the cardiac rehab team: a holistic … textbook on human anatomy ... diagnosis often involves...

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THE CARDIAC REHAB TEAM: A

HOLISTIC APPROACH TO

RECOVERY AND HEALING

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical

author. He graduated from Ross University School of Medicine and has completed his clinical

clerkship training in various teaching hospitals throughout New York, including King’s

County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed

all USMLE medical board exams, and has served as a test prep tutor and instructor for

Kaplan. He has developed several medical courses and curricula for a variety of educational

institutions. Dr. Jouria has also served on multiple levels in the academic field including

faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter

Expert for several continuing education organizations covering multiple basic medical

sciences. He has also developed several continuing medical education courses covering

various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the

University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-

module training series for trauma patient management. Dr. Jouria is currently authoring an

academic textbook on Human Anatomy & Physiology.

Abstract

Just as a serious limb injury requires rehabilitation to return to optimal

performance, the heart also requires serious rehab in order to function at its best

after a trauma. Additionally, when a cardiac event occurs, the patient may suffer

emotional difficulties and challenges to accept and overcome events that caused the

condition. Cardiac rehabilitation is a whole-body approach to restore health that

incorporates a multi-dimensional methodology to address body, mind, and spirit.

Exercise, counseling, and physical therapy combine with medical management to

ensure that as much normal function as possible is restored, and that every patient

is able to adapt to lifestyle changes that reduce the risk of a repeat occurrence. The

cardiac rehabilitation team and program goals for various cardiac diagnoses and

interventions are discussed in a two part series with helpful tables and references to

support further studies and to implement knowledge in everyday practice.


Continuing Nursing Education Course Director & Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement

This activity has been planned and implemented in accordance with the policies of

NurseCe4Less.com and the continuing nursing education requirements of the

American Nurses Credentialing Center's Commission on Accreditation for registered

nurses.

Credit Designation

This educational activity is credited for 6 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE) activities. All

authors and course planners participating in the planning or implementation of a

CNE activity are expected to disclose to course participants any relevant conflict of

interest that may arise.

Statement of Need

Assisting patients to lower their risk of heart disease following a new cardiac

diagnosis often involves specialized health professionals to encourage and educate

them on best practice exercise programs and healthy lifestyle choices. Nurses are

key partners within the health team to support the patient with heart disease in

their progress to heal and to lead a healthy life.

Course Purpose

To provide nursing professionals with knowledge of a holistic approach for cardiac

rehabilitation to support the patient with heart disease to recover and heal.


Learning Objectives

1. Identify the patient's role on the cardiac rehab team.

2. Explain the role of nurses on the cardiac rehab team.

3. Describe the initial medical evaluation of a new cardiac rehab patient.

4. Describe common timelines for in-patient cardiac rehab patients.

5. Explain the purpose of monitored exercise in cardiac rehab.

6. Describe the emotional impact of in-home exercise on a cardiac patient.

7. Identify the purpose of job-specific cardiac rehab.

Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses,

and Associates

Course Author & Director Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC

Release Date: 3/17/2015 Termination Date: 3/17/2018

Please take time to complete the self-assessment Knowledge Questions before

reading the article. Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course


1. In the United States, cardiovascular disorders are:

a. proven to be the leading cause of mortality and morbidity.

b. responsible for approximately fifty percent of annual deaths in the United States.

c. present in approximately 14 million people who suffer from some

form of coronary artery disease or its complications.

d. All of the above.

2. True or False: Overall, modern cardiac rehabilitation is safe and

well tolerated with a very low rate of major complications such as death, cardiac arrest, myocardial infarction or serious

injuries.

a. True.

b. False.

3. The following is/are true about cardiac rehabilitation exercise

training for patients with coronary heart disease or congestive heart failure (CHF).

a. Adverse outcomes or complications of rehabilitation exercise

training are common.

b. Cardiac rehabilitation exercise training for patients with CHF leads to objectively verifiable improvement in exercise capacity in men

and women, regardless of age.

c. The benefits decrease in patients with diminished exercise tolerance.

d. The benefits persist long-term after completion of cardiac

rehabilitation even without a long-term maintenance program.


4. The American Heart Association and other organizations have

outlined the core components of contemporary cardiac rehabilitation and secondary prevention programs. They include

which of the following?

a. exercise training and physical activity counseling

b. tobacco cessation

c. nutritional counseling and weight management


5. Healthcare team members have different tasks related to cardiac rehabilitation. The task of the nurse is:

a. to confirm referral to the program at the patient’s first visit and

encourage the patient to attend.

b. define the medical parameters of the rehabilitation program from the outset.

c. detect medical and other problems, and to refer patients to other

health care providers, when required.

d. prepare the patient for resuming work by assisting the patient with

work conditioning and, if required, conducting simulated work tests and visit the worksite.

6. When categorizing the intensity level of a physical activity

program, it is important to factor in age and cardiovascular disease status of the patient when:

a. using the Berg’s scale.

b. metabolic equivalents (“METs”) are used.

c. categorization is done using heart rate.



