

23. L. BERGFELDT, et al., (1999)

The physical training can be performed without complications in the subjects recovering from an acute coronary event and with a successful modification of exercise capacity and heart rate variability as a result.

J.THOMPSON et al., (2009)

After 12 weeks of moderate intensity exercises, the subjects decreased with five risk factors for cardio respiratory disease; percent body fat, fasting glucose, LDL cholesterol, systolic blood pressure, and sedentary lifestyle.

MARGARET A. MAHER et al., (2003)

Circuit training to reduce one's risk for cardiovascular disease is strongly recommended in the consensus statement from the centers for Disease control and Prevention and the American College of Sports Medicine.

A.STAHLE et al., 1999

A regular aerobic group training program me after an acute coronary event can significantly improve exercise capacity and modify heart rate variability in a prognostically favourable direction in elderly low-to-intermediate risk patients, recovering from an acute coronary event.

KARVONEN M. J et al., 1957

The target intensity needed to induce an aerobic training response corresponded to 60% to 70% of the individual's maximal oxygen uptake.

S.STREUBER et al., 2009.

The short term aerobic training can favourably modify heart rate recovery in patients with coronary artery disease with low exercise capacity.

YOSEFPARDO, M.D., et al., 2000

Exercise conditioning improves heart rate variability in cardiac patients. It lowers the risk of sudden cardiac death via increased vagal tone, which likely beneficially alters ventricular fibrillatory and ischemic thresholds.

AALOK AGARWALA et al., 2000

An average of 10 weeks (range of 6-12 weeks with a mean of 30 sessions) of exercise training should be prescribed in patients post cardiac events to achieve similar results in heart rate variability.

L. BERGFELDT, et al., 1999

The physical training can be performed without complications in the subjects recovering from an acute coronary event and with a successful modification of exercise capacity and heart rate variability as a result.

IMAI K, et al., 1994.

Heart Rate Recovery is correlated with vagal reactivation, which is thought to be primarily important during the first minute after exercise. Because increased vagal tone is associated with reduced risk of death among people with and without cardiovascular disease.

M.PUHAN, et.al. 2005.

Resistance training should be routinely incorporated in

Cardiac rehabilitation. It improves muscle weakness and atrophy.

R.GOSSELINK, 2002.

Whole body endurance training at a high intensity resulted in significant improvements in quality of life, exercise and peripheral muscle force in CABG patients.

ORTEGA F, Toral J.

The combination of strength and endurance training seems an adequate training strategy for CABG patients.

SARAH BERNARD; INSTITUTE DE CARDIOLOGIE et.al.,

Chronic inactivity and muscle deconditioning are the important factors in the loss in muscle mass and strength.

LEVSO, HONVOH F, 1982.

Exercises are a beneficial one for the CABG patients and to be improving the quality of life of CABG patients.

ACSM, (1999).

According to ACSM (1999) these recommendation aerobic training calls for rhythmical dynamic activity of large muscles. Performed 3-4 times a week for 20-30 minutes per session at an intensity corresponding to 60-80% of maximum heart rate.

ANDREW J(1997)

Moderate intensity CWT is safe and can improve strength in selected low-risk patients after coronary artery bypass surgery.

DL BALLOR(1988)

Concluded that weight training results in comparable gains in muscle area and strength for DPE and EO. Adding weight training exercise to a caloric restriction program results in maintenance of LBW compared with DO.

MARX, JAMES O(2001)

Significant improvements in muscular performance may be attained with either a low-volume single-set program or a high-volume, periodized multiple-set program during the first 12 wk of training in untrained women.

MILLER BJ(1994)

Concluded that circuit training has significant effect on reducing body fat percentage in older men.

ACSM(1984)

Concluded that high-intensity, variable-resistance strength training produces adaptative improvement in cardiovascular function.

AL HICKS et al(2003)

Concluded that long-term circuit training exercise has significant gains in both physical and psychological well-being.

Dr. JACK H(2004)

Circuit training resulted in improved fitness and had a positive impact on factors related to quality of life.

DAVID RS, et al(1990)

In patients with CAD, circuit training is effective method of increasing aerobic performance and strength

JENNIFFER H(2003)

Circuit training, can be used as an adjunct to routine therapy, in patients with a history of CAD.

