cr guidelines

8/7/2019 CR GUIDELINES

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GUIDELINES FOR

CARDIAC REHABILITATION

IN

NORTHERN IRELAND

May 2006

CRESTCRESTCLINICAL RESOURCE EFFICIENCY SUPPORT TEAM


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These guidelines have been published by the Clinical Resource Efficiency Support Team (CREST),

which is a small team of health care professionals established under the auspices of the Central

Medical Advisory Committee in 1988. The aims of CREST are to promote clinical efficiency in

the Health Service in Northern Ireland, while ensuring the highest possible standard of clinical

practice is maintained.

The guidelines have been produced by a sub-group of health care professionals from variedbackgrounds including Medical (Primary and Secondary care), Nursing, Management and Public

Health, Chaired by Professor Gary McVeigh. CREST wishes to thank them and all those who

contributed in any way to the development of these guidelines.

Further copies of this booklet and an executive summary may be obtained from:

CREST Secretariat

Room D1

Castle Buildings

StormontBELFAST

BT4 3SQ

Telephone 028 90 522028

Fax 028 90 523206

E-mail [email protected]

Or you can visit the CREST website at: www.crestni.org.uk

ISBN 1-903982-18-9

Executive Summary ISBN 1-903982-19-7


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CONTENTS: Page no:

Members of the Cardiac Rehabilitation Sub-Group 2

Executive Summary 4

Milestones for CREST Guidelines on Cardiac Rehabilitation 6

Chapter 1 Introduction 7

Chapter 2 Educational and Psychological Interventions 9

Chapter 3 Exercise 15

Chapter 4 - Target Patient Groups 21

Chapter 5 - Secondary Prevention: Use of Medication 24

Chapter 6 - Cardiac Rehabilitation in Primary Care 26

Chapter 7 - Implementation and Audit / Data Collection 29

References 32

Appendices 41

CRESTCRESTC LI NI CA L R ES OU RC E E FF IC IE NC Y S UP PO RT T EA M


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MEMBERS OF THE CARDIAC REHABILITATION SUB-GROUP

Professor Gary McVeigh

Professor of Cardiovascular Medicine

Dept of Therapeutics & Pharmacology

Queens University of Belfast

Ms Gerry Bleakney

Head of Health Promotion Commissioning

EHSSB

Dr Margaret Cupples

Department of General Practice

Queens University of Belfast

Ms Bernie Downey

Cardiac Nurse Specialist

Mater Hospital

Ms Siobhan Doyle

Clinical Lead PhysiotherapistMater Hospital Trust

Ms Donna Hanna

Cardiac Liaison Nurse, Coronary Care Unit

Causeway Hospital

Dr Niall Herity

Consultant Cardiologist

Belfast City Hospital Trust

Dr Anne Kilgallen

Consultant in Public Health Medicine

WHSSB

Dr Jackie McCall

Specialist Registrar in Public Health Medicine

EHSSB


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Ms Roisin OHare

Clinical PharmacistRoyal Victoria Hospital

Dr Clive Russell

Consultant Physician

Tyrone County Hospital

Secretariat

Maureen Henderson BCH

CREST Secretariat

Mr Gary Hannan

Mr Jim McKee

Mrs Christine Smith


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CARDIAC REHABILITATION GUIDELINES

EXECUTIVE SUMMARY

Coronary artery disease imposes a large burden on health and health care resources in

Northern Ireland. Cardiac rehabilitation with an exercise component is often offered to

patients with coronary artery disease. Comprehensive cardiac rehabilitation programmes

incorporate an exercise programme in combination with other secondary measures such as

coronary artery disease risk factor management, patient education and psychological

interventions.

The evidence indicates that a comprehensive cardiac rehabilitation programme whichincludes exercise has beneficial effects on cardiac mortality and total mortality. The benefits

compare favourably with standard coronary artery disease secondary prevention practice

(e.g. beta-blocker, anti platelet and statin therapy) in reducing cardiac and all-cause

mortality. The evidence is also consistent in showing that cardiac rehabilitation is cost

effective and may reduce cost to health care systems due to reduced rehospitalisation and

drug utilisation. Despite the beneficial effects of participating in cardiac rehabilitation, that

approximate to those that can be achieved with standard pharmacological interventions,

participation in rehabilitation programmes remains sub-optimal.

Under the auspices of CREST, an expert panel was convened to review the evidence forcardiac rehabilitation with an exercise component for secondary prevention of coronary

artery disease in terms of clinical effectiveness and cost effectiveness. An additional

objective was to focus on the impact of the evidence on the future direction and

development of cardiac rehabilitation services for the secondary prevention of coronary

artery disease in Northern Ireland. The panel included health care professionals from varied

backgrounds including medical (primary and secondary care), nursing, management and

public health and was chaired by Professor Gary McVeigh.

RECOMMENDATIONS

1. Given the strong evidence base for efficacy and cost effectiveness all Trusts should

ensure that eligible patients are offered the opportunity to participate in a cardiac

rehabilitation programme.

2. Based on evidence patients known to benefit would include those post-myocardial

infarction, post-coronary revascularisation and selected patients with congestive

heart failure and stable angina.

3. A comprehensive cardiac rehabilitation programme is recommended. This can be

hospital or community based depending on patient needs. The programme should

contain an exercise component.


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4. Cardiac rehabilitation includes secondary prevention. It should be an integral part

of, and begin at, the acute stages of care and be continued in the communitysetting. Cardiac rehabilitation is the responsibility of all health care professionals

involved in the care of cardiac patients.

5. Cardiac liaison nurses are ideally placed to identify and assess all eligible patients

in hospital, offer appropriate rehabilitation options, and provide discharge details to

the GP so that these patients are included in the practice based register for

coronary heart disease (CHD). They can liaise with other members of the

multidisciplinary team to ensure a holistic approach to patient care.

6. A designated staff member should be identified who carries overall responsibility forcoordinating cardiac rehabilitation in each Trust and a consultant cardiologist/

physician should hold clinical responsibility for cardiac rehabilitation.

7. Specific components of cardiac rehabilitation (e.g. supervision of exercise training,

dietary advice, and pharmacological advice) should be provided by suitably trained

and qualified staff.

8. Cardiac liaison nurses can provide integrated care and bridge the gap between the

primary and secondary settings to improve patient outcome.

9. Improvement in meeting secondary prevention goals may be achieved by integrating

cardiac rehabilitation services with secondary prevention clinics in primary care and

the collaborative working of nurses, pharmacists and general practitioners.

