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1.  Gender differences in risk factors of obese patients after cardiac rehabilitation program 
Background:
Obesity is common in patients with cardiovascular disease (CVD) and the vast majority of patients entering into cardiac rehabilitation program (CRP) are obese. Regarding the gender differences, the risk of developing coronary heart disease (CHD) is recognized to be different between obese men and women. So, the purpose of this study was to explore the effect of CRP in functional capacity (FC) and risk factors, such as obesity indexes, lipid profiles, and fasting blood sugar (FBS) in obese men and women with CHD.
Marterials and Methods:
In an observational study between 2000 and 2011, we evaluated a total of 156 obese men and women patients with CHD who were referred to cardiac rehabilitation of Isfahan Cardiovascular Research Institute. Before and after CRP, FC and risk factors were assessed and all the participants completed this period. Data were analyzed with SPSS software version 15. For comparing the mean of outcomes, independent t tests and paired sample t tests were used.
Results:
Data revealed, after CRP, obese women had significant improvement in most evaluated risk factors except total cholesterol (P = 0.05) and FBS (P = 0.09); and obese men had favorable changes in weight (P = 0.00) and body mass index (P = 0.00), FC (P = 0.00) and total cholesterol (P = 0.02); in spite of no significant differences in other lipid profiles. Comparing the 2 groups did not show any significant differences unless high-density lipoprotein cholesterol (P = 0.01) and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (P = 0.02) had greater improvement in obese women.
Conclusion:
We concluded that CRP is an important step initiating the process of risk reduction and restoration of FC in obese men and obese women with CHD under attendance and supervision of physician, nurse, and exercise physiologist.
PMCID: PMC3703080  PMID: 23853652
Cardiac rehabilitation program; coronary heart disease; gender; obesity; risk factor
2.  Is there any difference between non-obese male and female in response to cardiac rehabilitation programs? 
Introduction:
Coronary artery disease (CAD) is the leading cause of death and disability all over the world. A sedentary lifestyle and dyslipidemia are known to be the major risk factors, which play an important role in the progression of coronary artery disease. Regarding gender differences, the risk of developing coronary heart disease is recognized as being different between non-obese males and non-obese females. Hence, the aim of this study is to assess the benefits of a comprehensive cardiac rehabilitation program (CRP) on the functional capacity and lipid profiles, such as, total cholesterol, triglycerides, low density lipoprotein cholesterol, and high density lipoprotein cholesterol in non-obese males and non-obese females with coronary artery disease, and comparing these groups.
Materials and Methods:
We evaluated 585 non-obese males and females with coronary artery disease. All the participants completed the cardiac rehabilitation program for two months, which included 24 exercise training sessions, medical evaluation, and consultation. For investigation of the effects of the cardiac rehabilitation program on the functional capacity and lipid profiles, exercise tests were carried out by each patient, and also, their blood samples were taken on entrance and at the end of this period.
Results:
The findings, following 24 sessions in the cardiac rehabilitation program, showed that the functional capacity (P = 0.00) and all lipid profiles had significantly improved in both the groups, except that the high density lipoprotein cholesterol did not show a significant difference in non-obese females. In addition, comparing the two groups did not show any significant differences in lipid profiles, but the changes in functional capacity were significant (P = 0.00) between the two groups, following the cardiac rehabilitation program.
Conclusion:
The CRP, which was performed by the patients under supervision of a physician and an exercise physiologist, plays a key role in improving the functional capacity (FC) and all lipid profiles in non-obese males and females with coronary artery disease, without any attention to gender differences.
PMCID: PMC3687888  PMID: 23798948
Cardiac rehabilitation program; coronary artery disease; gender; risk factor
3.  The effect of the cardiac rehabilitation program on obese and non-obese females with coronary heart disease 
Introduction:
Obesity is strongly associated with coronary heart disease and it is known as an independent risk factor. So, the aim of this study was to investigate the effects of phase II comprehensive cardiac rehabilitation program on obesity indexes, functional capacity, lipid profiles, and fasting blood sugar in obese and non-obese female patients with coronary heart disease and to compare changes in these groups.
Materials and Methods:
Two hundred and five women with coronary heart disease participated in our study. At the beginning of study, body mass index, functional capacity, and lipid profiles and fasting blood sugar were evaluated; then, these patients were divided into two groups, patients who had BMI≥30 were known as obese and who had BMI<30 were known as non-obese patients. All of them completed the period of cardiac rehabilitation program, and 2 months later, all risk factors were examined for the second time in each group. Data were analyzed with SPSS software version 15. For comparing the mean of outcomes, independent t-tests and paired t-tests were used.
Results:
Data revealed that unless in weight (P=0.00) and functional capacity (P=0.001), there were no significant differences in obese and non-obese female patients, at baseline. As a result of the cardiac rehabilitation program, both groups had significant improvement in functional capacity (P=0.00), weight reduction (P=0.00), triglyceride (P=0.01 and P=0.02, respectively), low-density lipoprotein cholesterol (P=0.01), and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (P=0.00 and P=0.003, respectively). As well, significant improvement was observed in high-density lipoprotein (P=0.01) only in obese female, and non-obese female had significant differences in total cholesterol (P=0.003). However, there were not significant changes in total cholesterol (P=0.05) and fasting blood sugar (P=0.09) in obese female. Also, non-obese females didn’t have favorable differences in high-density lipoprotein cholesterol (P=0.23) and fasting blood sugar (P=0.13). In addition, comparing two groups didn’t show any significant differences in each risk factors except BMI (P=0.03).
Conclusion:
Our study revealed that comprehensive cardiac rehabilitation program results in significant improvement in cardiovascular risk factors and functional capacity at all levels of BMI in female with coronary heart disease.
doi:10.4103/2277-9175.96077
PMCID: PMC3507014  PMID: 23210076
Cardiac heart disease; obesity; risk factor
4.  Does significant weight reduction in men with coronary artery disease manage risk factors after cardiac rehabilitation program? 