III.METHODOLOGY

3.1 STUDY DESIGN

Comparative Study design

3.2 STUDY SETTING

Department of cardiology, K G Hospitals and post graduate medical institute, Coimbatore

3.3 STUDY DURATION

The duration of the study was 6 months

3.4 SAMPLING METHOD

All obese and non-obese patients with CABG, who are referred to the Department of Physiotherapy, K G Hospital for phase II cardiac rehabilitation, were selected. Among them by using purposive sampling method 15 obese and non-obese patients with CABG were selected and assigned into Group A and Group B. Group A consists of 15 obese patients, Group B consists of 15 non- obese patients.

3.5 CRITERIA FOR SELECTION

INCLUSIVE CRITERIA

Obese and non- obese male patients with and without diabetes mellitus and hypertension

Age group between 45-55

Patients who underwent triple vessel CABG

Patients who underwent CABG with warm blood cardioplegia

Non-smoking patients

EXCLUSIVE CRITERIA

Female patients

Patients with acute episodes of myocardial infraction

Patients treated with lipid lowering medications

Patients who underwent CABG with other methods of cardioplegia.

3.6 DEMOGRAPHIC DATA

NON-OBESE PATIENTS

S NO:

NUMBER OF PATIENTS

AGE

BMI

BODY FAT PERCENTAGE

DIABETES MELLITUS

HYPERTENSION

1

3

31

-

-

NO

NO

2

1

40

-

-

-

YES

3

4

35

22

15

NO

NO

4

2

37

-

-

YES

NO

5

5

36

21

17

-

NO

6

6

-

20

16

NO

-

OBESE PATIENTS

S NO:

NUMBER OF PATIENTS

AGE

BMI

BODY FAT PERCENTAGE

DIABETES MELLITUS

HYPERTENSION

1

3

31

-

24

NO

NO

2

2

42

25

-

-

NO

3

4

35

28

23

YES

-

4

1

32

27

-

NO

-

5

2

40

-

-

YES

YES

6

3

41

26

25

-

NO

7

5

-

29

22

NO

YES

3.7 MEASUREMENT TOOLS

Body Mass Index

Body Fat Percentage

Quality Of Life

3.8 OPERATIONAL TOOLS

Body Fat Analyser (Omron HBF-306)

Weighing machine

Inch tape

National Audit Quality Of Life Questionnaire for cardiac rehabilitation

3.9 PROCEDURE

15 obese patients were included in Group A and 15 Patients who were non-obese were included in Group B

Each patient's maximum heart rate was calculated by -

Heart rate (max) = 220-Chronological Age

Targeted heart rate was calculated using Karvonen's formulae -

THR = 60% to 70% of maximum heart rate.

Both the Groups underwent phase 2 cardiac rehabilitation.

The protocol consisted of 3 phases

Warm-up 2. Circuit training 3. Cool down phase.

Frequency- 2 to 3 times daily

5 sessions per week

Intensity - 60%-75% of heart rate(max)

Time - 30 minutes of conditioning exercise

10 minutes of warm-up

10 minutes of cool-down

Type - Aerobic / Endurance training in dynamic movement.

WARM UP PHASE

This phase consists of 10 minutes of duration which includes light exercises involving maximum number of joints with large muscle groups. Continuous Training is performed at sub-maximal level of exercise including Free Exercises, Stretching, Calisthenics and Light Isometric Exercises.

CIRCUIT TRAINING

This phase extends up to 30 minutes consisting of 6 stations. Each station is attended by the patients for 5 minutes of duration.

Stations

Treadmill

Biceps curl

Cycling

Lateral arm raise/alternate knee raise

Step march

Wall press-up

Out of this treadmill, cycling and step march is used for cardiovascular endurance and biceps curl, lateral arm raise and wall press ups are used for muscular strength endurance development.

Progression

The emphasis should be on improving cardiovascular endurance and greater duration of cardiovascular work may be achieved by individuals being encouraged to adopt some of the cardiovascular alternatives at even station numbers.

Station 1 Treadmill - via speed / Gradient

Station 2 Biceps Curls - via increasing the range of motion

Station 3 cycle - via resistance setting

Station 4 lateral Arm raise - via increasing range of motion

Station 5 step march - via increasing the height of the steps

Station 6 Wall Press Up - via increasing the range of motion

The intensity of the MSE component may be progressed by introducing dumbbells or resistance bands

Although individuals will vary considerably in the amount of cardiovascular work they can achieve it is suggested that for the treadmill, a walking speed of 2.5 to 3.0 miles per hour can be prescribed with the gradient altered to elicit a heart response within the target training heart rate range.

The cycle, 50 to 55 revolutions per minute is prescribed and the step height altered to elicit a heart response within the target training heart rate range.