7. With low intensity exercise training programs,

a. it is essential that staff have current training in cardiopulmonary resuscitation.

b. the administration of a diuretic should always be given to avoid

constipation caused by exercise.

c. the mandatory equipment includes a resuscitation cart and a defibrillator.


8. Blood pressure should be checked during pauses between exercises:

a. in patients after a significant variation in blood pressure is noted.

b. in all patients during low to moderate intensity exercise.

c. in new patients to note possible fall of blood pressure during activity.

d. but only during the cool down period.

9. Home-based exercise programs are a new option for heart

patients:

a. They are usually in addition to and in conjunction with facility-based

programs.

b. One of the benefits of home-based exercise programs is the program does not need to be closely monitored since the patient

self-monitors the program.

c. Patients receiving a home-based program should attend at least one group exercise session for guidance and to learn the level of

exercise recommended for them.

d. Home-based exercise programs do not require careful assessment before an exercise prescription is offered to the patient.


10. True or False: Some cardiac rehabilitation programs have been

developed to provide job specific rehabilitation. In these instances, the patient will only focus on areas that will aid in the

transition back to work.

a. True.

b. False.


Introduction

The primary goal of cardiac rehabilitation is to reverse limitations

experienced by patients who have suffered the adverse pathophysiologic and

psychological consequences of cardiac events. Just as a serious leg injury

requires rehabilitation to return the patient to optimal performance, the

heart also requires major rehabilitation in order to function at its best after a

trauma. Additionally, when a cardiac event occurs, the patient may suffer

emotional difficulties and challenges in accepting and overcoming the events

that caused the issue. Cardiac rehabilitation is a whole-body approach to

restoring health that incorporates a multi-dimensional approach to address

body, mind, and spirit. Exercise, counseling, and physical therapy combine

with medical management to ensure that as much normal function as

possible is restored to each patient, and that every patient is able to adapt

to lifestyle changes that reduce the risk of a repeat occurrence.

Cardiovascular disorders are proven to be the leading cause of mortality and

morbidity in the United States. They are responsible for approximately fifty

percent of annual deaths.1 In addition, those who experience cardiovascular

events and survive require a significant amount of care and lifestyle

modification post-event. Approximately 14 million people in the United

States suffer from some form of coronary artery disease (CAD) or its

complications, including congestive heart failure (CHF), angina, and

arrhythmias. Of this number, approximately one million survivors of acute

myocardial infarction (MI), as well as the more than 300,000 patients who

undergo coronary bypass surgery annually, are candidates for cardiac

rehabilitation.2


History of Cardiac Rehabilitation

Cardiac rehabilitation programs appeared in their earliest form in the late

1940’s and early 1950’s. Initially, these programs focused on helping

patients return to work: “At that time, there was an acute manpower

shortage and the possibility of returning unemployed or retired men to the

work force was considered. It was recognized that there were many men

capable of work that had been prematurely retired because of coronary

heart disease. In 1941, the first Work Evaluation Unit was established in

New York under the auspices of the American Heart Association. Many

people with coronary heart disease were medically reviewed and their

capacity for work evaluated. The majority returned to work and were found

to make satisfactory employees in occupations similar to those which they

had previously enjoyed.”12

By the 1970’s, more thorough hospital-based programs were developed to

assist patients with recovery. The programs were more comprehensive in

their approach and focused on more areas than preparing the patient to

return to work. This occurred as health providers recognized the significant

impact mobilization and supervised exercise programs had on all aspects of

recovery, not just on the patient’s ability to return to work. Programs

became more structured, and attempted to promote rehabilitation through a

variety of activities.

“Confirmation that early exercise testing and training could start within

two to three weeks of a myocardial infarction led to exercise training

starting immediately after discharge from hospital. However, because

the exercise was of relatively high intensity, careful monitoring was

necessary. These programs usually lasted up to twelve weeks and

patients attended three times per week during that period. Some


education was delivered during these programs; partly through the

natural exposure to interested health professionals who could supply

requested information to patients during supervised exercise sessions.

Gradually it was recognized that more formal patient education was

desirable. Therefore, group education was later added to many of the

group exercise programs.”13

Core Components of Cardiac Rehab Programs

Although the specific components will vary from program to program, and

will be tailored to the specific needs of the patient, there are a number of

core components that comprise a cardiac rehabilitation program. In some

instances, only a select few components will be used, while other programs

may utilize all of the components as part of the rehabilitation process. The

following table provides a thorough overview of all of the components that

can be included in a cardiac rehabilitation program:5

Patient Assessment

Evaluation

Medical History:

Review current and prior cardiovascular medical and surgical diagnoses

and procedures (including assessment of left ventricular function);

comorbidities (including peripheral arterial disease, cerebral vascular

disease, pulmonary disease, kidney disease, diabetes mellitus,

musculoskeletal and neuromuscular disorders, depression, and other

pertinent diseases); symptoms of cardiovascular disease; medications

(including dose, frequency, and compliance); date of most recent

influenza vaccination; cardiovascular risk profile; and educational barriers

and preferences. Refer to each core component of care for relevant

assessment measures.