Background:
Vast majority of cardiac patients who refer to cardiac rehabilitation program (CRP) are obese and obesity is associated with coronary heart disease (CHD). So, the aim of this study is to investigate the effects of CRP on obesity indexes, lipid profiles, and functional capacity (FC) in obese men with CHD and to explore whether significant weight reduction affected these risk factors and FC or not.
Materials and Methods:
In an observational study, we evaluated 536 patients, including 464 non-obese men and 72 obese men. All participants completed CRP for 2 months; then, obese patients were divided into two groups: patients with weight reduction ≥ 5% and patients who didn’t have significant weight reduction. Data were analyzed with SPSS software version 15. For comparing the mean of outcomes independent t-tests and paired t-tests were used.
Results:
Results showed following CRP, non-obese men had significant improvement in obesity indexes (P = 0.00), lipid profiles (P < 0.05), and FC (P = 0.00) and in obese men, favorable improvement were seen in obesity indexes (P = 0.00), FC (P = 0.00), and total cholesterol (P = 0.02). Comparing two groups revealed that there were significant differences in obesity indexes, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio. In addition, comparing subgroup of obese patients revealed that there were significant differences in FC (P = 0.00) and low-density lipoprotein cholesterol/ high-density lipoprotein cholesterol ratio (P = 0.04).
Conclusion:
CRP has more advantage in management of obesity, FC, and lipid profiles in both obese and non-obese patients. Also, weight reduction may cause greater improvement in FC and fitness levels in obese men with CHD.
PMCID: PMC3906786  PMID: 24523781
Coronary artery disease; obesity; risk factor cardiac rehabilitation program; weight reduction
5.  Effect of Cardiac Rehabilitation Program on Exercise Capacity in Women Undergoing Coronary Artery Bypass Graft in Hamadan-Iran 
Objectives:
The purpose of this study was to determine the effects of cardiac rehabilitation program (CRP) on exercise capacity and rate pressure product (RPP) in Iranian female patients undergoing coronary artery bypass grafting (CABG) in Hamadan, Iran.
Methods:
Sixty women after CABG were assigned into an exercise group (n = 30, mean age 58.5 ± 10.8 years), who performed physical training for 12 weeks, or a control group (n = 30, mean age 59.3 ± 8.6 years) who received usual care. Functional capacity and RPP were evaluated by six minute walking test (6MWT) and exercise test.
Results:
In comparison to before training, significant increases of estimated exercise capacity (10.72 ± 1.30 vs. 7.72 ± 1.6 MET’s, respectively) as well as 6MWT (556 ± 66.1 vs. 375.2 ± 28.1 meters, respectively) were observed in exercise group after 12 weeks training (P<0.001). Women increased their exercise duration time (464.6 ± 107.3 vs. 311.2 ± 101.7 seconds, respectively) by 49.2% and RPP (22361 ± 3206 vs. 20270 ± 2704.1, respectively) by 10.3% after training (P<0.001). However, no significant differences were found before and after CRP in the control group.
Conclusions:
Women referred for rehabilitation have similar levels of compliance and improvement in exercise capacity and supply of oxygen to cardiac muscles (measured by peak myocardial oxygen consumption). After CRP, women demonstrated significant improvements in exercise duration time, 6MWT, RPP and supply of oxygen to cardiac muscles. CRP can play an important role in improving functional independence in women.
PMCID: PMC3075520  PMID: 21566780
Cardiac Rehabilitation; Women’s Health; Treadmill Test; Rate Pressure Product; Walk Test
6.  The Impact of Obesity on Pulmonary Function in Adult Women 
Clinics (Sao Paulo, Brazil)  2008;63(6):719-724.
INTRODUCTION
Obesity can cause deleterious effects on respiratory function and impair health and quality of life.
OBJECTIVE
To evaluate the effects of obesity on the pulmonary function of adult women.
METHODS
An obese group, constituted of 20 women between 20 and 35 years old with a BMI of 35 – 49.99 kg/m2 who were non-smokers and sedentary and had no lung disease were recruited. The non-obese group consisted of 20 women between 20 and 35 years old who were sedentary and non-smokers and had no lung disease and a body mass index between 18.5 and 24.99 kg/m2. Spirometry was performed in all subjects. The statistical analysis consisted of parametric or non-parametric tests, depending on the distribution of each variable, considering p < 0.05 to be statistically significant.
RESULTS
The obese group presented a mean age of 25.85 ± 3.89 years and a mean BMI of 41.1 ± 3.46 kg/m2, and the non-obese group presented a mean age of 23.9 ± 2.97 years and a mean body mass index of 21.91 ± 1.81 kg/m2. There were no significant differences between the obese group and the non-obese group as to the age, vital capacity, tidal volume, forced vital capacity, and forced expiratory volume in one second. However, the obese group presented a greater inspiratory reserve volume (2.44 ± 0.47 L vs. 1.87 ± 0.42 L), a lower expiratory reserve volume (0.52 ± 0.32 L vs. 1.15 ± 0.32 L), and a maximal voluntary ventilation (108.5 ± 13.3 L/min vs. 122.6 ± 19.8 L/min) than the non-obese group, respectively.
CONCLUSION
The alterations evidenced in the components of the vital capacity (inspiratory reserve volume and expiratory reserve volume) suggest damage to the chest mechanics caused by obesity. These factors probably contributed to a reduction of the maximal voluntary ventilation.
doi:10.1590/S1807-59322008000600002
PMCID: PMC2664268  PMID: 19060990
Body Mass Index; Chest Mechanics; Spirometry; Pulmonary Volumes; Maximal Voluntary Ventilation
7.  The impact of obesity on hypertension and diabetes control following healthy Lifestyle Intervention Program in a developing country setting 
BACKGROUND:
The aim of this study was to evaluate the impact of obesity and overweight on diabetes mellitus (DM) and hypertension (HTN) control in a healthy lifestyle intervention program in Iran.