10. A system for identifying patients with characteristics, known to be associated with a

low uptake of cardiac rehabilitation, should be put in place to enhance uptake of

cardiac rehabilitation and should be audited.

11. Trusts should agree, implement and audit a detailed plan and protocol for identifying,

treating and following patients enrolled in the cardiac rehabilitation programme.


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MILESTONES FOR CREST GUIDELINES ON CARDIAC REHABILITATION

In addition to these recommendations the expert panel agreed the milestones that should

be attained for the provision of cardiac rehabilitation in Northern Ireland.

Milestone 1Within six months:

Every cardiac rehabilitation service (whether hospital or community based) should have an

agreed protocol for the identification, assessment and management of patients post-

myocardial infarction, post-coronary revascularisation and selected patients with chronic

heart failure and stable angina.

Milestone 2Within a further 12 months:

Every cardiac rehabilitation service should have, for all patients on their register, clinical

audit data no more than 18 months old covering the following areas:

Percentage of patients discharged from hospital with a primary diagnosis of

myocardial infarction or post-coronary revascularisation with documentation that

phase 1 cardiac rehabilitation has been provided.


myocardial infarction or post-coronary revascularisation with documentation that

phase 2 cardiac rehabilitation has been provided, whether by telephone call,

outpatient appointment or home visit. Data should include age, gender and race.


myocardial infarction or post-coronary revascularisation invited to a phase 3

cardiac rehabilitation programme. Data should include age, gender and race.

Percentage of patients invited to a phase 3 cardiac rehabilitation programme who

subsequently complete 50% or more of the programme. Data should include age,

gender and race.


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Chapter 1

INTRODUCTION

General Background

Cardiac disease is the leading cause of death in Northern Ireland and is the leading causeof hospitalisation for both men and women. Cardiac rehabilitation programmes arerecognised as a way to enhance recovery following acute cardiac events and encouragebehaviour aimed at the secondary prevention of coronary artery disease. There are manydefinitions of cardiac rehabilitation. The key elements of cardiac rehabilitation are contained

in the definition produced by the Scottish Intercollegiate Guidelines Network (SIGN):Cardiac rehabilitation is a process by which patients with cardiac disease, in partnershipwith a multidisciplinary team of health professionals are encouraged and supported toachieve and maintain optimal physical and psychological health1. The key elementsincluded in most comprehensive rehabilitation programmes are:

Education and risk factor management Exercise intervention Psychological interventions

The relative emphasis placed on each of these three elements differs in individual cardiac

rehabilitation programmes but it is widely agreed that the exercise training should form thebasis of cardiac rehabilitation provision.

A proposed pathway for cardiac rehabilitation is shown in Appendix 1.

The Four Phases of Cardiac Rehabilitation

Four phases of cardiac rehabilitation were defined by the British Association of CardiacRehabilitation (BACR) and endorsed by the National Service Framework (NSF) for CHD inEngland and Wales and SIGN for Scotland1,2. Each stage recognises different componentsof care.

Phase 1

This phase occurs before discharge from hospital. During this phase reassurance andeducation, correction of cardiac misconceptions, risk factor assessment, mobilisation anddischarge planning are the key elements.

Phase 2

This is the immediate post-discharge period and reinforces the information previouslysupplied in phase 1. In this phase, support can be provided by home visiting, telephonecontact or by supervised use of The Heart Manual3. The Heart Manual is a self-helpprogramme for patients recovering from an acute coronary event that has been shown to


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reduce anxiety, depression and hospital readmission rate.

Phase 3

This phase incorporates elements of the early post-discharge period including education,

risk factor assessment, and correction of cardiac misconceptions plus structured exercise

sessions to meet the assessed needs of individual patients. This can be undertaken in the

hospital or community setting and employs a menu-based approach to tailor the delivery of

services to the individual. Patients who are unable to take part in formal exercise should

receive phase 3 education and advice on appropriate activities.

Phase 4

This phase involves the long term maintenance of physical activity and lifestyle change. The

evidence suggests that both components need to be sustained for cardiac benefits to

continue.

Cardiac Rehabilitation Programmes in Northern Ireland

The NSF for England and Wales standard for cardiac rehabilitation states that NHS Trusts

should put in place agreed protocols / systems of care so that, prior to leaving hospital,

patients suffering from CHD have been invited to participate in a multidisciplinaryprogramme of secondary prevention and cardiac rehabilitation. The aim of the programme

will be to reduce their risk of subsequent cardiac problems and to promote the return to a

full and normal life. Provision of cardiac rehabilitation services in Northern Ireland varies

from Trust to Trust depending on funding. These guidelines are an attempt to standardise

the provision of cardiac rehabilitation services throughout Northern Ireland.

The provision of a cardiac rehabilitation service for all eligible patients throughout Northern

Ireland is clearly desirable for health and economic reasons. It is recognised that only a

minority of eligible patients participate in cardiac rehabilitation services with women and

elderly patients less likely to be invited to attend programmes. The barriers to attendance

in the programmes are well recognised and include social deprivation, level of education

and negative attitudes towards rehabilitation from partners and families. The aim of this

document is to emphasise and promote the importance of cardiac rehabilitation and

address the issues that represent barriers to participation in cardiac rehabilitation

programmes. In particular, provision of outreach classes in health and community centres

to increase the uptake in rural areas may be especially beneficial in the Northern Ireland

context.

Appendix 2 shows the British Heart Foundation (BHF) / BACR data set record form for

cardiac rehabilitation.


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Chapter 2

EDUCATIONAL AND PSYCHOLOGICAL INTERVENTIONS

Cardiac rehabilitation describes a process which embraces different approaches to helpingindividuals with cardiovascular disease return to as normal a life as possible and reduce therisk of further cardiac events. It represents a structured programme that should beincorporated as part of the care package for every cardiac patient. Patients should be ableto access services according to need and a menu-based approach to tailor the delivery ofservices on an individual basis is advocated1.

The information provided should be clear, concise and based on individual need. Theeducational approach should be based upon adult learning principles, be relevant to theindividual, involve dialogue, engage patients to be involved in the process, use visual aidsto support verbal instruction and allow for feedback and reinforcement1,2. Currently patienteducation and psychological support is offered. However if this is not modelled on anyproven educational or behavioural principle then its effectiveness may be limited.

ASPECTS OF EDUCATION

One of the most common concerns for patients recovering from a cardiac event is theirability to return to normal activity. With an ageing population and the increasing shift of

coronary syndromes from acute fatal events to a chronic disease state there is a growingneed for services that help patients improve their quality of life, increase functional capacityand decrease disability.