The steps, a stepping speed between 18 to 24 cycles per minute is prescribed and the step height altered to elicit a heart rate response within the target training heart rate range.

COOL DOWN PHASE

This phase extend up to 10 minutes of duration. This consists of light graded exercises like isometric and large group muscle stretch

3.10 STATISTICAL TOOLS

Paired 't' test

Where,

n = Total number of subjects

SD = Standard deviation

d = Difference between initial and final value

= Mean difference between initial and final value.

IV. DATA ANALYSIS AND INTERPRETATION

TABLE: I

BODY MASS INDEX- PRE TEST AND POST TEST VALUES OF GROUP A

S. NO:

BMI

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

27.5

5

1.33

14.3

17.98%

2.

Post test

22.5

From the above table, the calculated value of 't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of BMI in group A.

GRAPH 1

GRAPHICAL REPRESENTATION OF BODY MASS INDEX FOR GROUP A

TABLE: 2

BODY FAT PERCENTAGE - PRE TEST AND POST TEST VALUES OF GROUP A

S. NO:

Body Fat Percentage

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

23.3

10.7

0.61

66.9

45.85%

2.

Post test

12.6

From the above table, the calculated value of't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of Body Fat Percentage in group A.

GRAPH 2

GRAPHICAL REPRESENTATION OF BODY FAT PERCENTAGE FOR GROUP A

TABLE: 3

QUALITY OF LIFE - PRE TEST AND POST TEST VALUES OF GROUP A

S. NO:

Quality Of Life

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

38.7

21.2

1.22

67.4

54.9%

2.

Post test

17.5

From the above table, the calculated value of 't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of Quality Of Life in group A.

GRAPH 3

GRAPHICAL REPRESENTATION OF QUALITY OF LIFE FOR GROUP A

TABLE :4

BODY MASS INDEX- PRE TEST AND POST TEST VALUES OF GROUP B

S. NO:

BMI

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

20.8

1.1

0.99

4.43

5.43%

2.

Post test

19.7

From the above table, the calculated value of 't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of BMI in group B.

GRAPH 4

GRAPHICAL REPRESENTATION OF BODY MASS INDEX OF GROUP B

TABLE :5

BODY FAT PERCENTAGE- PRE TEST AND POST TEST VALUES OF GROUP B

S. NO:

Body Fat Percentage

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

16.1

4.2

0.83

19.2

25.76%

2.

Post test

11.9

From the above table, the calculated value of 't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of Body Fat Percentage in group B.

GRAPH 5

GRAPHICAL REPRESENTATION OF BODY FAT PERCENTAGE OF GROUP B

TABLE: 6

QUALITY OF LIFE - PRE TEST AND POST TEST VALUES OF GROUP B

S. NO:

Quality Of Life

Improvement

Paired 't' test

(p>0.05)

Percentage Difference

Mean

Mean difference

Standard deviation

1.

Pre test

38.5

12.3

2.13

22.5

32%

2.

Post test

26.2

From the above table, the calculated value of 't' was greater than the tabulated value of 't' (1.833) at 5% level of significance. The result showed that there is a significant difference in pre and post test values of Quality Of Life in group B.

GRAPH 6

GRAPHICAL REPRESENTATION OF QUALITY OF LIFE OF

GROUP B

GRAPH 7

GRAPHICAL REPRESENTATION OF PERCENTAGE DIFFERENCE BETWEEN GROUP A AND GROUP B FOR BODY MASS INDEX

GRAPH 8

GRAPHICAL REPRESENTATION OF PERCENTAGE DIFFERENCE BETWEEN GROUP A AND GROUP B FOR BODY FAT PERCENTAGE

GRAPH 9

GRAPHICAL REPRESENTATION OF PERCENTAGE DIFFERENCE BETWEEN GROUP A AND GROUP B FOR QUALITY OF LIFE

V. DISCUSSION

Coronary artery disease is a condition in which plaque builds up inside the coronary arteries which supply blood to the heart. Many patients have to undergo coronary artery bypass grafting in order to restore adequate blood supply to the myocardium. Physiotherapy has to be started prior to the surgery which continues in 4 phases after the surgery. The second phase is the early out-patient phase where the patient is trained for developing both his cardio vascular endurance as well as muscular strength.

Having the above statement in mind, the focus of the study was to evaluate the relative effects of a particular phase of cardiac rehabilitation on the Body Mass Index, Body Fat Percentage and eventually the Quality Of Life in a characteristically diverse population who are obese who underwent coronary artery bypass grafting surgery for coronary artery disease and compared the same parameters with patients not classified as obese.