METHODS:
Within the framework of the Isfahan Healthy Heart Program (IHHP), a community trial that was conducted to prevent and control cardiovascular disease and its risk factors, two intervention counties (Isfahan and Najafabad) and one reference county (Arak) were selected. Demographic information, medical history, anti-diabetic and anti-hypertensive medications use were asked by trained interviewers in addition to physical examination and laboratory tests for 12514 adults aged more than 19 years in 2001 and were repeated for 9572 adults in 2007.
RESULTS:
In women, the frequency of HTN control change significantly neither in normal weight nor in those with high body mass index (BMI), waist circumference (WC) or waist to hip ratio (WHR). In men, the frequency of HTN control was only significant among those with high WHR, whereas the interaction between changes in intervention compared to reference area from 2001 to 2007 was significant in men with normal or high WC or WHR. In intervention area, the number of women with high BMI who controlled their DM increased significantly from 2001 to 2007 (p = 0.008), however, this figure decreased in men. In reference area, obesity indices had no significant association with DM control. The percentage of diabetic subjects with high WC who controlled their DM decreased non-significantly in intervention area compared to reference area in 2007. A non-significant increase in controlled DM among men and women with high WHR was observed between intervention and reference areas.
CONCLUSIONS:
Our lifestyle interventions did not show any improving effect on HTN or DM control among obese subjects based on different obesity indices. Other lifestyle intervention strategies are suggested.
PMCID: PMC3252770  PMID: 22247721
Hypertension; Diabetes; Obesity; Control; Prevention; Iran
8.  Cardiopulmonary Rehabilitation, Exercise Training, and Preventive Cardiology: An Overview of a Decade of Research at the Ochsner Heart and Vascular Institute: Presented in part at Grand Rounds, Research Series, Ochsner Medical Institutions, May 17, 1999 
The Ochsner Journal  1999;1(4):177-186.
A decade of research from the Ochsner Heart and Vascular Institute's cardiopulmonary rehabilitation and exercise training programs demonstrates the benefits of this therapy on coronary risk factors, exercise capacity, cardiopulmonary parameters, behavioral characteristics, and quality of life in various subgroups of patients, including the elderly, women, obese patients, and groups with dyslipidemia and psychological distress, as well as in patients with congestive heart failure or severe lung disease. Substantial data from our program support the idea that cardiopulmonary rehabilitation and exercise training programs are underemphasized and underutilized for the secondary prevention of coronary artery disease.
PMCID: PMC3145438  PMID: 21845136
9.  The Effect of a Self Exercise Program in Cardiac Rehabilitation for Patients with Coronary Artery Disease 
Annals of Rehabilitation Medicine  2011;35(3):381-387.
Objective
To investigate the effect of self exercise in cardiac rehabilitation on cardiopulmonary exercise capacity for selected patients with coronary artery disease.
Method
The subjects of this study were patients who received percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery and who participated in a cardiac rehabilitation program. The supervised exercise group participated in 6-8 weeks of aerobic exercise training with telemetry ECG monitoring in hospital. The self exercise group, whose exercise risk was low, was instructed to participiate in self exercise training in a community exercise environment according to the exercise tolerance test (ETT) using a modified Bruce protocol. Both groups underwent ETTs before and 6 months after initiation of the cardiac rehabilitation program. We compared the supervised group with the self exercise groups on exercise capacity.
Results
After 6 months, the supervised exercise group showed significant changes in maximum oxygen consumption, maximal heart rate, resting heart rate, and submaximal rate pressure product. The self exercise group also showed significant improvement of maximum oxygen consumption and submaximal rate pressure product. However, the changing rate of maximum oxygen consumption was significantly higher in the supervised exercise group than the self exercise group.
Conclusion
Both the supervised and self exercise groups showed similar improvement of cardiopulmonary exercise capacity after 6 months' participation in the cardiac rehabilitation program. However, the changing rate of maximum oxygen consumption, maximal heart rate, and resting heart rate were significantly higher in the supervised exercise group than the self exercise group.
doi:10.5535/arm.2011.35.3.381
PMCID: PMC3309221  PMID: 22506148
Coronary artery disease; Exercise; Rehabilitation; Self
10.  Exercise-based cardiac rehabilitation improves hemodynamic responses after coronary artery bypass graft surgery 
ARYA Atherosclerosis  2012;7(4):151-156.
BACKGROUND:
Cardiovascular disorders are an important public health problem worldwide. They are also the leading cause of mortality and morbidity. Therefore, American Heart Association proposed cardiac rehabilitation program as an essential part of care for cardiac patients to improve functional capacity. The aim of this study was to evaluate the effectiveness of cardiac rehabilitation program on functional status and some hemodynamic responses in patients after coronary artery bypass graft (CABG) surgery.
METHODS:
Thirty two patients were selected for this study. All patients underwent cardiac surgery two months before admission. They were allocated to two groups. While the rehabilitation group (n =17, mean age: 62 ± 12 years) completed the cardiac rehabilitation program for two months, the reference group (n = 15, mean age: 58.5 ± 12.5 years) did not have any supervised physical activity during this period. Cardiac rehabilitation program consisted of exercise, nutritional, psychological consultation and risk factor management. At the beginning of the study, functional capacity of patients was evaluated by exercise test, 6-minute walking test and echocardiography. Functional capacity was evaluated for a second time after two months of cardiac rehabilitation. Data were analyzed by SPSS15. For comparing the mean of outcomes, Mann-Whitney test and Wilcoxon signed ranks test were used.
RESULTS:
As a result of cardiac rehabilitation, a significant improvement was observed in the distance walked in the rehabilitation group (P < 0.01) compared to the reference group (P = 0.33). It also caused a significant development in hemodynamic responses to exercise such as resting and maximum systolic and diastolic blood pressure, resting and maximum heart rate, ejection fraction and rate pressure product.
CONCLUSION:
Cardiac rehabilitation significantly improves functional capacity and some hemodynamic responses post coronary artery bypass grafting. Therefore, patients need to be referred to rehabilitation units.
