Medical Services
Heart Failure
Version 2 Final
EBM – Heart Failure
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1. Introduction
Definition
Heart failure is a clinical condition which occurs when an abnormality
of cardiac function causes failure of the heart to pump blood at a rate
sufficient for metabolic requirements under normal filling pressure
. [1]
In practical terms the definition is restricted to those patients whose
condition is sufficiently severe to cause signs or symptoms.
Classification
Clinically heart failure may be in one of three categories:-
LEFT sided failure
RIGHT sided failure
BIVENTRICULAR (or congestive cardiac) failure
The consequences of heart failure can be divided into those arising
from inadequate cardiac output (forward failure) and those arising
from increased filling pressure with fluid retention causing either
pulmonary or systemic venous congestion (backward failure).
Description
Heart failure manifests itself clinically with breathlessness, effort
intolerance, fluid retention, malaise and poor survival. [1]
Heart failure may arise as a consequence of a myocardial, valvular,
pericardial, endocardial or a conduction problem (or some
combination of these).
In contrast with chronic heart failure, the term acute heart failure is
often used to mean acute (cardiogenic) dyspnoea characterised by
signs of pulmonary congestion including pulmonary oedema.
Associated physiological changes in many organ systems occur and
cause biochemical, metabolic and functional impairments.
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Aetiology
The underlying diagnosis and aetiology must be sought in patients
presenting with heart failure syndrome.
A syndrome is a constellation of symptoms and signs and is not a
single disease. This is the only way in which optimum treatment can
be provided i.e. the treatment varies depending on whether the
underlying cause is myocardial dysfunction, valve disease or some
other aetiology.
The commonest cause of heart failure is myocardial dysfunction
which is commonly systolic, i.e. there is reduced left ventricular
contraction. Around two thirds of these cases result from coronary
heart disease (CHD) and there is often a past history of myocardial
infarction (MI).
The remainder have a non-ischaemic cardiomyopathy, which may
have an identifiable cause (e.g. hypertension, thyroid disease,
valvular disease, alcohol excess, or myocarditis) or may have no
known cause (e.g. idiopathic dilated cardiomyopathy). [2]
Prevalence
Both the incidence and prevalence of heart failure increase with age.
Studies of heart failure in the USA and Europe have found that under
65 years of age, the annual incidence is 1:1000 for men and 0.4:1000
for women.
Over 65 years of age, the annual incidence is 11:1000 for men and
5:1000 for women.
Under 65 years of age, the prevalence of heart failure is 1:1000 for
men and 1:1000 for women and over age 65 years the prevalence is
40:1000 for men and 30:1000 for women.
The prevalence of asymptomatic left ventricular systolic dysfunction
(LVSD) is 3% in the general population. The mean age of people with
asymptomatic LVSD is lower than that for symptomatic individuals.
Both heart failure and asymptomatic LVSD are more common in men.
Systolic heart failure is caused when the heart does not pump out
enough blood.
The prevalence of diastolic heart failure (caused when the heart does
not fully relax, so it does not fill properly with blood) in the community
is unknown.
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The prevalence of heart failure with preserved systolic function in
people in hospital with clinical heart failure varies from 13 – 74%.
Fewer than 15% of people with heart failure under 65 years of age
have normal systolic function, whereas in people over 65 years of age
normal function is maintained in about 40%
The ageing of the population in Western society has meant that heart
failure is becoming increasingly common.
Recent improvements in the management of myocardial infarction
and coronary artery disease, with an increased survival rate, have led
to the development of more heart failure in later life. [1]
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2. Diagnosis
The presentation of heart failure is variable. It depends on the
severity of the disease and the associated clinical disorders.
Diagnosis may be difficult in the early stages when symptoms are
non-specific.
The important points in the diagnosis are:
High index of suspicion
Thorough history taking
Directed clinical examination.
History and Symptoms
The main presenting symptoms are:
Reduced exercise capacity
Dyspnoea (wheeze, orthopnoea, paroxysmal nocturnal dyspnoea
(PND)
Reduced
appetite
Weight
loss.