15 obese patients and 15 non-obese patients were taken who underwent CABG, fulfilling the inclusive and exclusive criteria. By purposive sampling method they were divided into Group A and Group B, were Group A was obese patients and Group B was non-obese patients.

On reviewing various literatures between 1960 to 1994, overall percentage of obese population has increased from 12.8% to 22.5%, where in males it seems to have from 10.4% to 19.9%

According to Riyun Jin et al., 2005, Obesity is a major risk factor for atherosclerosis formation which is the root cause for myocardial infarction. High levels of LDL cholesterol account for this reason.

Obese acute coronary syndrome patients are hospitalized more frequently during the first ten years of their illness than non-obese patients. They also tend to increase higher cumulative inpatients medical costs, especially in very obese patients. Findings highlights the opportunities for therapeutic benefits that aggressive weight management and secondary prevention that may provide this population better outcome.

Obesity research (2002) Duke clinical research institute, North Carolina. Kristine Napier., 2006, concluded that obesity is strongly related with the cause for the formation of blocks in the coronary arteries. Peter C Hill et al., 2008, concluded that about 75% of patients undergo CABG for the purpose of restoring adequate blood supply to the myocardium.

The correlation between Body Mass Index, Body Fatness is fairly strong; however the correlation varies by sex, race and age. For example Men and Women can share the same BMI, but women can have more Body fat than men. Similarly, at the same BMI, older people on average tend to have more body fat than younger adults.

Therefore it was important to remember that BMI is not a direct measure of body fatness and that BMI is calculated from an individual's weight and height, where weight includes both muscle and fat. (Centre for disease Control and Prevention, July 27, 2009)

Keeping this above statement in mind, it was decided to take both BMI, Body fat percentage are two different outcome measures for the study.

An increasing proportion of patients undergoing coronary artery bypass grafting are obese and are thought to carry a higher morbidity and mortality in association with surgery, but data on whether health related Quality of Life improve similarly after coronary artery bypass grafting in obese and non-obese patients are limited. (Jarvinan O, World Journal Surgery Feb 2007)

Subjects with abnormally higher BMI values are prone for CAD to greater extends, according to Malina R M et al., 2005. Brochu M et al., 2000, concluded that Body Fat Percentage has got a direct relation with the incidence of occurrence of CAD in men. According to D Caprio L et al., 1980, Quality Of Life is increased to a greater extend in patients after CABG.

According to Marek Farenc et al., 2006, non obese patients have a reduced risk of developing CAD. Another main risk factors predisposing to CAD are hypertension and diabetes. Urata H., 2004, concluded that hypertension is a major risk factor leading to CAD. According to Coll Cardiol., 2003, diabetes is a major risk factor for unstable CAD.

Phase 2 cardiac rehabilitation is an out-patient phase of rehabilitation which consists of various rehabilitation protocols. This usually begins anywhere between 1 and 4 weeks after been discharged from the hospital.

Cardiac rehabilitation and exercise training have been proven to have beneficial effects on coronary heart disease risk factors including improving plasma lipids, insulin sensitivity, obesity individuals, exercise capacity and favourability affecting psychological function, behavioural characteristics and overall Quality of life.

Recent studies also have indicated significant effects of cardiac rehabilitation on reducing cardiac mortality even after coronary artery bypass grafting.

Vibhuthi N Singh et al., 2008, concluded that phase II cardiac rehabilitation is effective and safe for patients who had undergone CABG. Lavie C J., 1997, concluded that phase II cardiac rehabilitation is effective in reducing body fat percentage and improving functional ability of post CABG patients. Lavie C J., 1996, concluded that phase II cardiac rehabilitation is very effective in reducing fat in obese patients which is a major risk factor. Richard V Milani 1998, concluded that phase II cardiac rehabilitation is having less influence on fat reduction in non obese patients but significant improvements in exercise capacity.

VI. CONCLUSION

Statistical analysis was done using Student paired 't' test which was used to compare between the pre test and post test values. The changes in parameters for both the groups were analyzed by calculating the percentage difference, which had occurred after the treatment.

The results showed that there was a significant reduction in BMI (17.98%), Body Fat Percentage (45.85%) and improved Quality Of Life (54.9%) in obese patients. Although changes occurred in non obese patients also, the reduction in BMI (5.48%), Body Fat Percentage (25.76%) and improvement in Quality of Life (32%) was not well pronounced as in the obese group. So, comparatively phase II cardiac rehabilitation in which circuit training was included had better effects on Group A (obese patients) compared to Group B (non obese patients).