PMCID: PMC3413083  PMID: 23205048
Cardiac Rehabilitation Program; Hemodynamic Responses; Coronary Artery Bypass Graft Surgery (CABG)
11.  The influence of optimal medical treatment on the ‘obesity paradox’, body mass index and long-term mortality in patients treated with percutaneous coronary intervention: a prospective cohort study 
BMJ Open  2012;2(1):e000535.
Objective
To assess whether the obesity paradox persists in the long term and to study the effect of optimal medical treatment on this phenomenon.
Design
A retrospective cohort study.
Setting
A tertiary care centre in Rotterdam.
Participants
From January 2000 to December 2005, 6332 patients undergoing percutaneous coronary intervention for coronary artery disease were categorised into underweight (body mass index (BMI)<18.5), normal (18.5–24.9), overweight (25–29.9) and obese (>30).
Primary outcome measure
Mortality.
Secondary outcome measures
Cardiac death and non-fatal myocardial infarction.
Results
Optimal medical treatment was more common in obese patients as compared with normal weight patients (85% vs 76%; p<0.001). At a mean of 6.1 years, overweight and obese patients had a lower risk of all-cause mortality (HR: 0.75, 95% CI 0.66 to 0.86 and HR: 0.72, 95% CI 0.60 to 0.87, respectively). After adjusting for OMT in the multivariate analysis, BMI did not remain an independent predictor of long-term mortality (HR: 0.90, 95% CI 0.72 to 1.12 and HR: 1.07, 95% CI: 0.80 to 1.43, respectively).
Conclusion
BMI is inversely related to long-term mortality in patients treated with percutaneous coronary intervention. Patients with a normal BMI are on suboptimal medical treatment when compared with those with a high BMI. A more optimal medical treatment in the obese group may explain the observed improved outcome in these patients.
Article summary
Article focus
Whether the obesity paradox persists in the long term.
The effect of optimal medical treatment (OMT) on this phenomenon.
Key messages
Body mass index (BMI) is inversely related to long-term mortality in patients treated with percutaneous coronary intervention.
Patients with a normal BMI are on suboptimal medical treatment when compared with those with a high BMI.
A more optimal medical treatment in the obese group may explain the observed improved outcome in these patients.
Strengths and limitations of this study
Strengths of this study are that we examine the long-term effects of BMI on outcome and we try to explore the mechanisms of the obesity paradox. Limitations of the study are that we cannot prove the mechanism with an observational study and that details about OMT, such as duration of therapy and medication adherence, are lacking.
doi:10.1136/bmjopen-2011-000535
PMCID: PMC3277907  PMID: 22327630
12.  Obesity and statins are both independent predictors of enhanced coronary arteriolar dilation in patients undergoing heart surgery 
Background
A paradoxical inverse relationship between body mass index, morbidity and mortality in patients with ischemic heart disease has been noted; but the underlying mechanisms remain unclear. Given that coronary resistance arteries are the primary regulators of myocardial blood flow, we examined the effects of obesity and medication on dilator function in coronary microvessels.
Methods
Bradykinin-induced coronary dilation was assessed by videomicroscopy in ex vivo coronary arterioles obtained from 64 consecutive patients undergoing heart surgery. Multi-variable linear regression and logistic regression were used to investigate the effects of obesity (BMI ≥ 30 kg/M2) and the influences of medications on vessel responses.
Results
In isolated, pressurized (80 mmHg) coronary arterioles of obese and non-obese patient the active (73±4 vs. 79±13 μm) and passive (111 ± 5.5 vs. 118 ± 5.0 μm) diameters were similar. Bradykinin elicited substantial dilation in coronary arterioles, with a similar magnitude in obese and non-obese patients (to 10-8 M: 55 ± 5% vs. 46 ± 5%, P = 0.20), but with significantly enhanced sensitivity in obesity (EC50: 8.2x10-9 M vs. 1.9x10-8 M, respectively, P = 0.03). When adjusted for other risk factors and medications, obesity and statins were determined to be the only positive predictors of enhanced dilation, as assessed with multiple regression analysis. Moreover, obese patients with or without statin exhibited significantly increased coronary dilation to bradykinin, when compared to non-obese patients without statin therapy.
Conclusions
Obesity and statin therapy are independently associated with an enhanced dilator function of coronary arterioles in patients undergoing heart surgery, which may offer a potential mechanism for the better cardiovascular outcome described earlier as the obesity paradox.
doi:10.1186/1749-8090-8-117
PMCID: PMC3658876  PMID: 23631400
Obesity paradox; Microcirculation; Coronary arteriole; Statin
13.  Effects of a comprehensive cardiac rehabilitation program on quality of life in patients with coronary artery disease 
ARYA Atherosclerosis  2013;9(3):179-185.
BACKGROUND
Health-related quality of life is an important factor to evaluate effects of different interventions in cardiovascular diseases. Improvement in quality of life (QOL) is an important goal for individuals participating in cardiac rehabilitation (CR) programs. The purpose of this study was to assess the impact of comprehensive CR on QOL in patients with cardiovascular disease (CAD).
METHODS
In this quasi-experimental before-after study, the files of 100 patients with CAD who were referred to rehabilitation department of Isfahan Cardiovascular Research Institute were studied using a consecutive sampling method. Data collection was performed from the patient's files including their demographics, ejection fraction, functional capacity, and resting heart rate. All patients participated in a comprehensive CR program and completed the validated questionnaire Short-Form 36 Health Status Survey (SF-36), before and after CR program. Data was analyzed based on sex and age groups (≥ 65 and < 65 years) using independent t-test and paired t-test (to compare variables between groups and before and after CR, respectively).
RESULTS
After CR, scores of all physical domains of the SF-36 including physical function (PF), physical limitation (PL), body pain (BP) and vitality (V) in addition to general health (GH) were significantly improved in all patients (P < 0.05) compared to the baseline. Patients with age < 65 years had greater improvements in mental health (MH) and social function (SF) than patients with age ≥ 65 years (P < 0.05). Women had greater improvement in PF, V and MH compared to men (P < 0.05).