Physical Examination:

Assess cardiopulmonary systems (including pulse rate and regularity,

blood pressure, auscultation of heart and lungs, palpation and inspection

of lower extremities for edema and presence of arterial pulses); post-

cardiovascular procedure wound sites; orthopedic and neuromuscular

status; and cognitive function. Refer to each core component for

respective additional physical measures.

Testing: Obtain resting 12-lead ECG; assess patient’s perceived health-

related quality of life or health status. Refer to each core component for

additional specified tests.

Interventions

Document the patient assessment information that reflects the patient’s

current status and guides the development and implementation of (1) a

patient treatment plan that prioritizes goals and outlines intervention

strategies for risk reduction, and (2) a discharge/follow-up plan that

reflects progress toward goals and guides long-term secondary

prevention plans.

Interactively, communicate the treatment and follow-up plans with the

patient and appropriate family members/domestic partners in

collaboration with the primary healthcare provider.

In concert with the primary care provider and/or cardiologist, ensure that

the patient is taking appropriate doses of aspirin, clopidogrel, β-blockers,

lipid-lowering agents, and ACE inhibitors or angiotensin receptor blockers

as per the ACC/AHA, and that the patient has had an annual influenza

vaccination.

Expected

Outcomes

Patient Treatment Plan:

Documented evidence of patient assessment and priority short-term (i.e.,

weeks-months) goals within the core components of care that guide

intervention strategies. Discussion and provision of the initial and follow-

up plans to the patient in collaboration with the primary provider.


Outcome Report:

Documented evidence of patient outcomes within the core components of

care that reflects progress toward goals, including whether the patient is

taking appropriate doses of aspirin, clopidogrel, β-blockers, and ACE

inhibitors or angiotensin receptor blockers as per the ACC/AHA, and

whether the patient has had an annual influenza vaccination9 (and if not,

documented evidence for why not), and identifies specific areas that

require further intervention and monitoring.

Discharge Plan:

Documented discharge plan summarizing long-term goals and strategies

for success.

Blood Pressure Management

Evaluation

Measure seated resting blood pressure on ≥2 visits.

Measure blood pressure in both arms at program entry.

To rule out orthostatic hypotension, measure lying, seated, and standing

blood pressure at program entry and after adjustments in

antihypertensive drug therapy.

Assess current treatment and compliance.

Assess use of nonprescription drugs that may adversely affect blood

pressure.

Interventions

Provide and/or monitor drug therapy in concert with primary healthcare

provider as follows:

If blood pressure is 120-139 mm Hg systolic or 80-89 mm Hg diastolic:


Provide lifestyle modifications, including regular physical activity or

exercise; weight management; moderate sodium restriction and

increased consumption of fresh fruits, vegetables, and low-fat dairy

products; alcohol moderation; and smoking cessation.

Provide drug therapy for patients with chronic kidney disease, heart

failure, or diabetes if blood pressure is ≥130/≥80 mm Hg after lifestyle

modification.

If blood pressure is ≥140 mm Hg systolic or ≥90 mm Hg diastolic:

Provide lifestyle modification and drug therapy.

Expected

Outcomes

Short-term: Continue to assess and modify intervention until

normalization of blood pressure in prehypertensive patients; <140 mm

Hg systolic and <90 mm Hg diastolic in hypertensive patients; <130 mm

Hg systolic and <80 mm Hg diastolic in hypertensive patients with

diabetes, heart failure, or chronic kidney disease.

Long-term: Maintain blood pressure at goal levels.

Lipid Management

Evaluation

Obtain fasting measures of total cholesterol, high-density lipoprotein,

low-density lipoprotein, and triglycerides. Obtain a detailed history to

determine whether diet, drug, and/or other conditions that may affect

lipid levels can be altered (for patients with abnormal levels).

Assess current treatment and compliance.

Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months

after initiation or change in lipid-lowering medications. Assess creatine

kinase levels and liver function in patients taking lipid-lowering

medications as recommended by NCEP.12


Cardiac Rehabilitation Programs

In the past, cardiac rehabilitation was used to treat lower-risk patients who

had the physical capacity to exercise without the risk of additional

complications. However, in recent years, cardiac treatment and management

has evolved, thereby expanding the demographic of patients who can

participate in cardiac rehabilitation programs. A substantial component of

this new demographic includes approximately 400,000 patients who undergo

coronary angioplasty.3 In addition, there are approximately 4.7 million

patients with congestive heart failure who can participate in a modified

program of rehabilitation.4

Cardiac rehabilitation programs have been consistently shown to improve

objective measures of exercise tolerance and psychosocial wellbeing without

increasing the risk of significant complications. According to the U.S. Public

Health Service (USPHS), a cardiac rehabilitation program is defined as a

program that involves the following:5

Medical evaluation

Prescribed exercise

Education

Counseling of patients with cardiac disease

The following is the common definition of cardiac rehabilitation, as developed

by the United States Public Health Service:

“Cardiac rehabilitation services are comprehensive, long term

programs involving medical evaluation, prescribed exercise, cardiac

risk factor modification, education and counselling. These programs

are designed to limit the physiological and psychological effect of

cardiac illness, reduce the risk of sudden death or reinfarction,


control cardiac symptoms, stabilize or reverse the atherosclerotic

process, and enhance the psychosocial and vocational status of

selected patients. Cardiac rehabilitation services are prescribed for

patients who have had a myocardial infarction, have had coronary

bypass surgery, or have chronic stable angina pectoris.”6

One newer strategy is to use cardiac rehabilitation programs to treat those

at high risk of coronary heart disease, including those with other evidence of

vascular disease or who are at high risk of vascular disease, or any other

form of cardiac disease. With this new strategy in place, the current

definition of cardiac rehabilitation has been modified as follows: “The sum of

interventions required to ensure the best physical, psychological and social

conditions so that patients with chronic or post-acute cardiac disease may,

by their own efforts, preserve or assume their proper place in society.”7

Cardiac rehabilitation has to be comprehensive and, at the same time,

individualized. Patients must be identified and selected to participate in

cardiac rehabilitation, as there are a number of patients who may not benefit

or who are at risk of developing further complications through participation.

Patients generally fall into following categories:8

Lower-risk patients following an acute cardiac event

Patients who have undergone coronary bypass surgery

Patients with chronic, stable angina pectoris

Patients who have undergone heart transplantation

Patients who have had percutaneous coronary angioplasty

Patients who have not had prior events but who are at risk because of

a remarkably unfavorable risk factor profile

Patients with stable heart failure

Patients who have undergone non-coronary cardiac surgery


Patients with previously stable heart disease who have become

seriously deconditioned by intercurrent, comorbid illnesses

Part of the identification process requires a determination of the specific

needs and goals of the patient. If these goals align with the primary goals of

cardiac rehabilitation, the patient may be a candidate, assuming there are

no risks of developing secondary complications. The primary goals of cardiac

rehabilitation include:9

Curtail the pathophysiologic and psychosocial effects of heart disease

Limit the risk for reinfarction or sudden death

Relieve cardiac symptoms

Retard or reverse atherosclerosis by instituting programs for exercise

training, education, counseling, and risk factor alteration

Reintegrate heart disease patients into successful functional status in

their families and in society

The primary goals listed above can be further broken down into short term

and long term goals. These goals are as follows:

Short-term goals:

"Reconditioning" the patient sufficiently enough to allow him or her to

resume customary activities

Limiting the physiologic and psychological effects of heart disease

Decreasing the risk of sudden cardiac arrest or reinfarction

Controlling the symptoms of cardiac disease

Long-term goals:10

Identification and treatment of risk factors

Stabilizing or reversing the atherosclerotic process


Enhancing the psychological status of the patients

Cardiac rehabilitation programs are incredibly beneficial when properly

administered. The following table provides an overview of the most

significant benefits associated with cardiac rehabilitation:11

Improved

exercise

tolerance

Cardiac rehabilitation exercise training for patients with coronary

heart disease or congestive heart failure (CHF) leads to objectively

verifiable improvement in exercise capacity in men and women,

regardless of age. Adverse outcomes or complications of exercise

are exceedingly rare. The nonfatal infarction rate is 1 patient per

294,000 patient-hours; the cardiac mortality rate is 1 patient per

784,000 patient-hours. The benefits are even greater in patients

with diminished exercise tolerance. This beneficial effect does not

persist long-term after completion of cardiac rehabilitation without a

long-term maintenance program. Therefore, exercise training must

be maintained long-term to sustain the improvement in exercise

capacity.

Control of

symptoms

In patients with coronary heart disease, angina significantly

improves during the cardiac rehabilitation exercise program.

Objective evidence of improvement in ischemia has been seen by

performing interval stress ECG or radionuclide testing. Similarly,

patients with LV failure or dysfunction show improvement in the

symptoms of heart failure. Use of gas analysis (CPX) has shown that

patients' exertional tolerance improves significantly with exercise

training.

Improvement in

the blood levels

of lipids

Improvements in lipid and lipoprotein levels are observed in patients

undergoing cardiac rehabilitation exercise training and education.

Exercise must be combined with dietary and medical interventions

for required lipid control.


Effect on body

weight

Exercise training as a sole intervention has an inconsistent effect on

controlling excess weight. Optimal management of obesity requires

multifactorial rehabilitation, including nutritional education and

counseling, behavioral modification, and exercise training.

Effect on blood

pressure

Rehabilitation exercise training as a sole intervention has minimal

effect; however, multifactorial intervention has been shown to have

beneficial effects. Inconsistencies with this theory remain

unresolved.

Reduction in

smoking

Cardiac rehabilitation services with well-designed educational,

counseling, and behavioral modification programs result in cessation

of smoking in a significant number of patients. Cessation of smoking

can be expected in 16-26% of patients. This reduction is combined

with the spontaneously high smoking cessation rates following acute

coronary events.

Improved

psychosocial

well-being

Cardiac rehabilitation exercise and educational services enhance

measures of psychological and social functioning.