The clinical symptoms occur as a result of the effects of the impaired
ventricular function on the various organs. There is an increase in
pulmonary pressure with an accumulation of fluid leading to an
increase in the work of breathing.
The oedematous swelling may also cause a non-asthmatic bronchial
constriction mimicking asthma.
Increasing pulmonary hypertension may eventually cause gross
dyspnoea, lung crackles and pink frothy sputum in acute failure.
In chronic failure, the patient remains dyspnoeic but with less well
marked lung changes.
Heart failure can cause expiratory airflow reduction, especially at
night. This may cause confusion in differentiating heart failure from
asthma.
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Informal Observations
In chronic heart failure the patient will tend to walk slowly, with signs
of breathlessness and fatigue. The observed tachypnoea with the
use of accessory muscles of respiration and gasping gives an
indication of the severity of heart failure and disability.
These observations will be noticeable on climbing on and off the
examination couch, dressing and undressing, and walking up stairs.
At more severe degrees of disablement they will be apparent on
walking on the flat and ultimately even at rest.
Clinical Signs
The important signs on examination are:
Abnormal blood pressure
Forceful apex beat
Abnormal
pulse
Respiratory
crackles
Oedema
Abnormal heart sounds
Raised
JVP
Hepatomegaly/ascites
Pleural
effusion
Parasternal
heave.
A similar picture can develop in conditions with volume or pressure
overload such as:
Severe
anaemia
Overtransfusion
Arteriovenous
malformation
Shunts
Prosthetic valve dysfunction
Investigations
Basic early investigations are necessary to differentiate heart failure
from other conditions and to provide prognostic information.
Urinalysis, serum urea and creatinine tests may help to determine if
there is kidney failure since symptoms of kidney failure are similar to
those of CHF (chronic heart failure).
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Chest X-ray may indicate signs of CHF such as cardiomegaly,
pulmonary congestion or pleural effusion and also non-cardiac
indications such as lung tumours which account for breathlessness.
Other basic investigations should include:-
Full blood count
Fasting blood glucose
Serum urea and electrolytes
Thyroid function.
Further Investigations
Following clinical examination and basic investigation a decision
should be made as to whether the patient should undergo
echocardiogram. To help make this decision the patient should
undergo either:-
Electrocardiogram (ECG)
or
Brain natriuretic peptide (BNP) test
or both.
ECG
The ECG is used firstly as a screening test to assess the likelihood of
CHF and the need for subsequent echocardiography to confirm or
refute a diagnosis
It is unusual for a patient with Chronic Heart Disease to have a normal
ECG. The ECG changes reported in CHD are non-specific and
common in elderly patients. CHD is a disease of the heart caused by
decreased blood flow to the heart muscle which may result in
myocardial infarction, or in angina but not necessarily with failure.
Electrocardiograph abnormalities seen in CHD may include:-
Pathological Q waves
Left bundle branch block
Left ventricular hypertrophy (LVH)
Atrial fibrillation
Non-specific ST and/or T wave changes
In CHF there has been described association of peripheral (o)edema
(PERED), sometimes even imperceptible on physical examination, of
patients with CHF, and attenuation (ATTEN) of the amplitude of P-
waves, QRS-complexes, and T-waves.
Electrocardiography is also useful once the diagnosis of CHF has
been confirmed as it may help to determine the cause (e.g. Q waves
indicate previous MI, LVH is seen in hypertension and aortic valve
disease) and it is important to exclude atrial fibrillation.
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B-Type Natriuretic Peptide
Brain natriuretic peptide and N terminal-pro-BNP (NT-proBNP) are
peptide hormones produced in the heart by breakdown of a precursor
protein (pro-BNP). BNP promotes natriuresis (the process of excretion
of
sodium in the urine via action of the kidneys), diuresis,
vasodilatation and muscle relaxation. NT-proBNPis inactive.
Plasma BNP and NT-proBNP tend to rise in patients with heart failure
and the concentrations tend to rise with New York Heart Association
(NYHA) classification. (see Appendix C)
Echocardiography
Echocardiography is a safe and relatively inexpensive investigation
which is very helpful in diagnosing heart failure and determining the
cause.