CONCLUSION
These results indicated that CR can improve QOL in cardiac patients especially in women. Elderly patients get benefit the same as other patients in physical domains.
PMCID: PMC3681279  PMID: 23766774
Quality of Life; Cardiac Rehabilitation; Cardiovascular Diseases
14.  Urbanization and Non-Communicable Risk Factors in the Capital City of 6 Big Provinces of Iran 
Iranian Journal of Public Health  2013;42(Supple1):113-118.
Background:
The prevalence of non-communicable diseases such as hypertension and diabetes including obesity has increased over the past few years in Iran. The increase in these diseases has been associated with increased urbanization and lifestyle changes. The burden of non-communicable diseases (NCD) is increasing in low and middle-income countries. The aim of this report is to address the threat of NCDs in the capital city of 6 big provinces of Iran.
Methods:
A community based cross sectional study was carried out between March 2010 to January 2011 in 6 provinces’ capital cities (Isfahan, Karaj, Mashad, Shiraz, Tabriz, and Tehran). Participants were men and women of 30 years and older who had been screened through the National Diabetes Prevention and Control Program. BMI, blood pressure, fasting blood glucose and lipids were measured.
Results:
439406 cases (60% female & 40% male) were studied. The prevalence of pre-diabetes (13%), diabetes (13%), hypercholesterolemia (14%), hypertension (11%), overweight (27%) and obesity (20%) was higher than expected. Only 35% of participants were healthy.
Conclusion:
This study reveals a high prevalence of NCDs in urban living population in those capital cities. It also shows that increasing urbanization may be an important threat to public health regarding NCDs especially in developing countries. It is crucial to implement a comprehensive NCD program (across the life time) in the health system with a strong collaboration with all stakeholders (governmental and non-governmental sector, academic, research centers and scientific associations) in the community (Multisectoral Approaches).
PMCID: PMC3712588  PMID: 23865027
Non-communicable disease; Risk factors; Urbanization; Iran
15.  Operative and early results of coronary artery bypass grafting in female patients in different body mass indexes 
Background
Female gender has been reported to be an independent risk factor for coronary artery bypass grafting (CABG) in European System for Cardiac Risk Evaluation. The effect of the body size on the CABG outcome is less clear. There is ongoing debate about obesity as a risk factor for adverse outcomes after cardiovascular procedures. The goal of this retrospective study is to evaluate the in hospital and early postoperative outcomes in severe obese, obese and normal-slightly obese female patients after CABG.
Methods
In a four year period a total of 427 female patients underwent isolated CABG under cardiopulmonary bypass. The patients were allocated into three groups according to the Body Mass Index (BMI) as follows; group 1: severe obese patients; BMI > 35, group 2: obese patients; 30≤BMI≤35, group 3: normal-slightly obese patients; BMI < 30
Results
The patients in group 3 were older than the group1 and group 2 (65,6 ± 8,3 year vs 63,01 ± 8,0 and 63,57 ± 8,4 year p < 0,05). In group 1 diabetic patients were more than in group 2 and group 3 respectively (54,4% vs 43,4% and 40%, p < 0,05). Urgent operation was more in group 1 than in group 2 and 3 respectively (37,6% vs 17,2% and 21,2% p < 0,05). The patients in group 3 had significantly greater postoperative drainage at 24 h compared with values in group 1 and group 2 (647 ± 142 ml vs. 539 ± 169 ml and 582 ± 133 ml, p < 0,05). Mortality rate in group 1 was 0,8%, 0% in group 2 and 1,2% in group 3 respectively. Wound problem has occured in 41 patients (9,6%).The percentage of postoperative wound problems was higher in group 1 but did not show statiscially difference. Following discharge a total of 43 (10,1%) patients re-hospitalized within 30 days. Re-hospitalization rate was 16,1% in group1, 9,8% in group 2 and 6,5% in group 3 (p < 0,05).
Conclusion
This study may give an aspect for evaluations of the inhospital-early mortality and morbidity after CABG in female patients in different BMI. Severe obesity is not a risk factor in-hospital mortality in female patients. However, severe obese female patients appear to have more wound problems and re-hospitalization rate after CABG compared to obese and normal-slightly obese patients.
doi:10.1186/1749-8090-5-119
PMCID: PMC3006378  PMID: 21110862
16.  Obesity Is Associated with Lower Coronary Microvascular Density 
PLoS ONE  2013;8(11):e81798.
Background
Obesity is associated with diastolic dysfunction, lower maximal myocardial blood flow, impaired myocardial metabolism and increased risk of heart failure. We examined the association between obesity, left ventricular filling pressure and myocardial structure.
Methods
We performed histological analysis of non-ischemic myocardium from 57 patients (46 men and 11 women) undergoing coronary artery bypass graft surgery who did not have previous cardiac surgery, myocardial infarction, heart failure, atrial fibrillation or loop diuretic therapy.
Results
Non-obese (body mass index, BMI, ≤30 kg/m2, n=33) and obese patients (BMI >30 kg/m2, n=24) did not differ with respect to myocardial total, interstitial or perivascular fibrosis, arteriolar dimensions, or cardiomyocyte width. Obese patients had lower capillary length density (1145±239, mean±SD, vs. 1371±333 mm/mm3, P=0.007) and higher diffusion radius (16.9±1.5 vs. 15.6±2.0 μm, P=0.012), in comparison with non-obese patients. However, the diffusion radius/cardiomyocyte width ratio of obese patients (0.73±0.11 μm/μm) was not significantly different from that of non-obese patients (0.71±0.11 μm/μm), suggesting that differences in cardiomyocyte width explained in part the differences in capillary length density and diffusion radius between non-obese and obese patients. Increased BMI was associated with increased pulmonary capillary wedge pressure (PCWP, P<0.0001), and lower capillary length density was associated with both increased BMI (P=0.043) and increased PCWP (P=0.016).
