Activation of myocardial A 1 adenosine receptors (A 1 AR) protects the heart from ischemic injury. In this study transgenic mice were created using the cardiac-specific ␣-myosin heavy chain promoter and rat A 1 AR cDNA. Heart membranes from two transgene positive lines displayed Ϸ1,000-fold overexpression of A 1 AR (6,574 ؎ 965 and 10,691 ؎ 1,002 fmol per mg of protein vs. 8 ؎ 5 fmol per mg of protein in control hearts). Compared with control hearts, transgenic Langendorff-perfused hearts had a significantly lower intrinsic heart rate (248 beats per min vs. 318 beats per min, P < 0.05), lower developed tension (1.2 g vs. 1.6 g, P < 0.05), and similar coronary resistance. The difference in developed tension was eliminated by pacing. Injury of control hearts during global ischemia, indexed by time-to-ischemic contracture, was accelerated by blocking adenosine receptors with 50 M 8-(p-sulfophenyl) theophylline but was unaffected by addition of 20 nM N 6 -cyclopentyladenosine, an A 1 AR agonist. Thus A 1 ARs in ischemic myocardium are presumably saturated by endogenous adenosine. Overexpressing myocardial A 1 ARs increased time-to-ischemic contracture and improved functional recovery during reperfusion. The data indicate that A 1 AR activation by endogenous adenosine affords protection during ischemia, but that the response is limited by A 1 AR number in murine myocardium. Overexpression of A 1 AR affords additional protection. These data support the concept that genetic manipulation of A 1 AR expression may improve myocardial tolerance to ischemia.

Objectives. The exercise capacity of children with congenital heart disease (CHD) is often depressed. This depression is thought to be attributable to (1) residual hemodynamic defects and (2) deconditioning secondary to physical inactivity. We hypothesized that this latter component would be ameliorated by a formal cardiac rehabilitation program designed specifically for children. The objective of this study was to characterize the effect of a cardiac rehabilitation program on the exercise performance of children with CHD and to define the physiologic mechanisms that might account for any improvements that are observed.Methods. Nineteen patients with CHD who were referred for exercise testing and found to have a peak oxygen consumption (VO 2 ) and/or peak work rate <80% of predicted were enrolled in the study. Sixteen patients (11 Fontan patients, 5 with other CHD) completed the program and had postrehabilitation exercise tests, results of which were compared with the prerehabilitation studies.Results. Improvements were found in 15 of 16 patients. Peak VO 2 rose from 26.4 ؎ 9.1 to 30.7 ؎ 9.2 mL/kg per min; peak work rate from 93 ؎ 32 to 106 ؎ 34 W, and the ventilatory anaerobic threshold from 14.2 ؎ 4.8 to 17.4 ؎ 4.5 mL/kg per min. The peak heart rate and peak respiratory exchange ratio did not change, suggesting that the improvements were not attributable merely to an increased effort. In contrast, the peak oxygen pulse rose significantly, from 7.6 ؎ 2.8 to 9.7 ؎ 4.1 mL/beat, an improvement that can be attributed only to an increase in stroke volume and/or oxygen extraction at peak exercise. No patient experienced rehabilitation-related complications.Conclusion. Cardiac rehabilitation can improve the exercise performance of children with CHD. This improvement is mediated by an increase in stroke volume and/or oxygen extraction during exercise. Routine use of formal cardiac rehabilitation may greatly reduce the morbidity of complex CHD. Pediatrics 2005;116:1339-1345; congenital heart defects, exercise, cardiac rehabilitation.

In patients with congenital heart disease, cardiac rehabilitation produces significant, sustained improvements in exercise function, behavior, self-esteem, and emotional state.

BACKGROUND AND OBJECTIVES: Chest pain is a complaint for which children are frequently evaluated. Cardiac causes are rarely found despite expenditure of considerable time and resources. We describe validation throughout New England of a clinical guideline for cost-effective evaluation of pediatric patients first seen by a cardiologist for chest pain using a unique methodology termed the Standardized Clinical Assessment and Management Plans (SCAMPs). METHODS: A total of 1016 ambulatory patients, ages 7 to 21 years initially seen for chest pain at Boston Children’s Hospital (BCH) or the New England Congenital Cardiology Association (NECCA) practices, were evaluated by using a SCAMPs chest pain guideline. Findings were analyzed for diagnostic elements, patterns of care, and compliance with the guideline. Results from the NECCA practices were compared with those of Boston Children’s Hospital, a regional core academic center. RESULTS: Two patients had chest pain due to a cardiac etiology, 1 with pericarditis and 1 with an anomalous coronary artery origin. Testing performed outside of guideline recommendations demonstrated only incidental findings. Patients returning for persistent symptoms did not have cardiac disease. The pattern of care for the NECCA practices and BCH differed minimally. CONCLUSIONS: By using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources. The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers that often limit clinical practice guideline implementation.