It may reveal previously undiagnosed valve disease.
It provides a semi-quantitative assessment of left ventricular systolic
and diastolic function, valve disorders can usually be accurately
delineated, and pulmonary artery systolic pressure can be estimated.
As it may not be feasible or cost effective to refer all patients with
suspected heart failure for echocardiography, screening with either
ECG and/or BNP is desirable. Brain natriuretic peptide testing has the
practical advantage of being a simple blood test.
See diagram below. [2]
Chest X-ray
This is still considered important in the assessment of left heart
failure. The rise in pulmonary venous pressure first shows as a
distension of the upper pulmonary lobe veins.
Subsequent changes include the development of Kerley B lines.
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Diagnostic algorithm for patients with suspected
chronic heart failure
Symptoms or signs
suggestive of CHF
Clinical examination
(full blood count, fasting blood glucose, serum urea and electrolytes,
urinalysis, thyroid function and chest x-ray)
B N P
(or NT pro-BNP)
and / or ECG
Low BNP (or NT pro-BNP)
Raised BNP (or NT pro-BNP)
and normal ECG
or abnormal ECG
CHF excluded
C H F possible
Consider alternative cause for
Refer for echocardiography
symptoms
E C G
(If not already done, to
determine cause of CHF)
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3. Management
Lifestyle Changes
The mainstays of treatment are listed in Appendix B and include:
General life style advice
Treatment
of
any
underlying cause(s)
Drug
therapy.
General Measures
Advice should be given as to:
Influenza and pneumococcal immunisation,
Abstinence from smoking,
Moderation of alcohol intake,
Avoidance
of
harmful
drugs.
Restriction of salt intake may be useful in some patients
Adequate patient education is important, and the patient should be
made aware of the necessity of any required lifestyle modifications
and of the need for any regular medication.
Exercise training
This can improve functional capacity by 15 - 20% and reduce cardiac
events. It is advised in those with stabilised mild to moderate heart
failure. [4] [7]
Concurrent Illness
Any associated disease (e.g. hypertension, hypothyroidism, coronary
artery disease, and cardiomyopathy) which may be contributing to the
heart failure should be treated.
(see Appendix A)
Mood Disorders
Depression is common in patients with chronic heart failure and is
associated with an increased risk of mortality in some but not all
studies and may be related to morbidity and rehospitalisation.
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Screening in heart failure may help to identify patients who are at
poorer prognostic risk. If antidepressant medication is to be used then
a tricyclic antidepressant should not be used in patients with chronic
heart failure.
Drug Therapy
Drug therapy, and in particular balanced vasodilatation, leads to the
greatest clinical benefit.
Angiotensin Converting Enzyme Inhibitors
ACE inhibitors (such as enalapril or ramipril): These improve
function and reduce mortality by 23% and hospital admissions by
35%. [2] They are used as first line treatment in patients with a
reduced left ventricular (LV) ejection fraction. If used in asymptomatic
LV dysfunction, fewer develop heart failure. [4] [11] Side effects of
cough, the development of allergy, renal impairment or hyperkalaemia
may limit their use.
Beta Blockers
-blockers: Combining -Blockers with ACE inhibitors can reduce
hospital admissions and mortality. Careful titration of the dose is
needed to avoid bradycardia and hypotension.
Bisoprolol and Carvedilol have been shown to reduce mortality.
Treatment should be initiated under specialist supervision
There is consistent evidence for positive benefits from beta blockers
in patients with heart failure, with a risk of mortality from
cardiovascular causes reduced by 29%, mortality due to pump failure
reduced by 36% and all cause mortality reduced by 23%. [2]
Angiotensin Receptor Blockers
Angiotensin II type1 receptor blockers (ARBs) block the biological
effect of angiotensin II, mimicking the effect of ACE inhibitors.
Unlike ACE inhibitors they do not produce cough as a side effect and
should be used in patients who cannot tolerate an ACE inhibitor.
Candesartan is the drug of choice.