Smoking

Smoking is one of the major modifiable risk factors for cardiovascular disease. Cigarettesmoking is responsible for about 17% of deaths from CHD3. Stopping individuals fromsmoking represents the best and most cost effective way of improving health outcomes.The risk of death from a myocardial infarction is reduced by 50% within 2 years of quitting4,5.Brief intervention from a doctor/nurse or pharmacist can be highly effective in helping

patients to stop smoking6,7. The National Institute for Health and Clinical Excellence (NICE)suggests that combining pharmacological treatment with advice and behavioural supporthas been shown to be the most effective way to help smokers quit and that nicotinereplacement therapy (NRT) and the use of bupropion is a cost effective intervention in termsof life years gained8, although side effects may limit use.

Hypertension

High blood pressure is one of the most preventable causes of premature morbidity andmortality in developed and developing countries. In non-diabetic populations withhypertension, optimal BP treatment goals are; SBP


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Lifestyle measures include weight reduction, reduced salt intake, limited alcohol

consumption, increased physical activity, increased fruit and vegetable intake and reducedtotal fat and saturated fat intake. Drug treatments are covered elsewhere in the guidelines.

Healthy Eating

The British Dietetic Association has recently updated their evidence based guidelines on

diet in secondary prevention of cardiovascular disease10. These guidelines advise a

Mediterranean diet which includes:

Increased omega-3 fat intake (from dietary or supplemental fish oils)

Increased intake of fruit and vegetables (at least five portions a day)

Reduction in saturated fats and total or partial replacement by unsaturated fats(rapeseed or olive oil)

Reduction in processed foods

Alcohol

Recent research suggests that modest alcohol consumption (1 to 2 units / day) can provide

cardiovascular protection. In general, alcohol consumption should be restricted to these

moderate levels, given the myocardial depressant properties of alcohol11. Heavier

consumption of alcohol increases the prevalence of hypertension and the risk of

cerebrovascular disease. Heavy drinking increases the risk of sudden death12.

Serum Lipids

Serum cholesterol and LDL cholesterol continue to be risk factors for recurrent CHD events

after MI13. A full lipid profile should be recorded for each patient. Since the publication of the

4S study in 1994, the CARE and LIPID studies have confirmed that in patients with known

coronary disease treatment with statins reduces non fatal and fatal event rates by 23% and

33%14. The Heart Protection Study indicates that statin therapy is effective at all baseline

levels of serum cholesterol. However the full lipid profile may indicate the need for other

drug therapies in combination with statins or on their own. Patients should be aware that

this may be a long term therapy. Dietary advice should be given to all patients.

Diabetes

Diabetic patients should receive education regarding the need for good glycaemic control,

target blood pressure and lipids to reduce the risk of further cardiac events. In Type 1

diabetes glucose control requires appropriate insulin therapy and concomitant professional

dietary advice. In Type 2 diabetes, professional dietary advice, weight reduction and

increased physical activity should be incorporated in the treatment plan. Drug treatment is

added if these measures do not achieve excellent glucose control 15.


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Advice Regarding Medication

Education and advice regarding medication administration is essential to improve

compliance. The health care professional should advise the patient regarding the name,

dose, timing and route of administration. Desired effects and potential side effects should

be discussed. The importance of adherence to therapeutic regimen should be emphasised.

Patients should be advised to contact their health care professional if they have side effects

from the medication.

Physical Activity

A sedentary lifestyle is associated with an increased risk of cardiovascular disease.

Maintenance of regular physical activity and good physical fitness protects againstcardiovascular disease16,17.

Regular aerobic exercise has favourable effects on body weight, plasma lipids, blood

pressure, glucose tolerance and insulin sensitivity. Furthermore exercise has favourable

psychological effects. Exercise regimens need not be intensive to bring benefits, but must

be sustained.

Sexual Activity

Many cardiac patients are concerned about resuming sexual relations. Some patients worry

that sexual activity will put too much strain on the heart. Partners of heart patients oftenworry about these issues even more so than the patient. As a result of these concerns,

many couples are reluctant to resume sexual activity.

There are no definitive guidelines, but if patients are able to walk one mile or climb two

flights of stairs without symptoms it is generally safe to return to sexual activity. This equates

to 5-6 Mets of energy expenditure. General advice includes the avoidance of sex in stressful

situations, in an uncomfortable environment or with an unfamiliar partner18. However,

specific recommendations for resuming sexual relations depend on a number of factors,

including the degree of residual heart function.

Erectile dysfunction in cardiac patients is extremely common and occurs in 50-75% of

patients. All current available treatment for erectile failure is suitable for a cardiovascular

patient and, if used according to the instructions, does not increase the cardiovascular risk18.

Driving

Most people are permitted to drive after 4 weeks following a myocardial infarction and 4-6

weeks following cardiac surgery. After a non ST elevation myocardial infarction driving may

recommence 1 week after successful angioplasty, if no other disqualifying condition exists.

Driving may resume 1 week following percutaneous coronary intervention (PCI). For

patients with angina, driving may recommence when satisfactory symptom control isachieved19.


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Advice for group 2 license holders is more stringent and details are available from the Driver

and Vehicle Licensing Northern Ireland (DVLNI). As the guidelines are constantly updated,it is advised that the health professional refers to current DVLNI guidelines. It is the patientsresponsibility to inform the DVLNI of their cardiac condition.

Flying

Patients are advised not to fly for 2-3 weeks post-myocardial infarction, 3-5 days post-angioplasty, 10-14 days following cardiac surgery. Long haul flights are generally notadvised for 3-6 months20. Airlines usually only request medical clearance when fitness totravel is in doubt21.

Return to Work

Patients with an uncomplicated recovery from a myocardial infarction and who have asedentary job may be able to return to work within 6 weeks. Those with manual jobs arecommonly advised not to return to work for 8-12 weeks22. In practice, discussion should takeplace between the patient and the multidisciplinary team prior to return to work. Anincreasing trend is for the earlier return to work especially following an uncomplicatedmyocardial infarction.

Depression - Psychological Adjustment

Poor psychological adjustment is predictive of subsequent mortality but is not related to theseverity of the cardiac illness. Depression is associated with increased mortality in cardiacpatients especially in post-myocardial infarction and unstable angina patients. Depressioncan also interfere with and decrease the effectiveness of secondary preventioninterventions to reduce cardiovascular disease. All members of the multidisciplinary teamneed to be alert to the signs and symptoms of depression in patients with cardiovasculardisease.