Reduction of

stress

In multifactorial cardiac rehabilitation programs, improvement in

emotional-stress measurements occurs, as does a reduction of type

A behavior patterns. This reduction of stress is consistent with

improvement in psychosocial outcomes that occurs in

nonrehabilitation settings.

Enhanced social

adjustment and

functioning

Cardiac rehabilitation exercise training improves social adjustment

and functioning.

Return to work

Cardiac rehabilitation exercise training exerts less influence on rates

of return to work than on other aspects of life. Many nonexercise

variables also affect this outcome (e.g., prior employment status,

employer attitude, economic incentives).


Reduced

mortality

Scientific data suggest a survival benefit for patients who participate

in cardiac rehabilitation exercise training, but it is not attributable to

exercise alone. This survival benefit is due to multifactorial

interventions. A meta-analysis of post–myocardial infarction (MI),

randomized, controlled trials of exercise showed a 25% reduction in

mortality at 3-year follow-up. The magnitude of this benefit is as

large as that seen with the post-MI use of beta blockers or with the

use of ACE inhibitors in LV dysfunction along with MI. Trials that

involve exercise alone still show a 15% mortality reduction.

The scientific evidence pertaining to the relationship between cardiac

rehabilitation exercise training and mortality also includes scientific

reports that have appeared on the U.S. National Institutes of Health

Web site. Among the data in these reports was the finding, through

randomized trial, that 3-year coronary mortality and sudden death

rates were significantly lower (P < .02) in patients who, after

suffering myocardial infarction, underwent multifactorial cardiac

rehabilitation, starting 2 weeks after hospital discharge. This

beneficial outcome persisted at the 10-year follow-up.

Data/Statistics

regarding

benefits

The benefits achieved with cardiac rehabilitation are the result of the

combination of all its components. Approximately half of the

mortality reduction achieved by exercise-based cardiac rehabilitation

(28%) can be attributed to reductions in major risk factors,

particularly smoking. Other factors may also contribute to the

benefits of cardiac rehabilitation. These include a reduction in

inflammation (a decrease in serum C-reactive protein concentration

that is independent of weight loss and other medical therapies),

ischemic preconditioning, improved endothelial function and a more

favorable fibrinolytic balance. Other important benefits of cardiac

rehabilitation include an increase of tolerated metabolic equivalents

by 33% and of maximal oxygen consumption by 16%.

This improvement in exercise performance is associated with

beneficial effects on the quality of life and cardiovascular events.


Patient’s life quality benefits are also achieved through the

improvement of symptoms (lessening of chest pain, dyspnea and

fatigue), stress reduction and the enhancement of the overall sense

of psychosocial wellbeing.

The benefits of cardiac rehabilitation in patients with coronary

disease are summarized in two recent meta-analyses. One meta-

analysis of 63 randomized trials with a total of 21,295 patients

showed a 17% reduction of recurrent myocardial infarction at 12

months and a 47% reduction of mortality at 2 years with cardiac

rehabilitation.

Another meta-analysis of 48 randomized trials with a total of 8,940

patients with coronary disease showed that cardiac rehabilitation

was associated with a significant reduction in all-cause mortality

(odds ratio [OR] =0.80; 95% [CI] 0.68 to 0.93) and cardiac

mortality (OR =0.74; 95% CI 0.61 to 0.96). There were no

significant differences in the rates of nonfatal myocardial infarction

and revascularization.

In a recent study of more than 600,000 Medicare patients

hospitalized for acute coronary syndrome, percutaneous coronary

intervention, or coronary artery bypass graft surgery, 73,049

patients (12.2%) participated in cardiac rehabilitation. After 1 yr.,

there was a 2.2% mortality rate for cardiac rehabilitation

participants vs. 5.3% for nonparticipants. This benefit was sustained

at 5 yrs. with a mortality rate of 16.3% for participants vs. 24.6%

for nonparticipants. There was a dose–response relationship with

cardiac rehabilitation. Patients who attended 25 or more sessions

had a 20% lower 5-yr mortality rate than those who attended less

than 25 sessions.

The first studies showing the benefits of cardiac rehabilitation in

heart failure patients were small, monocentric with results that were

disputed.


ExtraMatch, a meta-analysis of 9 randomized studies, confirmed a

35% decrease in mortality for heart failure patients. A large

randomized controlled trial of exercise training in heart failure (HF-

ACTION) involving 2331 patients with an ejection fraction of 35% or

less showed that exercise training can achieve significant reductions

(15%) in all-cause and cardiovascular mortality and heart failure

hospitalization. It should be noted that the initial analysis in

intention to treat did not show a difference between the exercise

training and the standard treatment groups. The positive result was

obtained after adjustment of pre-specified prognostic criteria.

Risks Of Cardiac Rehabilitation

Although cardiac rehabilitation has proven to be extremely beneficial to

patients recovering from cardiac events, there are some risks involved. The

following is an overview of the most common risks associated with cardiac

rehabilitation:14

In a contemporary study of over 25,000 patients participating in 65

cardiac rehabilitation centers in 2003, there was one cardiac event for

every 8484 exercise tests performed, one cardiac event for every

50,000 patient hours of exercise training, and 1.3 cardiac arrests for

every million patient hours of exercise.