Aldosterone Antagonists
Aldosterone produces many adverse extra-renal effects, for example
on vascular function and myocardial fibrosis.
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The RALES trial demonstrated that adding the aldosterone antagonist
Spironolactone to an ACE inhibitor reduced all cause mortality by
30% and cardiac mortality by 31%. The frequency of hospitalisation
for worsening heart failure was 35% lower in patients receiving
Spironolactone
Diuretics/ Loop Diuretics/ Metolazone
Diuretics: These are essential for the treatment of fluid overload and
can cause a rapid improvement in symptoms and exercise tolerance.
Both thiazides (such as bendroflumethiazide) and loop diuretics (such
as furosemide) are used, often with an ACE inhibitor. Side effects
such as gout or urinary retention in subacute prostatism may become
a problem.
Digoxin
A Cochrane review has shown a 64% improvement in symptoms and
a 23% reduction in hospitalisation for patients receiving Digoxin.
Digoxin did not improve survival.
Evidence of benefit must be weighed against the possibility of an
increase in sudden death due to toxicity associated with Digoxin.
In patients with heart failure and atrial fibrillation a beta-blocker is
preferred for control of ventricular rate, though digoxin may be used
initially while the beta-blocker is being introduced.
If excessive bradycardia occurs with both drugs then digoxin should
be withdrawn. [2]
Summary of the use of major drug classes in the treatment of
Heart Failure [2]
Class Prescribe
NYHA I
ACE inhibitor
Beta blocker
NYHAII-III ACE
inhibitor
Beta blocker
Candesartan (initiation requires specialist advice)
NYHA III-IV ACE inhibitor
Beta blocker
Spironolactone (initiation requires specialist advice)
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Other Measures
Bed rest for a short period is a common treatment for acute failure.
However it is preferable that the patient be treated in the sitting
position rather than lying prone.
In cases of severe, intractable failure, surgical intervention such as
cardiomyoplasty or cardiac transplantation may be considered. [9]
Prognosis
The prognosis of heart failure is poor, with 5 year mortality ranging
from 26% – 75%. Up to 16% of people are readmitted with heart
failure within 6 months of first admission.
In the USA, heart failure is the leading cause of hospital admission
among people over 65 years of age.
In people with heart failure, a new myocardial infarction increases the
risk of death by nearly eight fold.
(Relative risk 7.8; [95% Confidence interval 6.9 to 8.8]).
About a third of all deaths in people with heart failure are preceded by
a major ischaemic event. Sudden death, mainly caused by ventricular
arrhythmia, is responsible for 25 – 50% of all deaths, and is the most
common cause of death in people with heart failure.
This is being constantly improved with increasing use of implanted
intracardiac defibrillators (AICDs).
The presence of asymptomatic LVSD increases an individual's risk of
having a cardiovascular event.
One large prevention trial found that the risk of heart failure,
admission for heart failure, and death, increased linearly as the
ejection fraction fell.
Relative risk for heart failure was 1.20 (95% confidence interval 1.13
to 1.26).
Relative risk for hospital admission was 1.28 (95% confidence interval
1.18 to 1.38).
For each 5% reduction in ejection fraction the relative risk for mortality
was1.20 (95% confidence interval of 1.13 to 1.29).
The annual mortality for people with diastolic heart failure varies in
observational studies (1.3% – 17.5%).
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The reasons for this variation appear to include age, the presence of
coronary artery disease, and variation in the partition value used to
define abnormal ventricular systolic function.
The annual mortality for left ventricular diastolic dysfunction is lower
than that found in people with systolic dysfunction. [1]
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4. Main Disabling Effects
General Considerations
The actual disability due to chronic heart failure is very variable, and
each patient must be assessed individually.
In the early stages, there is very little impairment of daily function. The
decrease in exercise tolerance in severe heart failure can be very
limiting.
Functional capacity can be improved by alteration in general and
lifestyle factors and most notably by drug treatment.
One of the most marked changes in the skeletal system is a
substantial reduction in total skeletal muscle bulk, and subtle changes
may be functionally important in heart failure.