Anxiety

High levels of anxiety may have an adverse effect on outcome22,23. Anxiety is generally at its

highest during the first few hours after myocardial infarction, reducing as the patientscondition is stabilised. These levels may rise again prior to discharge. This anxiety can bereduced by providing information and advice on how to manage their condition post-discharge.

Psychological Interventions

Psychological distress and poor social support are known to be powerful predictors ofoutcome following an acute coronary event, independent of the degree of physicalimpairment1. Psychological distress is an important predictor of rehospitalisation. Costsfollowing a cardiac event and total health care costs are linked to anxiety and depression.

The prevalence of depression after an acute cardiac event ranges from 15%-45%1.Depression is associated with a 3-4 fold increase in cardiac mortality and is predictive of


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poor symptomatic and functional outcome at 3 and 12 months. High levels of anxiety have

also been shown to have an adverse effect on outcome in the inpatient setting and duringlonger term follow up1.

Specific psychological challenges for CHD patients include the experience of a frightening

life threatening event, the prospect of continued symptoms, reduced life expectancy, the

fear of a future event and the prospect of family or a partner being left alone. They also

include threats to employment and financial status and of being treated differently by other

people24, the need to take medications, the prospects of possible medication side effects

and lifestyle changes in relation to smoking, diet and activity. Although the details of chronic

illness management will depend on the illness in question, many of the principles of

effective management are common to all chronic conditions24

.

Most of the day to day responsibilities for the care of chronic illness fall on patients and their

families. Medical care must be delivered in collaboration with patients and their families, and

to enable patients to play an active role in their care and improve their knowledge and self

management skills. The common elements of an effective chronic illness management

programme include collaboration between service providers and patients, a personalised

written care plan, tailored education in self management, planned follow up, monitoring of

outcome and adherence to treatment, targeted use of specialist consultation of referral and

protocols for stepped care24. These principles are embodied in the United Kingdom expert

patient programme: the expert patient: a new approach to chronic disease management forthe 21st century25.

Although psychological interventions have been diverse in nature and incompletely

described in the literature meta-analysis suggests that intervention can result in significant

reductions in morbidity and mortality post-myocardial infarction. No consensus exists on the

most appropriate instrument for measurement of psychological wellbeing or the timing of

administration but SIGN has recommended that screening for anxiety and depression

should take place at discharge, 6-12 weeks post event and be repeated thereafter if

appropriate1.

Behavioural Interventions

Many patients have some idea about what they should be doing but have problems

deciding how to translate the health messages into practical strategies to improve health

outcomes1. Achieving behaviour change is not easy and an understanding of the principles

of behaviour change is essential. There are many models and theories that have been

shown to be effective in achieving behaviour change. Not all health professionals will be

trained in the psychological principles of behaviour change and motivational interviewing,

that can be used in consultations with patients. It is important to be realistic and understand

that telling people what to do is not effective in altering behaviour1,2.


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Care needs to be taken in explaining the impact of certain behaviours in relation to health

and offering options for change without attributing blame or guilt. Advice needs to beprioritised. Making lifestyle changes is difficult and it is important not to invite failure by

overburdening patients with advice. Simple instruction and consideration of cultural, social

and economical factors when giving advice is key. A positive approach that addresses the

major risk factors is most likely to succeed in producing favourable health outcomes.

Cardiac rehabilitation:

Empowers the patient to make lifestyle changes to reduce some and

eliminate other risk factors

Further increases the knowledge of their condition and addresses cardiacmisconceptions

Enables the patient to resume their daily activities with confidence

Assists the patient and their partner to attain psychological wellbeing

Assists the patient to return to their employment where appropriate

Promotes adherence to secondary prevention medication

Provides a review of patients symptoms, clinical measurements and general

recovery


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Chapter 3

EXERCISE

The World Health Organisations (WHO), Global Strategy on Diet, Physical Activity and

Health26 indicates that:

Physical inactivity is estimated to cause about 22% of ischaemic heart disease

The risk of developing a cardiovascular disease increases by 1.5 times in people

who do not follow minimum physical activity recommendations

WHO states that regular physical activity not only reduces the risk of heart disease but alsoimproves glucose metabolism, reduces body fat, lowers blood pressure, improves

musculoskeletal health, controls body weight and reduces symptoms of depression.

A Cochrane review27 concluded that exercise-only cardiac rehabilitation reduced all-cause

mortality by 27% and cardiac mortality by 31%. An updated meta-analysis on exercise

based cardiac rehabilitation programmes for coronary artery disease by the Canadian Co-

ordinating Office for Health Technology Assessment confirmed the earlier findings of the

Cochrane Review28. Exercise based cardiac rehabilitation was responsible for relative risk

reduction in all-cause mortality of 24%, and cardiac mortality of 23%. Taking the usual care

mortality as the baseline risk, the data suggest that 66 and 49 patients need to receiveexercise based cardiac rehabilitation to prevent 1 overall death and 1 cardiac death

respectively, over an average of 28 months follow up. This estimate compares favourably

with the numbers needed to treat per year from all-cause mortality of accepted / standard

coronary artery disease secondary prevention practices such as beta-blocker therapy

post-MI (NNT=84) anti platelet therapy post-MI (NNT=306), and statin therapy (NNT=11 to

56). Importantly, there was no statistical evidence of a difference in treatment effect

between the time periods of the meta-analysis. This would indicate that the beneficial

effects of cardiac rehabilitation on mortality appear to have been retained even with the

advent of new treatments and technologies. A further recent study29 found that not only was

participation in cardiac rehabilitation associated with decreased mortality after MI but also

with lower risk of recurrent MI.

Ades et al30 analysed baseline physical functioning in a population of patients with CHD

entering a cardiac rehabilitation programme and determined the subsequent response of

physical function score to exercise rehabilitation. They found that physical function score

increased substantially (+22%) along with increases in peak VO (+16%), peak exercise

capacity (+50%), leg strength (+28%) and upper body strength (+17%), and a decrease in

depression score (-54%). Patients with the lowest baseline physical function score were

the most likely to show an improvement in this measure after rehabilitation.


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Assessment Before Exercise Training

The majority of patients with stable cardiac disease will benefit from a prescribed exercise

programme. Those patients deemed unstable would be excluded from exercise training.

Exercise should be delivered by experienced staff with training in exercise physiology and

prescription.