The 2007 American Heart Association scientific statement on exercise

and acute cardiovascular events estimated that the risk of any major

cardiovascular complication (cardiac arrest, death or myocardial

infarction) is one event in 60,000 to 80,000 patient-hours of

supervised exercise.

Patients most at risk are those with residual ischemia, complex

ventricular arrhythmia and severe left ventricular dysfunction (ejection


fraction of less than 35%), especially NYHA III or IV. The respect of

indications and contraindications and proper risk stratification are key

to the safety of cardiac rehabilitation.

Overall, modern cardiac rehabilitation is safe and well tolerated with a

very low rate of major complications such as death, cardiac arrest,

myocardial infarction or serious injuries.

The Cardiac Rehabilitation Team

While more than one member of the team can share many tasks, some

tasks require specific skills and training and should be performed by the

appropriate, designated health professional. Team members have different

backgrounds and training and therefore different areas of expertise. It is

important to determine in advance those tasks, which should be undertaken

by a designated team member and those, which may be shared by several

team members. Failure to do so can create tension within the team.7

Activities such as processing referrals, coordinating programs and following

up patients after program discharge may be allocated to any team member

who has good organizational and interpersonal skills and sufficient time

available to carry out these duties.

Patient Cardiac Rehab Team Member

The patient is not often considered part of the cardiac rehabilitation, but it is

important to consider the patient’s role in the rehabilitation process.

Patients must be fully engaged in their treatment plan, especially with

cardiac rehabilitation programs. These programs require significant lifestyle

and dietary changes, and the patient will not be successful if he or she is not

fully engaged in the process. Therefore, treatment providers will need to


include the patient as part of the team from the beginning. When the patient

feels like an active member of the group, he or she is more apt to be fully

engaged in the process.130

Physician Cardiac Rehab Team Member

There are a number of physicians that may be part of the cardiac

rehabilitation team. The specific physicians involved will be determined by

the specific needs of the patient. In all instances, the patient’s general

practitioner will be a member of the team. However, some situations may

warrant the involvement of other physicians. In most instances, the cardiac

rehabilitation team will involve the following physicians:

General practitioner

Referral to an ambulatory rehabilitation program should be organized before

the patient is discharged from hospital. However, the general practitioner

should confirm referral to the program at the patient’s first visit and

encourage the patient to attend. Failure of medical practitioners to advise or

encourage patients to attend a cardiac rehabilitation and secondary

prevention program is a major reason for poor participation rates. According

to one study, the strength of the primary physician’s recommendation to

attend a cardiac rehabilitation program was the most powerful predictor of

attendance. The general practitioner should reinforce the goals of

rehabilitation, ensuring that the patient understands the expected benefits of

the program and the functions of other team members. To fulfill these roles

adequately, the general practitioner needs sufficient information about the

aims and content of cardiac rehabilitation and secondary prevention

programs. Information about available programs should be circulated to

general practitioners.


General practitioners consider that their role in cardiac rehabilitation has

been limited to date and that they are underutilized as a resource. In their

opinion, cardiac rehabilitation offers opportunities for a shared care approach

in which their input could be very valuable. While recognizing that the

cardiologist is in charge of the medical management of patients in hospital,

the general practitioner is in an ideal position to put follow-up plans into

action and to coordinate the patient’s medical management after discharge

from hospital. To maximize the contribution of the general practitioner, the

cardiologist should involve the general practitioner in the early stages of

each patient’s recovery and provide clear guidelines on how to manage

patients following their acute events. Follow-up of patients by the general

practitioner may be further improved if the general practitioner was

informed of the patient’s admission to hospital and was able to visit the

patient in hospital.

The general practitioner is primarily responsible for the long-term medical

follow-up of patients and for assisting patients to maintain healthy lifestyle

changes. Thus, the general practitioner has an important educational role,

especially after the patient completes the ambulatory group program. The

program coordinator should ensure that the general practitioner receives a

discharge summary about what the patient has achieved at the program.

Any difficulties the patient is experiencing on completion of the program

should also be communicated. This information should be sent to the general

practitioner directly, as well as recorded on a card for the patient to take to

the general practitioner. A patient held record may encourage patients to

take increased responsibility for their health. Early communication with the

general practitioner should minimize the likelihood of patients receiving

conflicting information. The general practitioner has continuing responsibility

for ensuring that there is long-term satisfactory control of patients’


symptoms, lipids, smoking habit, blood pressure, diabetes, weight and

wellbeing. This may necessitate intermittent or regular testing, as indicated

by national or other current guidelines.8,11,131

Cardiologist

Cardiac rehabilitation and secondary prevention programs include a

significant component of education concerning medical topics. These topics

include cardiovascular disease risk factors, the development of coronary

heart disease, acute cardiac events, procedures and investigations. It is

essential that patients and family members receive accurate medical

information from team members. Thus, the cardiologist should define the

medical parameters of the program from the outset, reviewing the medical

content at intervals to ensure information is current and accurate. Some

cardiologists have expressed concern that inaccurate medical information is

given by nurses and allied health workers during cardiac rehabilitation and

secondary prevention programs. Further, they maintain that nurses often

give restrictive dietary advice to patients and that information provided to

patients by general practitioners often conflicts with advice from

cardiologists.