Patients frequently complain that muscle fatigue is a major limitation
to their daily performance. Some patients with chronic failure may
benefit from exercise training. In a patient with stable chronic heart
failure and no evidence of exercise induced ventricular arrhythmia,
regular exercise should be encouraged. [5]
For those in employment, heavy industry where the employee is
required to climb stairs or carry heavy weights (e.g. 20 kg) may be
impossible, but lighter or sedentary work may be well within their
capabilities (see Appendix D).
An ability to reach Stage 4 of the Bruce Protocol (see Appendix E) is
judged to place an individual at low risk of sudden cardiac events.
This is reflected in the DVLA guidelines which allow vocational driving
at this stage. These guidelines are now being applied more widely to
other occupations where there may be a significant risk attached to a
sudden cardiovascular collapse.
Assessing the Claimant
Clinical examination findings in mild to moderate heart failure do not
correlate well with functional ability and the assessment is best made
from the evidence of:
1. The History of Activities of Daily Living (Typical Day) taking
variation into account.
2. Informal Observation of the claimant’s activities at examination.
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3. Medication taken (see Appendix B.) and attendance at Cardiac
Clinic.
Claimants with well treated mild and moderate failure are likely to
retain the ability to self care, and although exercise tolerance may be
reduced should be able to walk to local shops or round a
supermarket.
Severe heart failure can cause appreciable functional impairment. It
is likely that in these cases the claimant would be under active
specialist care and be on maximum doses of medication. Significant
abnormalities would be present on clinical examination.
The drugs used in the treatment of heart failure usually have few side
effects, but can occasionally have a functional effect e.g. causing
postural hypotension or polyuria with diuretics.
Psychological factors may sometimes be very important in the
disability due to heart failure. An individual may have only mild
physical symptoms, but be significantly restricted due to depression or
fear of an untoward event. Similarly, the family may try to protect the
patient and erroneously discourage any physical activity. [10]
In the IB-PCA, the functional areas first affected are Walking Up and
Down Stairs, and then Walking.
Later the effort of mild exertion limits activities, such as dressing and
undressing, washing, rising from sitting and walking even a few steps.
Eventually even minimal effort is not tolerated and there will be
breathlessness at rest.
Exemption from the assessment should be considered if the limitation
of effort tolerance is severe and progressive, causing significant
limitation of normal daily activities such as self care tasks.
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Appendix A - Causes of Heart Failure
Most Common Cause:
Ischaemic Heart Disease
Other Causes:
Hypertension
Cardiomyopathy (familial, infective, toxic)
Rheumatic heart disease.
Valvular disorders
Arrhythmias
Endocarditis
Endocrine disorders.
Rare Causes:
Nutritional deficiencies (e.g. thiamine, iron)
Infiltrative conditions (e.g. sarcoid, neoplasms)
Myocardial fibrosis
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Appendix B - Treatment of Chronic Heart Failure
General Measures.
Achieve optimal weight
No smoking
Encourage exercise
Discourage added salt
Treat hypertension if appropriate
Discourage excess alcohol
Detect and treat associated risk factors (e.g. diabetes,
myxoedema, hyperlipidaemia)
Mild Failure
Thiazide loop diuretic
ACE inhibitor
Beta blocker for atrial fibrillation
Moderate Failure:
Loop diuretic or combination of diuretics
ACE inhibitor
Beta blocker
Severe Failure:
ACE inhibitor
Beta blocker
Spironolactone
Digoxin
Cardiomyoplasty
Transplant
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Appendix C - Functional Classification of
Cardiac Diseases
New York Heart Association Functional Classification
of Cardiac Disease
Grade 1 Ordinary
activity
does not cause symptoms of
undue fatigue, palpitations, dyspnoea, or anginal pain.
Grade 2 Greater than ordinary physical activity results in
symptoms. (Relevant for PCA)
Grade 3 Ordinary physical activity results in symptoms.