Prior to participation in exercise training patients will be assessed and risk stratified into low,

medium and high risk categories using one of the recognised classifications such as the

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) as

recommended by American College of Sports Medicine31.

Clinical risk stratification is sufficient for low to moderate risk patients undergoing

low to moderate intensity exercise1.

Exercise testing and echocardiography are recommended for high risk patients

and/or high intensity exercise training (and to assess residual ischaemia and

ventricular function where appropriate)1.

Functional exercise capacity should be evaluated before and on completion of

exercise testing using a valid and reliable measure such as the Shuttle Walking

Test 1,32.

Exercise Content

All sessions should include:

Warm-up

Conditioning phase

Cool-down

Relaxation

Warm-Up

The warm-up period should include graduated low intensity aerobic exercise and short

dynamic stretches to increase myocardial blood supply, soft tissue flexibility and mobilise

joints33. A minimum of 15 minutes should be allowed for warm-up34.

Conditioning Phase

All patients participate in a progressive exercise training programme, which is modified to

meet individual need.


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Frequency

Supervised exercise should be twice weekly for a minimum of 8 weeks1,2. In addition

patients should be given a home exercise programme.

Intensity

Low to moderate intensity exercise31,34 is most suitable to meet the needs of a broad range

of patient groups. Individual patients should be prescribed target heart rate ranges and/or

Borg rating of perceived exertion35 (Appendix 3) based on assessment and risk stratification.

Time

Optimum training effect is achieved with 20 30 minutes of continuous aerobic activity 31,33.

Progression of conditioning phase depends on initial functional capacity,

age and health status.

Interval type training may be more appropriate for more deconditioned

patients31.

Type

Aerobic type activities (such as cycling, walking) have been found to be most beneficial27,31.

Aerobic exercise should include simple repetitive movements of large muscle groups.

Monitoring

Exercise intensity should be monitored and modified using the Borg RPE scale and/or heart

rate monitoring.

Limitations exist when each of these methods is used individually. Heart rate

response to exercise can be altered by medication and co-existing pathology. In addition RPE scores are subjective and have been shown to be underrated by

cardiac patients compared to age matched controls 36.

Cool-Down

The conditioning phase should be followed by a minimum of 10 minutes cool-down.

Cool-down should include low intensity exercise and muscle stretching.

Patients should be supervised for a minimum of 15 minutes following cool-down

phase33.


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Resistance Training

Cardiac patients may require resistance training to facilitate a return to physically

demanding activities. This is only appropriate for low moderate risk patients and should

not be introduced until 46 weeks of supervised aerobic exercise have been completed 31.

Relaxation

Exercise sessions should be followed by a period of relaxation.

Long Term

By the end of phase 3 rehabilitation of all patients long term exercise plans are agreed andarrangements should be made for transference of care37.

People with stable coronary disease should be encouraged to continue regular moderate

intensity aerobic exercise. Some people may devise their own exercise programmes, return

to previous sports, or use a home based exercise programme. Others prefer formal class

based cardiac exercise programmes.

Phase 4 is a community based activity which follows immediately after the completion of the

phase 3 programme. The key aim is long term compliance to exercise and thus the

programme must be enjoyable and convenient38. Regular supervised training sessions are

provided and exercise prescription is individualised for additional unsupervised physicalactivity. Phase 4 provides a regular review of the patients progress, for which the exercise

prescription can be altered accordingly. In the case of deterioration in functional capacity, a

referral can be made back to the primary care team. Phase 4 exercise programmes are run

by suitably trained staff with the appropriate knowledge and skill to prescribe and deliver

safe and effective exercise. A phase 4 training course, which has been developed by BACR

supported by BHF, is available. Strong links have been formed between clinical specialists

and exercise professionals within this field of rehabilitation to ensure a high standard of care

for the cardiac patient.

The BACR have given the following guidelines for the delivery of phase 4:

Inclusion Criteria for Patients

Significant improvement in functional capacity since MI/cardiac event

Psychological adaptation to chronic disease

Commitment to long term lifestyle change

Ability to exercise according to prescription

Ability to monitor and moderate exercise intensity

Ability to recognise signs and symptoms of possible myocardial ischaemia

Ability to identify goals in relation to risk factor modification


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Referral

Patient has attended phase 3 and is assessed by the physiotherapist on completion A relevant referral form is completed Written consent should be gained from the patient for their discharge summary to be

made available to phase 4 staff

Exercise Prescription

An individual exercise prescription is developed in partnership with the patient. Thiswill follow the same principles as phase 3

Warm-up and cool-down will be included similar to phase 3

All patients should be reassessed when there is any change from the initialassessment

Health and Safety

Requirements for Phase 3 and 4

1. It is recommended that patients should not exercise if they are generally unwell,symptomatic or clinically unstable on arrival e.g. if they present with:

Fever and acute systemic illness

Unresolved/unstable angina Resting blood pressure systolic>180mmHg and diastolic >100mmHg Significant unexplained drop in blood pressure Tachycardia >100 bpm New or recurrent symptoms of breathlessness, palpitations, dizziness Swelling of ankles or significant lethargy

If any of these signs or symptoms are present the patient should be seen by their generalpractitioner and/or cardiologist39.

2. Prior to exercise patients should be fully inducted in safe use of all equipment.

3. All staff should be trained in basic life support procedures and regularly updatedaccording to local protocols.

4. Appropriate resuscitation equipment including a defibrillator, with at least onemember of staff trained in its use and advanced life support should be available atevery supervised exercise session.

5. Protocols for the management of medical emergencies must be available.

6. Rapid access to emergency services must be available e.g. crash team orambulance.

7. Equipment must be maintained on a regular basis.


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8. Venue must be suitable i.e. adequate space, temperature (65 72 0F,

18 23 0C), ventilation, humidity 65%.

9. Drinking water should be available.

STAFFING

Phase 3

Current guidelines recommend two trained staff should be present at all times during

exercise training with a patient to staff ratio of not more than 5:1.

Phase 4

In the absence of guidelines for staffing levels in phase 4, recommendations for phase 3

should be followed.

There is a perception that exercise training for cardiac patients is dangerous but if the above

safety issues are implemented, available data suggest that cardiac rehabilitation

programmes result in very few complications and the incidence of death is one per 1.3

million exercise hours39.

LOCATION

Phase 1

Hospital inpatient.

Phase 2

Early discharge period support can be provided by home visits, telephone contact and by

supervised use of The Heart Manual.