Conclusions
Obesity and its accompanying increase in left ventricular filling pressure were associated with lower coronary microvascular density, which may contribute to the lower maximal myocardial blood flow, impaired myocardial metabolism, diastolic dysfunction and higher risk of heart failure in obese individuals.
doi:10.1371/journal.pone.0081798
PMCID: PMC3843695  PMID: 24312359
17.  Cost-Effectiveness of New Cardiac and Vascular Rehabilitation Strategies for Patients with Coronary Artery Disease 
PLoS ONE  2008;3(12):e3883.
Objective
Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation.
Data Sources
Best-available evidence was retrieved from literature and combined with primary data from 231 patients.
Methods
We developed a Markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of $75 000 was used.
Results
ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44 251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95% CI: −0.17, 0.29) at a threshold willingness-to-pay of $75 000/QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30 246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:−0.24, 0.46) compared to current practice. The results were robust for other different input parameters.
Conclusion
ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only.
doi:10.1371/journal.pone.0003883
PMCID: PMC2587698  PMID: 19065259
18.  Effect of education on anthropometric indices in obese parents and children after one year of follow-up 
ARYA Atherosclerosis  2012;8(1):21-26.
BACKGROUND
Childhood obesity has reached epidemic levels. Children obesity predisposes them to risk of cardiac disease in adulthood. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide. Furthermore, family life style has a great influence on children obesity. This study aimed to determine the effect of family-oriented weight reduction program on the children’s anthropometric measurements.
METHODS
This was a non-pharmacological clinical trial study which was performed on 4-18 years old children attending outpatient clinics of Isfahan Endocrine and Metabolism. Anthropometric measurements were recorded for all the participants. Children took part in one educational session in which they were taught about ways and benefits of having a regular physical activity each day and also benefits of having healthy nutrition. All the participants took part in every 4 months one-hour educational sessions and their anthropometrics were measured.
RESULTS
Fifty eight single-mother families participated in this study. Fourteen single-father families started the intervention but did not follow it to the end. Children’s body mass index (BMI) z-score decreased significantly after the study. Children waist circumference (WC) and hip circumference (HC) significantly increased. Mothers WC and waist to hip ratio (WHR) increased significantly. Regression test showed that mother BMI was an independent factor (B = 0.307; P < 0.021). The effect of the pattern of children’s BMI changed across a one-year period.
CONCLUSION
Our study showed significant effect of repetitive family life style education on children’s BMI z-score changes. Family, as the first place for children behavior formation, must be regarded as one of the best place to tackle childhood obesity.
PMCID: PMC3448397  PMID: 23056096
Children Obesity; Parents; Life Style Intervention; Education; Anthropometric Indices
19.  Body Mass Index, Waist-circumference and Cardiovascular Disease Risk Factors in Iranian Adults: Isfahan Healthy Heart Program 
Considering the main effect of obesity on chronic non-communicable diseases, this study was performed to assess the association between body mass index (BMI), waist-circumference (WC), cardiometabolic risk factors and to corroborate whether either or both BMI and WC are independently associated with the risk factors in a sample of Iranian adults. This cross-sectional study was performed on data from baseline survey of Isfahan Healthy Heart Program (IHHP). The study was done on 12,514 randomly-selected adults in Isfahan, Najafabad and Arak counties in 2000-2001. Ages of the subjects were recorded. Fasting blood glucose (FBG), 2-hour post-load glucose (2hpp), serum lipids, systolic and diastolic blood pressure (SBP and DBP), BMI, WC, smoking status, and total daily physical activity were determined. Increase in BMI and WC had a significant positive relation with the mean of FBG, 2hpp, SBP, DBP, serum lipids, except for HDL-C (p<0.001 for all). After adjustment for age, smoking, physical activity, socioeconomic status (SES), and BMI, the highest odds ratio (OR) (95% CI) for diabetes mellitus (DM) according to WC was 3.13 (1.93-5.08) and 1.99 (1.15-3.44) in women and men respectively. Moreover, the highest ORs based on BMI with adjustment for age, smoking, physical activity, SES, and WC were for dyslipidaemia (DLP) [1.97 (1.58-2.45) in women and 2.96 (2.41-3.63) in men]. The use of BMI or WC alone in the models caused to enhance all ORs. When both BMI and WC were entered in the model, the ORs for all risk factors, in men, according to BMI, were more compared to WC. However, in women, ORs for DM and hypertension (HTN) in WC quartiles were more than in BMI quartiles. BMI is the better predictor of DM, HTN, and DLP in men compared to WC. Conversely, in women, WC is a superior predictor than BMI, particularly for DM and HTN. Furthermore, the measurement of both WC and BMI in Iranian adults may be a better predictor of traditional risk factors of CVDs compared to BMI or WC alone.
PMCID: PMC3805889  PMID: 24288953
Body mass index; Diabetes mellitus; Dyslipidaemia; Hypertension; Obesity; Risk Factor; Waist-circumference; Iran
20.  Effects of Cardiac Rehabilitation Program on Right Ventricular Function after Coronary Artery Bypass Graft Surgery 
Background
Cardiac rehabilitation has been recognized as one of the most effective strategies for managing cardiovascular indices as well as controlling the cardiovascular risk profile, in particular after coronary artery bypass graft surgery (CABG). However, the effect of this program on right ventricular function following CABG is unclear. The aim of this study was to evaluate the impact of cardiac rehabilitation on the right ventricular (RV) function in a cohort of patients who underwent CABG.
Methods:
A total of 28 patients who underwent CABG and participated consecutively in an 8-week cardiac rehabilitation program at Tehran Heart Center were studied. The control group consisted of 39 patients who refused to attend cardiac rehabilitation and only received postoperative medical treatment after registration in the Cardiac Rehabilitation Clinic. Two-dimensional and Doppler echocardiography was performed to assess the RV function in both groups at the three time points of before surgery, at the end of surgery, and at the end of the rehabilitation program.