This study therefore rejects the null hypothesis and supports the alternate hypothesis.

VII. LIMITATION AND RECOMMENDATION

LIMITATIONS

Dichotomous variables were chosen for the study

Heterogeneity of groups

Only male patients were included

Small sample size

Pre- morbid status of the patients were not taken into account

Only patients with coronary artery bypass grafting are taken

Psychological status not evaluated

Dietary pattern was not considered

Diabetic and Hypertension medications taken by the patients was an uncontrollable factor

RECOMMENDATIONS

Monogenecity of groups to be considered

Female patients can be included for the study

Larger age group can be considered

Sample size can be increased

Pre-morbid status should be considered

Patients who underwent treatment with Percutaneous Transluminal Angioplasty, Stent Placement or other interventions for coronary artery disease can be included for the further study

Psychological and Dietary factors can be considered

VIII. BIBLIOGRAPHY

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American College of Sports Medicine. Guidelines for exercise testing and prescription. 3rd ed. Philadelphia: Lea & Febiger,1986; 157-72

Schotte DE, Stunkard AJ. The effects of weight reduction of blood pressure in 201 obese patients. Arch Intern Med 1990;150:1701-04

Scherrer U, Nussberger J, Torriani S, et al. Effect of weight reduction in moderately overweight patients on recorded ambulatory blood pressure and free cytosolic platelet calcium. Circulation 1991; 83:552-58c Lavie CJ, Milani RV.

Effects of cardiac rehabilitation and exercise training to improve low-density lipoprotein cholesterol in patients with hypertryglyceridemia and coronary artery disease. Am J Cardiology 1994; 74:1192-9

Kannel WB, Belanger A, D'Agostino R, et al. Physical activity and physical demand on the job and risk of cardiovascular disease and death: the Framingham study. Am Heart J 1986; 112:820-24

Blair SN, Kohl HW III, Barlow CE, et al. Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995; 273:1093-98

Lavie CJ, Milani RV. Benefits of cardiac rehabilitation [letter]. Arch Intern Med 1993; 153:2603

Lavie CJ, Milani RV. Patients with high baseline exercise capacity benefit from cardiac rehabilitation and exercise training programs. Am Heart J 1994; 128:1105-09

BOOKS:

ACSM'S guidelines for exercise testing and prescription, 6th edition, Lippincott Williams and wilkins.

Carolyn Kisner, MS, PT, Therapeutic Exercise Foundation and Techniques, 4th Edition, Jaypee Brothers , Newdelhi 2003.

Donna frownfelter, PT, Dpumat, Cardiovascular and Pulmonary Physical Therapy 4th Edition, Mosby Elsevier Company, Philidelphia 2006.

Ellen A Hillegan, Ed.D, PT CCC, Essentials Of Cardiopulmonary Physical Therapy, 2nd Edition, WA Saunders Company, USA 2000.

Jennifer A Pryor, MBA, Msc, FNZS, Physiotherapy for Respiratory and Cardiac Problems, 3rd Edition, Elseiver, INDIA, 2004.

Jonnathan N Myer, Phd, Essentials Of Cardiopulmonary Exercises Testing, Human Kinetics, USA 1996.

Kothari, CR. Research Methodology Methods and Techniques, edition -1991, Vishwaprakasam, Newdelhi, 2001.

Mandy Smith, MCSP, SRP, Cash Textbook of Cardiovascular Respiratory Physiotherapy, Mosby Elsevier, UK 2005.

Michael I Powllock, Phd, Heart Disease and Rehabilitation, 3rd Edition, Human Kinetics USA 1995.

P.S.S. Sundar Rao and J. Richard , Introduction to Biostatistics, 3rd edition, 2001, Prentice Hall Of India, Pp:77-80.

Rob Hebert, BAppsc, Mappsc, Phd, Practical Evidence Based Physiotherapy, Elsevier, USA 2005.

Robert A, ROBERGS, Phd, FASEP, Fundamental Principles Of Exercise Physiology. The Mc Grawhill Companies USA 2000.

Scott Irwin, DPT, CCS, Cardiopulmonary Physiotherapy, 4th Edition, Mosby Elsevier Company, Philadelphia 2004.

Stuart BA.Porter, Bsc Hons Gard Dip Phys MCSP, SRP Cer MHS, Tidy's Physiotherapy, 13th edition , Elsevier science limited, New Delhi 2005.