Phase 3

Low to moderate intensity exercise training can be carried out in the hospital setting or

community (including non-health sector settings such as leisure centres), as long as agreed

standards are adhered to. Exercise training for high risk patients and for those who require

high intensity exercise should be hospital based or in a venue with full resuscitation

facilities.

Phase 4

Long term maintenance of physical activity and lifestyle changes in the community.


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Chapter 4

TARGET PATIENT GROUPS

While cardiac rehabilitation has been defined as relevant to all patients with heart disease

most of the research concerns middle-aged white males with a recent myocardial infarction.

There is an increasing body of evidence that the benefits of exercise rehabilitation extend

to other cardiac groups beyond low risk post-myocardial infarct patients. These include

patients post-coronary artery bypass grafting (CABG), post-angioplasty and patients with

angina pectoris. Unfortunately women and older patients continue to be underrepresented

in clinical trials. The percentage of females included in 1995 and before is 6.8% and post

1995 is 13.6%27. In respect of age, the mean age across trials 1995 and before is 54.4 years

and post 1995 is 56.7 years.

Post-Myocardial Infarction

It is in this patient group that the strongest evidence linking cardiac rehabilitation with

improved outcomes exists. Meta-analyses of randomised clinical trials showed that in both

exercise-only and comprehensive cardiac rehabilitation programmes, total mortality,

cardiovascular mortality and fatal reinfarction were significantly and substantially reduced 40-

42. Comprehensive cardiac rehabilitation has also been shown to improve psychological

function43, return to work44 and biological risk factors 45.

Worldwide, the clinical presentation of myocardial infarction has been changing in recent

years. Increasing numbers of patients with small myocardial infarctions are being

diagnosed as a result of sensitive cardiac marker assays. Similarly, the number of patients

presenting with ST segment elevation myocardial infarction is falling46. In the Northern

Ireland population, most patients with myocardial infarction present without ST segment

elevation on the initial electrocardiogram.

Recommendations

Comprehensive cardiac rehabilitation is recommended for all patients following ST segment

and non ST segment elevation myocardial infarction.

Post-Coronary Revascularisation

Initial studies of the benefits of cardiac rehabilitation in this setting were predominantly

conducted in patients CABG. Within recent years however, the number of patients

undergoing CABG has been static while the number of patients undergoing PCI has been

increasing logarithmically. Currently approximately twice as many patients undergo PCI in

the United Kingdom compared with CABG47.

Proven beneficial effects of cardiac rehabilitation after CABG have included measures of

quality of life, return to work and cardiovascular risk factors48,49

.


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After PCI, randomisation to an exercise based programme improved quality of life and

reduced cardiovascular events and the likelihood of readmission. No difference inrestenosis was observed50.

Recommendation

Comprehensive cardiac rehabilitation is recommended for patients who have undergone

coronary revascularisation including all patients who have had percutaneous coronary

revascularisation.

Congestive Heart Failure

Patients with congestive heart failure have been underrepresented in trials of cardiac

rehabilitation as well as in clinical cardiac rehabilitation programmes51. Nonetheless trials

that have addressed whether patients with heart failure benefited from exercise based

rehabilitation showed improvements in exercise capacity, quality of life, mortality and the

need for hospital admission52.

Separate comprehensive disease management programmes for heart failure have been

shown to reduce hospital attendance and to improve quality of life and medication

compliance53,54. Most of these programmes did not include an exercise component. Such

disease management programmes have been widely established throughout NorthernIreland and have provided a major source of psychological as well as educational support

for patients with chronic heart failure.

Although patients with congestive heart failure may derive benefit from exercise based or

comprehensive cardiac rehabilitation, the evidence is less robust compared with patients

post-myocardial infarction and post-revascularisation42.

Recommendation

Patients with congestive heart failure may be suitable for cardiac rehabilitation

programmes, but this should only be undertaken when adequate provision has been made

to include all patients with recent myocardial infarction and recent coronary

revascularisation. Patients with congestive heart failure should not be excluded from

exercise based cardiac rehabilitation regimes if they are otherwise deemed suitable.

Stable Angina

In the setting of stable coronary artery disease, exercise based and comprehensive cardiac

rehabilitation programmes have shown improvements in exercise capacity and symptoms

as well as retarding progression of disease. Benefits have also been shown in terms of

quality of life and on cardiovascular risk factor status55,56 but not mortality or acutecardiovascular events.


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Recommendation

Cardiac rehabilitation is not recommended for every patient with stable angina but may be

suitable for selected individuals with disabling symptoms.

Patients Post-Cardiac Transplantation or Post-Valve Surgery; Patients with

Congenital Heart Disease; Patients with Implantable Cardioverter Defibrillators

(ICD's):

In each of these patient groups there is limited evidence to support the benefits of cardiac

rehabilitation57-60. In many cases the number of patients involved is small and it might be

counterproductive to target these patients as a group. Instead an individualised approachshould be taken as the need arises.

Many patients with ICD's will also fall into the categories of congestive heart failure,

previous myocardial infarction, previous revascularisation or stable coronary artery disease.

It is recognised that patients with ICD's have some of the greatest psychological morbidity

of all patients with cardiovascular disease and individuals may benefit from the support

offered by a comprehensive or menu-based cardiac rehabilitation61.

Women, Older Patients and Ethnic Minorities

As with many other forms of treatment for cardiovascular disease, such patient groups have

often been underrepresented in cardiac rehabilitation trials and programmes62-64. There is no

reason to believe that these groups would benefit from cardiac rehabilitation programmes

to a lesser extent than other members of the target population.

Recommendation

Patients should not be excluded from cardiac rehabilitation programmes on the basis of

age, gender or ethnicity.


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Chapter 5

SECONDARY PREVENTION: USE OF MEDICATION

The ability to implement effective and appropriate secondary prevention to patients with

CHD is a challenge. Evidence shows that several interventions reduce the risk of recurrent

disease and death. The responsibility for secondary prevention straddles primary and

secondary care and two recent government initiatives support implementations in both

settings:

1. The NSF for CHD advocates the use of registers for patients with CHD to facilitate

long term follow up and it also sets standards / milestones for secondaryprevention.

2. The General Medical Services (GMS) contract encourages primary care teams to

implement evidence based care.

Drugs and Secondary Prevention

The benefits of secondary prevention medication pre and post cardiac event have been

demonstrated in large randomised trials that have resulted in publication of national

guidelines for the management of dyslipidaemias, hypertension, obesity, smoking

cessation, diabetes mellitus and most recently, heart failure.