Results:
Significant increase of RV function parameters were observed in both rehabilitation group (RG) and control group (CG) at the end of the rehabilitation program compared with post-CABG evaluation in terms of tricuspid annular plane systolic execution (RG: 12.50 mm to 14.18 mm; CG: 13.41 mm to 14.56 mm), tricuspid annular peak systolic velocity (RG: 8.55 cm/s to 9.14 cm/s; CG: 9.03 cm/s to 9.26 cm/s), and tricuspid annular late diastolic velocity (RG: 8.93 cm/s to 9.39 cm/s; CG: 9.26 cm/s to 9.60 cm/s).The parameters of the RV function did improve in both groups, but this improvement was not associated with participation in the complete cardiac rehabilitation program.
Conclusion:
The RV function parameters gradually improved after CABG; this progress, however, was independent of the exercise-based cardiac rehabilitation program.
PMCID: PMC3466878  PMID: 23074631
Rehabilitation; Coronary artery bypass; Heart ventricles; Exercise
21.  Effects of orlistat plus diet on postprandial lipemia and brachial artery reactivity in normolipidemic, obese women with normal glucose tolerance: A prospective, randomized, controlled Study 
Background:
Postprandial lipemia (PPL) is an independent predictor of earlyatherosclerosis and coronary artery disease. It is defined as a postprandial triglyceride (TG) level ≥80% higher than the fasting level. Brachial arterial reactivity (BAR) is used to identify early-phase atherosclerosis. Data concerning whether orlistat improves PPL and endothelial function are lacking.
Objective:
The aim of this study was to determine the effects of orlistat on PPL and BAR in normolipidemic, obese women with normal glucose tolerance.
Methods:
This prospective, randomized, controlled study was conducted at Baskent University, Ankara, Turkey. Normolipidemic, obese women aged 18 to 65 years with normal glucose tolerance were eligible for screening. On screening, demographic information, anthropomorphic parameters (body mass index [BMI], waist circumference [WC], hip circumference, waist-hip ratio), BAR, laboratory test results (level of insulin resistance assessed using the homeostasis model assessment-insulin resistance [HOMA-IR] index, serum lipid profile, fasting plasma levels of glucose and insulin [FPI]), and oral fat-loading test results were recorded as baseline values. The primary end points were the effects of orlistat + diet on PPL (assessed using the AUC of TG) and BAR. Women found on screening to be PPL positive were randomly assigned in a 2:1 ratio to treatment with orlistat 120 mg TID plus low-calorie diet (600-kcal/d deficit; minimum, 1200 kcal/d) or low-calorie diet only (control) for 12 weeks. After 12 weeks, all of the above assessments were repeated, and AUC values for lipid parameters were calculated as secondary outcome measures. To assess tolerability and compliance, women were monitored by telephone each week and instructed to return every 4 weeks for clinic visits.
Results:
Twenty-seven women were identified as PPL positive and assigned to the orlistat + diet group (18 subjects) or the control group (9) (mean [SD] age, 45.9 [2.3] years; mean [SD] weight, 87.4 [2.5] kg; mean [SD] BMI, 36.0 [0.8] kg/m2). Treatment with orlistat + diet was associated with significantly greater changes from baseline compared with controls in WC (P= 0.003), fasting and postprandial serum TG levels (P = 0.012 and P < 0.001, respectively), FPI level (P = 0.001), and HOMA-IR index (P < 0.001). Logistic regression analysis found that 12 weeks of treatment with orlistat + diet was associated with a numeric, but statistically non-significant, 4.1-fold change in PPL, which was independent of reductions from baseline in weight and WC. Neither treatment was associated with significant changes from baseline in BAR. The prevalences of gastrointestinal symptoms previously found to be related to orlistat use were statistically similar between the orlistat + diet and control groups (9 [50.0%] vs 3 [33.3%] subjects).
Conclusions:
The results of this small study in normolipidemic, obesewomen with normal glucose tolerance suggest that 12 weeks of treatment with orlistat 120 mg/d plus low-calorie diet was associated with a numeric, but statistically nonsignificant, 4.1-fold change from baseline in PPL, which was independent of reductions from baseline in weight and WC. Treatment with orlistat + diet was associated with significant effects on WC, TG, and level of insulin resistance, but not BAR.
doi:10.1016/j.curtheres.2006.06.001
PMCID: PMC3966008
postprandial lipemia; brachial reactivity; orlistat; obesity.
22.  Effect Modification of Obesity on Associations between Endogenous Steroid Sex Hormones and Arterial Calcification in Women at Midlife 
Menopause (New York, N.Y.)  2011;18(8):906-914.
Objective
To examine whether obesity modify the effects of endogenous steroid sex hormones on arterial calcification in women at midlife.
Methods
Associations between estradiol, testosterone, sex hormone binding globulin and free androgen index and the presence and extent of coronary and aortic calcification were evaluated in 187 obese (body mass index ≥30) and 281 non-obese (body mass index <30) women from the Study of Women’s Health Across the Nation. Logistic and linear regressions were used as appropriate.
Results
Prevalence rates of coronary and aortic calcification were significantly higher among obese compared to non-obese (P <0.001, for both). In multivariable analyses, steroid sex hormones were not associated with presence of coronary calcification. However, for extent of coronary calcification, significant interactions were found between obesity and both sex hormone binding globulin (P<0.0001) and free androgen index (P=0.008). In non-obese women, higher sex hormone binding globulin (P=0.0006) and lower free androgen index (P=0.01) were associated with greater extent of coronary calcification while lower sex hormone binding globulin was associated with greater extent of coronary calcification in obese women (P=0.05). For aortic calcification outcomes, higher sex hormone binding globulin was associated with presence of aortic calcification among non-obese (OR:1.64, 95%CI:1.16, 2.32, for each 1-SD greater sex hormone binding globulin).