(May be exemptible for PCA)
Grade 4 Symptoms at rest, and worse with any physical
activity. (Exemptible for PCA. May be relevant for DLA/AA)
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Appendix D - Haskell Work Classification
Type of Work
Activity
Very Heavy
Climb stairs
Medium
Carry 50 lbs. (22.5 kg)
Light
Carry 20 lbs. (9 kg)
Sedentary
Sit/carry 10 lbs. (4.5 kg)
This is a standard grading of work effort requirement.
The critique that it does not take into account the occasional
increased episodic requirements for normal jobs is entirely
reasonable. [13]
The classification can be linked to graded exercise tests
(see Appendix E)
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Appendix E- Bruce Protocols
Full (Standard) Bruce Protocol
Stage Speed Gradient Duration Cumulative time METS
(mph) (%)
(min.)
(mins
I 1.7
10 3 3
5
II 2.5
12 3 6
7
III 3.4 14 3
9
10
IV 4.2 16 3
12
13
V 5.0
18 3
15
16
VI 5.5 20 3
18
19
VII 6.0 22
3
21
22
This is a standard graded exercise test, and is a good
measure of exercise tolerance in cardiac disease.
It may be too strenuous for the deconditioned subject, in
which case the modified Bruce protocol can be used.
The energy used to accomplish a particular task can be
calculated in METS (a measure of energy expenditure as a
multiple of resting energy expenditure).
Haskell Work Classification (Appendix D)
Task Grade
Peak METs
Activity
Very Heavy
>6
Climb stairs
Medium
4-6
Carry 50 lbs (22.5 kg)
Light
2-4
Carry 20 lbs ( 9 kg)
Sedentary
<2
Sit. Carry 10 lbs (4.5 kg)
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Modified Bruce Protocol
Stage Speed Gradient Duration Cumulative METS
(mph) (%)
(mins.)
time(mins.)
1
1.7
0
3
3
2
II
1.7
5
3
6
3
III
1.7
10
3
9
5
IV 2.5
12
3
12
7
V 3.4
14
3
15
10
VI 4.2
16
3
18
13
VII 5.0
18
3
21
16
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References
1.
BMJ Clinical Evidence 2006
2. Management of Chronic Heart Failure. Scottish Intercollegiate
Guidelines Feb 2007
3 The Framingham Disability Study: relationship of various coronary heart
disease manifestations to disability in older persons living in the community.
Am J Pub Health 1990 Nov 80;
11: 1363-7
4. Remme WJ, Swedberg K. (Task Force Chairmen, European Society of
Cardiology) Task Force Report. Guidelines for the Diagnosis and
Treatment of Chronic Heart Failure.
European Heart Journal 2001;
22: 1527-1560
5. Aronow WS, Tresch D. Epidemiology, pathophysiology and etiology of
congestive heart failure in older adults.
J Am Geriatr Soc 1997;
45: 968-974
6 .Armstrong PW, Moe GW. Medical Advances in the Treatment of
Congestive Heart Failure.
Circulation 1993;
88 (No.6): 2941-52
7 .Piepoli MF, Scott AC, Capucci A, et al. Skeletal Muscle Training in Chronic
Heart Failure.
Acta Physiol Scand 2001;
171: 295-303
8. Packer M. β - Adrenergic blockade in chronic heart failure; principles,
progress and practice.
Prog Cardiovasc Dis;
41: 39-52
9. Grady KL, Jalowiec A, White Williams C. Improvement in quality of life in
patients with heart failure who undergo transplantation.
J Heart Lung Transplant 1996;
15: 749-57.
10. Lipkin DP, Scriven AJ, Crake T et al. Six minute walking test for
assessing exercise capacity in chronic heart failure.
Br Med J (Clin Res Ed)1986;
292: 653-5
11. Yusuf S, Sleight P, et al. Effects of an angiotensin-converting enzyme
inhibitor, ramipril, on cardiovascular events in high risk patients.
New England Journal of Medicine 2000;
342(3): 145-153
12. Cay EL, Walker DD. Psychological factors and return to work.
European
Heart Journal 1988;
9 (Suppl L):74-81
13. Ainsworth BE. (2002, January) The Compendium of Physical Activities
Tracking Guide. Prevention Research Center, Norman J. Arnold School of
Public Health, University of South Carolina.
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