William d mc cardle, Exercise Physiology, 4th Edition A Wolters Kluwer Company, Baltimori Maryland 1996.

William e Deturk, PT, Phd, Cardiovascular and Pulmonary Physical Therapy.

IX. APPENDIX

APPENDIX - I

CARDIO PULMONARY ASSESSMENT

DEMOGRAPHIC DATA:

Name: Age:

Sex:

Occupation: Date of admission:

Height: Date of assessment:

Weight:

Present complains:

HISTORY

Past medical history :

Present medical history :

Family history :

Social history :

Associated problems :

Vital signs

Blood pressure :

Respiratory rate :

Heart rate :

Temperature :

OBJECTIVE ASSESSMENT

On observation:

Built :

Colour :

Chest Shape :

Symmetry :

Breathing pattern :

Respiratory rate :

Chest movement :

Intercostals retraction :

Periphery/extremities :

Clubbing :

Cyanosis :

Oedema :

Respiratory distress :

Type of respiration :

Usage of accessory muscles :

Vocal fremitus :

On palpation:

Tracheal deviation :

Chest expansion

Axillary level :

Nipple level :

Xiphoid level :

Tenderness

Oedema

On examination

On auscultation

Lung sounds :

Breath sounds :

Heart sounds :

Percussion :

Investigation

X-Ray :

ECG :

Echocardiogram :

ABG analysis :

Blood test :

Exercise tolerance :

Diagnosis

APPENDIX II

CHARTS AND QUESTIONAIRE

BMI (www.weightloss.co.cc)

BODY FAT PERCENTAGE (www.builtlean.com)

NATIONAL AUDIT CARDIAC REHABILITATION

QUALITY OF LIFE QUESTIONAIRE (www.cardiacrehabilitation.org.uk)

PHYSICAL FITNESS During the past week what was the hardest physical activity you could do far at least 2 minutes?

Very heavy 1

Heavy 2

Moderate 3

Light 4

Very light 5

FEELINGS During the past week how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable or downhearted and blue?

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

DAILY ACTIVITIES During the past week how much difficulty have you had doing your usual activities or task, both inside and outside the house because of your physical and emotional health?

No difficulty at all 1

A little bit of difficulty 2

Some difficulty 3

Much difficulty 4

Could not do 5

SOCIAL ACTIVITIES During the past week has your physical and emotional health limited your social activities with family, friends, neighbours or groups?

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

PAIN During the past week how much bodily pain have you generally had?

No pain 1

Very mild pain 2

Mild pain 3

Moderate pain 4

Severe pain 5

CHANGE IN HEALTH How would you rate your overall health now compared to a week ago?

Much better 1

A little better 2

About the same 3

A little worse 4

Much worse 5

OVERALL HEALTH During the past week how would you rate your health in general?

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

SOCIAL SUPPORT During the past week was someone available to help you if you needed help?

As much as i wanted 1

Quite a bit 2

Some 3

A little 4

Not at all 5

QUALITY OF LIFE How have things been going for you during the past week?

Very well 1

Pretty good 2

Good 3

Pretty bad 4

Very bad 5

APPENDIX III

Machine

BODY FAT ANALYZER (Omron HBF-306)

Omron offers a revolutionary new way of measuring new way of measuring Bioelectric Impedance Analyses that is faster, easier, less intensive and includes a lightweight portable and handheld device making this a simple one step process.

Input of personal values of height, weight, gender and age into the body logic process stand with both feet slightly apart.

Hold the grip electrodes with outstretched arm and wrap middle finger around the groove in the handle. Place the palm of hand on the top and bottom electrode. Put thumb up, resting on the unit.

Hold arm straight out at a 90 degree angle to body. Don't move during measurement.

Push the start button. The display starts turn on.

Electrodes in the hand sensor pads send a low, safe signal through the body.

Body fat content and Body mass index is calculated automatically and displayed in 7 seconds.

APPENDIX IV

CONSENT FORM

This is to certify that I, _______________________________ totally agree to be a subject for the project work "A STUDY TO ANALYZE THE EFFECT OF PHASE II CARDIAC REHABILITATION ON BODY MASS INDEX, BODY FAT PERCENTAGE AND QUALITY OF LIFE FOR OBESE AND NON-OBESE PATIENTS WITH CORONARY ARTERY BYPASS GRAFTING" and I assure that I will not initiate or undergo any other treatment or concurrent exercise program during the course of this study.

I own all the responsibilities of my health condition, if any untoward development happened during the courses of this study.

Date : Signature of the Patient

Date : Signature of the researcher

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