Conclusions
Associations between endogenous steroid sex hormones and arterial calcification vary by obesity status among perimenopausal women. Further research is needed to better understand the possible mechanisms.
doi:10.1097/gme.0b013e3182099dd2
PMCID: PMC3181045  PMID: 21471825
atherosclerosis; coronary calcification; aortic calcification; hormones; obesity; sex hormone binding gloublin
23.  Effect of Exercise-Based Cardiac Rehabilitation on Ejection Fraction in Coronary Artery Disease Patients: A Randomized Controlled Trial 
Background:
Exercise training as a part of cardiac rehabilitation aims to restore patient with heart disease to health. However, left ventricular ejection fraction (LVEF) is clinically used as a predictor of long-term prognosis in coronary artery disease (CAD) patients, there is a scarcity of data on the effectiveness of exercise-based cardiac rehabilitation on LVEF.
Objective:
To investigate the effectiveness of exercise-based cardiac rehabilitation on LVEF in early post-event CAD patients.
Patients and Methods:
In a single blinded, randomized controlled trial, post-coronary event CAD patients from the age group of 35-75 years, surgically (Coronary artery bypass graft or percutaneous coronary angioplasty) or conservatively treated, were recruited from Golsar Hospital, Iran. Exclusion criteria were high-risk group (AACVPR-99) patients and contraindications to exercise testing and training. Forty-two patients were randomized either into Study or Control. The study group underwent a 12-week structured individually tailored exercise program either in the form of Center-based (CExs) or Home-based (HExs) according to the ACSM-2005 guidelines. The control group only received the usual cardiac care without any exercise training. LVEF was measured before and after 12 weeks of exercise training for all three groups. Differences between and within groups were analyzed using the general linear model, two-way repeated measures at alfa=0.05.
Results:
Mean age of the subjects was 60.5 ± 8.9 years. There was a significant increase in LVEF in the study (46.9 ± 5.9 to 61.5 ± 5.3) group compared with the control (47.9 ± 7.0 to 47.6 ± 6.9) group (P=0.001). There was no significant difference in changes in LVEF between the HExs and CExs groups (P=1.0).
Conclusion:
A 12-week early (within 1 month post-discharge) structured individually tailored exercise training could significantly improve LVEF in post-event CAD patients.
doi:10.4103/1995-705X.86013
PMCID: PMC3221192  PMID: 22121461
Cardiac rehabilitation; coronary artery disease; ejection fraction; exercise training
24.  Cardiac rehabilitation outcomes following a 6-week program of PCI and CABG Patients 
Coronary artery events requiring intervention are associated with depressed cardiac autonomic function. Whether a 6-week cardiac rehabilitation (CR) differs in effectiveness in improving exercise capacity (6MWT), cardiorespiratory function (peakVO2), and autonomic function (HRV) following either cardiac bypass surgery (CABG) or percutaneous coronary revascularization (PCI) is unknown. The current study therefore compared the change in 6MWT and peak VO2 to HRV variables following a 6-week CR program and with patients having either PCI or CABG. Thirty-eight patients, (PCI, n = 22 and CABG, n = 16) participated in the CR program and results for pre and post 6 min walk test (6MWT), peakVO2, and heart rate variability (HRV) were obtained. Our study has shown that a 6 weeks program following either PCI or CABG improves function. However, the effect on post-CABG differs to that of post-PCI patients. The change in distance walked (6MWT, metres) was higher in the CABG (Δ6MWT: 61, p < 0.001) compared to the PCI group (Δ6MWT: 41, p < 0.001). Maximum exercise capacity (peak VO2, ml/kg.min) also changed significantly with a greater change in the CABG group (ΔPCI: 0.7, p < 0.001; ΔCABG: 1.0, p < 0.001) but did not reach normal population values. Although an improvement in HRV parameters was noted for the PCI group, a statistically significant improvement in HRV was observed only in the CABG group for the following; SDNN (ms) (baseline vs. post-rehabilitation (median ± IQR): 31.2 ± 25.6 vs. 51.8 ± 23.1, p < 0.01), RMSSD (19.32 ± 19.9 vs. 42.1 ± 34.2, p < 0.01); LF (ms2) (191 ± 216 vs. 631 ± 693, p < 0.01) and HF (107 ± 201 vs. 449 ± 795.0, p < 0.05). A significant interaction in the PCI group but not in the CABG group was observed using correlation analysis between the 6MWT and peak VO2 with HRV parameters indicating that being healthier that is, a better 6MWT and peak VO2 led to better HRV results but no significant effect of CR in the PCI group. When the results were investigated for baseline 6MWT and peak VO2 effect using a covariate analysis, a significant influence of CR on HRV parameters was retained in the CABG group (p = 0.0072). Our study indicates that a 6-weeks CR program benefits both patient groups in terms of exercise capacity, cardiorespiratory function and autonomic nervous system modulation of heart rate, with CABG patients showing the most improvement. HRV can be a useful additional variable to gauge cardiac function following CR.
doi:10.3389/fphys.2013.00302
PMCID: PMC3812547  PMID: 24198786
cardiac rehabilitation; exercise; percutaneous coronary angioplasty; coronary artery bypass drafting; heart rate variability
25.  Motivational factors of adherence to cardiac rehabilitation 
Background:
Main suggested theories about patients’ adherence to treatment regimens recognize the importance of motivation in positive changes in behaviors. Since cardiac diseases are chronic and common, cardiac rehabilitation as an effective prevention program is crucial in management of these diseases. There is always concern about the patients’ adherence to cardiac rehabilitation. The aim of this study was to describe the motivational factors affecting the patients’ participation and compliance to cardiac rehabilitation by recognizing and understanding the nature of patients’ experiences.
Materials and Methods:
The participants were selected among the patients with cardiac diseases who were referred to cardiac rehabilitation in Isfahan Cardiovascular Research Center, Iran. The purposive sampling method was used and data saturation achieved after 8 semi-structured interviews.
Findings:
The three main concepts obtained from this study are “beliefs”, “supporters” and “group cohesion”.
Conclusions:
In cardiac rehabilitation programs, emphasis on motivational factors affects the patient’s adherence. It is suggested that in cardiac rehabilitation programs more attention should be paid to patients’ beliefs, the role of patients’ supporters and the role of group-based rehabilitation.
PMCID: PMC3702154  PMID: 23833634
Heart diseases; rehabilitation; motivation; patient compliance; qualitative research

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