Anti-Platelet Therapy

Aspirin has become a standard of care for secondary prevention in post-MI patients. In

patients with acute ST elevation myocardial infarction, 160mg of aspirin reduced 35 day

mortality by 23%, compared to a 25% reduction with streptokinase. Together the

interventions displayed a synergistic effect. The benefit was evident in all groups, including

the elderly65. The four-year mortality follow up data showed a significant long term benefit

among those allocated aspirin. In addition to reducing mortality, aspirin also reduced the

incidence of strokes and reinfarction. A recent meta-analysis supported the long term use

of low dose aspirin (75-150mg daily) in secondary prevention66. Higher doses are no more

effective and are associated with gastrotoxicity.

Clopidogrel 75mg is an effective but expensive alternative in patients with genuine allergy

or proven gastric intolerance to aspirin67. The addition of clopidogrel to aspirin patients with

acute coronary syndromes, with or without ST segment elevation, is beneficial in preventing

future coronary events68,69.

Beta-Blockers

Beta-blockers reduce the risk of death, non fatal recurrent myocardial infarction and sudden

cardiac death and are recommended in national guidelines70,71. The use of beta-blockers as

a coronary prevention measure remains sub-optimal72.


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Beta-blockers are often implicated in producing adverse events. A recent review showed no

significant increased risk of depression and small increases in the risk of sexual dysfunctionand fatigue73. The contraindication of beta-blockers in patients with asthma and chronic

obstructive pulmonary disease (COPD) has also been questioned by a Cochrane Review

that indicated they do not produce adverse respiratory effects in patients with mild to

moderate airways disease74. Care must be taken but the drugs should not necessarily be

withheld. A study of 46,000 survivors of MI with asthma or COPD showed a 40% reduction

in mortality with beta-blockers, with benefits extending to the elderly and those with heart

failure. Beta-blockers also appear to have little effect on the peripheral circulation in patients

with less severe forms of peripheral vascular disease (PVD)75.

ACE Inhibitors

Angiotensin converting enzyme ACE inhibitors after acute myocardial infarction have been

recommended for patients with signs of heart failure or confirmed left ventricular

dysfunction76.

Recent trials have assessed the effects of ACE inhibition in low risk patients with stable

coronary artery disease, but no clinical heart failure77,78. One trial showed a reduction in

cardiovascular end-points with ACE inhibition while the other trial was essentially negative.

Importantly there was little difference in cardiovascular events documented in the placebo

arms in each of these studies. ACE inhibitors should be endorsed post-MI and in patientswith impaired left ventricular systolic function and congestive heart failure. The use of ACE

inhibition is more contentious in stable CHD. Angiotensin II antagonists have been

advocated when patients are intolerant to ACE inhibitors79.

HMG-CoA Reductase Inhibitors

Statins decrease the risk of coronary events and all-cause mortality in patients after a

myocardial infarct80. The benefits apply to both sexes, older individuals and the relative

reduction in risk is independent of initial cholesterol concentrations81.

Statins should be prescribed to survivors of a myocardial infarction irrespective of initial

cholesterol concentration. Compliance with therapy can be a problem with a recent study

indicating a 60% non-adherence rate in elderly patients 2 years after a coronary event82.

A recent cohort study examined the effects of combinations of drugs in the secondary

prevention of all-cause mortality in patients with ischaemic heart disease. Combinations of

statins, aspirin and beta-blockers improved survival in these high risk patients but the

addition of an angiotensin converting enzyme inhibitor conferred no additional benefit83.


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Chapter 6

CARDIAC REHABILITATION IN PRIMARY CARE

Patient Held Record

Following an acute coronary event and the early stages of cardiac rehabilitation, continuing

provision of follow up care is dependent on a patients involvement with primary and

community services. Ongoing medical care, cardiac rehabilitation and secondary

prevention of CHD often overlap.3 A seamless transition between hospital provision of

cardiac rehabilitation and the continuing support provided by primary care practitioners

requires good communication between all involved in the care of patients with CHD. Onesuggestion to enhance communication and involve patients in their own management is the

introduction of a patient held record. Such a record should include details of the patients

clinical diagnosis, hospital procedures, pharmacological treatments, cardiac rehabilitation

programme and plans for hospital review. Contacts with all health professionals should be

indicated in this record and it should allow tracking of changes in lifestyle, risk factors and

medication.

Continuing Care

Evidence suggests that continued support is necessary for patients to maintain healthylifestyles and continue exercise programmes84. Whilst the main responsibility for compliance

with optimal management advice lies with the individual patient, this should be facilitated in

primary care. Practitioners should ensure that their patients are aware of the need to

continue leading a healthy lifestyle and adhering to therapeutic regimens in order to

maintain benefit for the reduction of risk of subsequent cardiac events. Provision of

secondary prevention of CHD is effective85-87 and in primary care it is enhanced by organised

programmes involving nurse-led clinics88,89. A proactive approach to monitoring patients

progress is recommended and the value of specialist care for patients with complicated

disease must be acknowledged3.

Disadvantaged Groups

Little information has been published regarding levels of uptake of cardiac rehabilitation

services across Northern Ireland. Reports from other parts of the United Kingdom indicate

that those who are least likely to participate in cardiac rehabilitation include socially

disadvantaged groups, women and older people90-92. Appropriate resources should be made

available to primary care practitioners to enable them to assess the needs of these

individuals and address their concerns, doing so would enhance the likelihood of successful

involvement in cardiac rehabilitation93,94.


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Identifying Needs

There is evidence of a need to tailor services appropriately to the needs of individuals 95,96.

Failure to take up cardiac rehabilitation contributes to a widening gap in health status across

the social classes. Improving access to cardiac rehabilitation should increase participation

rates, reduce health inequality97, increase life expectancy and increase the number of years

people are free from disability, which are goals of the Investing for Health Strategy in

Northern Ireland95. It is important that further information should be obtained about the

needs of individuals and of the needs and priorities of local communities. Primary care

practitioners are well placed to help identify these.

Multidisciplinary Communication

Good communications between all professionals involved in cardiac rehabilitation can help

alleviate suffering and concern, not only for the patients involved but also for their relatives

and friends. The primary care team, with detailed knowledge of an individuals social and

medical background, includes professionals who are likely to be aware of the implications

of CHD for both the individual and their family. Accurate information should be shared

between the various members of multidisciplinary teams across both primary and

secondary care to help enable the early and appropriate involvement of family members in

rehabilitation programmes3.