Better communication between cardiologists, general practitioners and other

team members could minimize the amount of conflicting and inappropriate

advice. While cardiologists do not generally play an active role within group

cardiac rehabilitation programs, they can make a significant contribution by

referring patients to programs, encouraging them to attend, enquiring about

the patient’s progress at the program and supporting the roles of other team

members.


Where possible, it is highly desirable for the cardiologist to facilitate an

occasional group discussion during the outpatient program. Occasional brief

visits by the cardiologist to a group discussion or an exercise session are

also much appreciated by patients. Patients perceive the cardiologist as an

authoritative figure. The cardiologist’s participation in, or visit to, the group

enhances patients’ acceptance of the program as being important to their

recovery. Further, the cardiologist should supervise the discharge review

and, if undertaken, the discharge exercise test. In some larger city hospitals,

the registrar or resident may participate in place of the cardiologist.124,132-138

Nursing Cardiac Rehab Team Members

Nurses are involved in most ambulatory cardiac rehabilitation and secondary

prevention programs. Their primary role is to detect medical and other

problems, and to refer patients to other health care providers, when

required. Nurses are also extensively involved in patient education. They

commonly facilitate group discussions on heart disease, risk factors for

cardiovascular disease and other medical topics.

In many smaller hospitals and community health centers, nurses are

responsible for a greater range of activities, including conducting exercise

sessions and recruiting patients to programs. Nurses provide continuity for

patients after discharge from hospital and are often perceived by patients to

be the program coordinator.5

Specialist Cardiac Rehab Team Member

Physical Educator

A physical educator may conduct exercise sessions and supervise patients

with cardiovascular disease, providing appropriate additional training has


been obtained. Previous experience with cardiac patients, especially those

who have recently suffered an acute cardiac event or those who are aged

and infirm, is also required.139

Physiotherapist

The physiotherapist is mainly concerned with the physical aspects of the

patient’s recovery. Specific roles of the physiotherapist include assessing the

physical needs and cardiovascular fitness of patients at entry to the

program, prescribing exercise to minimize the deconditioning effects of

physical inactivity and promoting reconditioning. The exercise program

needs to be flexible and adapted to the needs of the individual patient. It

should aim to facilitate recovery to a level necessary for patients to resume

their work and other activities of daily living. The physiotherapist is

considered best equipped to design and conduct exercise sessions.140

While focusing particularly upon the patients’ physical needs, the

physiotherapist will also address emotional concerns of patients and explore

any perceived barriers to exercise. For those patients who have been almost

totally inactive, the physiotherapist needs to design an acceptable exercise

program, encouraging such patients to initiate and continue the

recommended exercises.11

Other key roles of the physiotherapist include monitoring patients during

exercise sessions. Pain and other physical problems reported by patients

need to be assessed by the physiotherapist. The physiotherapist should

provide practical advice to patients about what they can and cannot do

safely, including any sporting activities. Patients seeking to exercise at high

levels require particular attention and usually require medical clearance.

Such patients may benefit from referral to a trained exercise therapist. The


physiotherapist may play a useful role in addressing the work requirements

of patients, especially if the job is physically demanding. In this respect, the

role of the physiotherapist may overlap to some extent with that of the

occupational therapist.119

Occupational Therapist

The occupational therapist plays in integral role in the cardiac rehabilitation

process. As part of the cardiac rehabilitation team, the occupational therapist

works with the patient to help him or her develop effective and independent

functioning skills related to employment, family, social and recreational

activities. Where this is not possible or appropriate, the occupational

therapist should assist the patient to live as productive a life as possible

within any constraints imposed by the cardiac condition or other

limitations.141

The occupational therapist will provide vocational assessments to determine

the feasibility and capacity of the patient to resume work at a reasonable

level of physical or other occupational demand. To prepare the patient for

resuming work, the occupational therapist will assist the patient with work

conditioning and, if required, may also conduct simulated work tests and

visit the worksite. The occupational therapist also assesses the patient’s

functional status and potential for resuming usual activities of daily living.

Leisure and social activities are assessed. Realistic goals are set and

activities are prescribed, which are functionally based. The skills acquired by

the patient can then be transferred to the home or work setting.142

While occupational therapists have a particular role in facilitating

occupational recovery of the patient, their training is broadly based and they

can contribute to the program in several areas and back up. For example,


stress management sessions are sometimes conducted by the occupational

therapist. Occupational therapists are involved in patient education and

counseling and are trained in-group dynamics and facilitating groups.

In some programs, the occupational therapist participates in the group

exercise sessions. It is important for other team members to refer patients

to the occupational therapist, if there are perceived occupational

problems.143

Although the roles of the occupational therapist and physiotherapist may

overlap, their primary functions differ, with the physiotherapist using

exercise and physical modalities to improve physical status, while the

occupational therapist’s approach is a functional one, which applies the

patient’s skills to perform a wide range of activities of daily living or at work.

