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rehabilitation forms an essential factor of the standard care in modern
cardiology. Most cardiac rehabilitation referrals are for patients with acute
coronary syndrome (ACS) (Sunamura et al., 2017). According to the National
Institute for Health and Care Excellence, cardiovascular diseases are one of
the leading causes of death worldwide, in which the prevalence of coronary
heart disease and myocardial infarction is increasing (Saxon, Cunningham & Adams,
2013; Montecucco, Carbone & Schindler, 2015). ACS is characterized by
partial or complete occlusion of coronary arteries due to atherosclerosis (Leon
et al. 2005), resulting in myocardial necrosis and the classical signs and
symptoms of chest pain, electrocardiographic ST-segment elevation, and an
elevated serum concentration of myocardial proteins (Saxon, Cunningham & Adams,
2013). After a myocardial infarction, the heart undergoes extensive myocardial remodeling
through the accumulation of fibrous tissue, which increases tissue stiffness,
and accounts for ventricular dysfunction (Garza, Wason & Zhang, 2015). The
risk of a second attack is considerably increased in especially post-acute
myocardial infarction patients, making secondary prevention an intrinsic aim in
the cardiac rehabilitation intervention program (Saxon, Cunningham & Adams
(2013). Cardiac rehabilitation is a class I recommendation in the treatment of
patients with coronary artery disease (Mampuya, 2012; Balady et al., 2011; Corra
et al. 2010).

the past four decades, the scope of cardiac rehabilitation has shifted from
patient monitoring for the safe return to physical activities to a
multidisciplinary approach that has evolved to emphasize overall risk factors
and behavioral modification (Mampuya, 2012; Piotrowicz & Wolszakiewicz, 2008;
Giannuzzi et al, 2003). Cardiac rehabilitation refers to coordinated and
multifaceted interventions designed to restore the quality of life and to
maintain or improve functional capacity, in addition to reduce morbidity and
mortality. Cardiac rehabilitation programs require comprehensive components,
including patient assessment, exercise training, physical activity counselling,
risk factor management (i.e., lipids, hypertension, weight, diabetes, and
smoking), dietary and lifestyle education, as well as psychosocial, behavioral
and social management that can affect patient outcomes (Balady et al., 2011; Corra
et al., 2010; Piepoli et al., 2010). Exercise training and physical activity
counselling form a central element in cardiac rehabilitation as evidence has
shown how physical activity can directly benefit the heart and coronary
vasculature, including myocardial perfusion, myocardial oxygen demand, and the
development of coronary collateral vessels (Garza, Wason & Zhang, 2015; Andersen,
Laustsen & Petersen, 2017; Montecucco, Carbone & Schindler, 2015). Many
components of risk factor management can be mediated through physical activity
counselling and exercise training (Corra et al., 2010).

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in healthy lifestyle management is becoming increasingly important, as the
rising incidence of obesity, hypertension, and diabetes result in epidemic
proportions (Sunamura et al., 2013). There is growing clinical consensus about
the benefits of exercise training and its effect on the remodeled heart and
cardiac functioning. Regardless of its etiology, cardiac rehabilitation is
immediately initiated following an acute, life-threatening period of the
cardiac disease and as a therapeutic measure following myocardial infarction,
percutaneous coronary intervention (PCI), cardiac surgery, and permanent
pacemaker or cardioverter-defibrillator implantations (Piotrowicz &
Wolszakiewicz, 2008).

Despite the growing research and
documented results, cardiac rehabilitation remains vastly underutilized (Corra
et al., 2010). Recent studies have demonstrated that cardiac rehabilitation
improves the patient prognosis by reducing cardiac mortality and risk of
hospital admissions. Moreover, cardiac rehabilitation is more cost-effective in
terms of cost per year life saved when compared to post-MI treatments that
include thrombolytic therapy, coronary bypass surgery, and cholesterol lowering
drugs (Ades, Pashkow & Nestor, 1996).

patients often suffer from symptoms such as dyspnea, fatigue and nausea that
could affect a reduced physical capacity and functioning. Patient assessment
and behavioral modification must be achieved to prevent a further state of
inactivity and deconditioning (Andersen, Laustsen & Petersen, 2017).

Exercise capacity is a strong marker for mortality among patients with a
cardiac condition and is a measure of physical health. Many studies postulate
that an improved exercise capacity enhances the ability of patients to operate
physical activities at higher intensity levels, as well as improve the
health-related quality of life (HRQOL) of cardiac patients (Saeidi, Mostafavi,
Heidari & Masoudi, 2013; Andersen, Laustsen & Petersen, 2017). The
assumption that participation of exercise-based cardiac rehabilitation leads to
enhanced exercise capacity and HRQOL, could predict a strong correlation
between improved exercise capacity and a higher HRQOL. Many studies in the
current literature support the beneficial effects of exercise-based cardiac
rehabilitation to improve cardiac functioning (Garza, Wason & Zhang, 2015; Saeidi,
Mostafavi, Heidari & Masoudi, 2013; Piepoli 2010), however, some authors
have shown varying results on the correlations between exercise capacity and
health-related quality of life (West, Jones & Henderson, 2011; Andersen,
Laustsen & Petersen, 2017). It is still unknown how strong exercise
capacity and HRQOL are correlated with cardiac rehabilitation, and additionally
how large improvements in exercise capacity are required to reflect
improvements in HRQOL. Therefore, the purpose of this study is to examine the
correlation between exercise capacity and HRQOL in ACS cardiac patients when
engaging into exercise-based cardiac rehabilitation.

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