Across the United Kingdom there is wide variation in the content of cardiac rehabilitation

programmes offered to patients93,98. For cardiac rehabilitation to be provided in an effective

manner across Northern Ireland there should be a co-ordinated communication network

between all providers of this care. In a recent project a cardiac liaison nurse was employed

to develop an integrated and seamless system for cardiac rehabilitation; patients were

offered a choice of home or hospital based rehabilitation and the report concluded that

integration of home and hospital based services improved the provision of secondary

prevention of CHD 99.

Cost Implications

There are cost implications100 in providing cardiac rehabilitation, both in respect of staff

required (which may include nurses, doctors, physiotherapists, dieticians, pharmacists,

psychologists, and audit and clerical staff) and resource materials, for example, in respect

of smoking cessation services. Good communication between staff involved in provision of

care should avoid unnecessary duplication of provision and promote best practice. It must

be recognised that increased uptake of cardiac rehabilitation may result in increased

prescribing costs within primary care and appropriate resources should be identified to

support this.


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Community Support

Within the community patients may find support from self-help groups but not all patients

may wish to attend groups or discuss their health with other people. The importance of

tailoring services to individuals personal needs must not be forgotten. For patients who do

not feel empowered to participate in formal rehabilitation programmes, opportunities for

promoting their health lie largely with primary care practitioners. There are, however, often

difficulties in engaging such patients. Alongside the limitations of health services in

improving the health of such individuals the potential for help from other sources of social

and community support in promoting physical and psychosocial health must be recognised.


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Chapter 7

IMPLEMENTATION AND AUDIT / DATA COLLECTION

The standards recommended for use are those of the NSF for CHD. Trusts should put in

place protocols/systems of care so that, prior to leaving hospital, people admitted to hospital

suffering from CHD will have been invited to participate in a multidisciplinary programme of

secondary prevention and cardiac rehabilitation. The aim of the programme will be to

reduce their risk of subsequent cardiac problems and to promote their return to a full and

normal life.

Implementation of the guidelines is the responsibility of each Trust and is an essential part

of clinical governance.

Mechanisms should be put in place to ensure that the care provided is reviewed against the

guideline recommendations and the reasons for any differences assessed and, where

appropriate, addressed.

The initial focus should be on ensuring comprehensive and high quality services post-MI

and for those undergoing revascularisation.

Equality is an important consideration. In particular, the inclusion of women, older people,

ethnic minorities and patients with a disability should be addressed.

Monitoring and Evaluation of the Programme

Trusts should carry out clinical audit using routinely collected data.

Long term goals can be monitored by observing changes over time in incidence and

mortality from CHD.

Resource Implications of Implementing the Guidelines

The SIGN Cardiac Rehabilitation Guidelines for Scotland outline the resource implication

for implementing their guidelines (www.sign.co.uk). This CREST document has adopted theeconomic evaluations utilised by SIGN.

The SIGN review of the evidence available estimated that the cost per life year gained from

cardiac rehabilitation was 6,400 and the cost per QALY (Quality Adjusted Life Year) was

2,700 (1999 prices). Cardiac rehabilitation was found to compare favourably in cost

effectiveness terms with other cardiovascular interventions such as treatment of

hypertension, hyperlipidaemia, use of thrombolytics for inferior myocardial infarction and

angioplasty for patients with severe angina and single vessel disease.

There has been minimal investment in the development of publicly funded services, with

much of the funding, to date, being derived from charitable sources. The Big Lottery iscurrently funding a three-year cardiac rehabilitation project in the EHSSB area (200407).


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The economic implications of delivering a high quality cardiac rehabilitation service will vary

depending on how the service is to be delivered, and the associated quality standards, whothe service is to be delivered to and where it is to be delivered. The existing provision of

funded services and the associated costs of staff and facilities will also influence the

economic implications. The fact that much of the current funding is not from mainstream

recurrent funds complicates the analysis.

There will be potential economic effects on prescribing budgets, primary care costs, and

from potential demands on limited services such as psychology, dietetics, physiotherapy,

and pharmacy. The need for audit and review of services will have resource implications for

clinical audit departments in Trusts.

There are also potential economic consequences for patients who will need to attend

sessions such as the loss of their time in alternative economic or caring activities, the cost

of prescriptions and any shoes or clothing they might require for participation.

For leisure service providers there will be a potential new market of clients for phase 4

programmes but there will be associated economic consequences of training staff and

developing accredited programmes.

The SIGN guidelines developed an estimate of the staff resources required to deliver

multidisciplinary cardiac rehabilitation to 500 patients with a wide range of needs.

The following assumptions were made for their calculations:

The 500 patients will be a mixture of post-MI, revascularisation, angina, and heart

failure patients, with post-MI and revascularisation patients predominating.

All patients will be suitable for some form of rehabilitation, with 250 (50%) opting for

group exercise training, 150 (30%) preferring a home based programme, and 100

(20%) not interested in any rehabilitation.

Patients attending phase 3 group classes and those who undertake home basedprogrammes will each have a formal assessment of functional capacity at the

beginning and the end of their programmes.

Group exercise classes will run twice a week for eight weeks and will accommodate

12-15 patients at any one time. It follows that six separate classes will be required

each week.

The population served will be predominantly urban, arbitrarily defined as 80% of

patients living within 10 miles of a district general or teaching hospital. For Health

Boards with a significant rural population, costs are likely to be higher because ofsmaller class sizes and longer travelling times.


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The first point of contact for patients with psychological distress will be a nurse

therapist with training in cognitive behaviour therapy, rather than a clinicalpsychologist. A smaller number of clinical psychologist hours will then be required to

help those patients whose anxiety or depression does not resolve with the advice

and treatment provided by their nurse therapists.

Staff costs for 500 patients using assumptions in SIGN guidelines and costs as of 1 April

2005 (subject to change under Agenda for Change)

Cost of 500 patients with rural supplement = 216,983

Cost of 500 patients without rural supplement = 200,467

In Northern Ireland there is minimal home based rehabilitation.

In 2003/04, the number of patients admitted to hospitals in Northern Ireland with CHD was

15,888.


31

Staff Costs WTE Total (including employer costs)

G Grade Nurse 3.0 99,096

Senior 1 Physiotherapist 2.0 65,360

Senior 1 Dietician 0.3 9,804

D Grade Pharmacist 0.2 8,124

Clinical Psychologist (Grade A) 0.2 9,760

Admin and Clerical (Grade 3) 0.5 8,323

Rural supplementG Grade Nurse

0.5 16,516

TOTAL 216,983


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