However, as revealed by surveys of cardiac rehabilitation programs, either

team member may undertake many tasks. Typically, however, the

occupational therapist is more involved in the later stages of the patient’s

recovery rather than in hospital.144

Dietitians/Nutritionists

The dietitian/nutritionist is an integral part of the cardiac rehabilitation team.

His or her primary responsibility involves providing group and individual

counseling about nutrition and appropriate dietary habits. Patients receive

some initial dietary guidelines at the onset of their cardiac condition (either

from the hospital staff or their general practitioner), however, dietary advice

is best provided by the dietitian during the outpatient program when more

time is available. Most nutrition counseling will occur over a period of

weeks, especially for those with limited ability to comprehend dietary

information. For the most part, regularly scheduled dietary sessions are


recommended, as many patients are unable to process all of the necessary

information at once.145

During the preliminary stages of education and counseling, patients will

receive information about healthy dietary habits and explanations about food

labels. This information will help them make informed choices about their

diet. Practical advice about the preparation of food is also vital. Dietary

information needs to be realistic, simply presented and easy to follow. Once

the patient receives the foundational dietary education, the remainder of the

program will be tailored to provide individual advice specific to the patient’s

needs.8

An important function of the dietitian is to clarify misconceptions about diet

and nutrition. There is considerable confusion in the community, among

health care providers, and even among dietitians themselves, about dietary

guidelines. Moreover, guidelines seem to change intermittently. As a result,

patients receive conflicting dietary advice from different health care

providers and are understandably confused about which advice they should

follow.146

Mental Health Specialists

Many patients will require mental health care as part of the cardiac

rehabilitation process. In some instances, patients will require counseling or

mental health treatment to help them cope with the lifestyle changes

brought about because of the cardiac condition. Other patients may require

mental health treatment to help reduce stress and anxiety levels, which can

further exacerbate cardiac problems. If a patient is already receiving mental

health care for unrelated conditions, the mental health provider will need to

be involved in the treatment process to ensure the treatment does not affect


the patient’s mental health status.135 The following is a list of the types of

mental health providers that may be involved in the treatment

process:5,7,121,132

Psychiatrist

The psychiatrist’s role in cardiac rehabilitation programs is primarily to

manage patients with a psychiatric illness or psychiatric symptoms.

Psychiatric referrals are appropriate only for a minority of patients,

such as those with a premorbid psychiatric illness, which is

exacerbated by the cardiac event, or illness. The social worker,

psychologist and other staff trained or experienced in counseling are

able to help most patients who are experiencing psychological

problems, referring them to a psychiatrist if it is indicated.

Psychologist

Psychologists have a role in conducting relaxation or stress

management sessions. The psychologist may also be trained in

individual and group counseling and can therefore facilitate sessions

with patients and spouses. In undertaking counseling and stress

management, the psychologist’s role overlaps to some extent with that

of the social worker and the occupational therapist. The roles of the

psychologist may also include assessing the psychological status or

cognitive functioning of cardiac patients and relaying the results to the

doctor and other team members. Such information can be useful in

developing the patient’s rehabilitation plan.

Clinical psychologists can also make a significant contribution by using

behavioral strategies to help patients acquire skills to change and

maintain healthier behaviors. This aspect of secondary prevention


needs further development in cardiac rehabilitation programs.

Psychologists should be more extensively involved in programs to

address this need.

Primary Components Of Cardiac Rehabilitation Programs

Traditionally, cardiac rehabilitation is divided into three phases. All phases of

cardiac rehabilitation aim to facilitate recovery and to prevent further

cardiovascular disease. These are described below:121,140,147,148

Cardiac Rehab: Phase I

Phase I or inpatient phase is initiated while the patient is still in the hospital.

It consists of early progressive mobilization of the stable cardiac patient to

the level of activity required to perform simple household tasks. The shorter

hospital stay with modern cardiology makes it difficult to conduct formal

inpatient education and training programs. Thus inpatient cardiac

rehabilitation programs are mostly limited to early mobilization to make self-

care possible by discharge, and brief counseling about the nature of the

illness, the treatment, risk factors management and follow-up planning.

Cardiac Rehab: Phase II

In most programs, phase II is a supervised ambulatory outpatient program

of 3 to 6 months duration which consists of outpatient monitored exercise

and aggressive risk factor reduction.

Cardiac Rehab: Phase III

Phase III is a lifetime maintenance phase in which physical fitness and

additional risk-factor reduction are emphasized. It consists of home- or


gymnasium-based exercise with the goal of continuing the risk factor

modification and exercise program learned during phase II.

The American Heart Association, the American College of Cardiology

Foundation and the American Association of Cardiovascular and Pulmonary

Rehabilitation have outlined the core components of contemporary cardiac

rehabilitation and secondary prevention programs and produced guidelines

for detection, management and prevention of cardiovascular disease. These

core components include patient assessment, exercise training, physical

activity counseling, tobacco cessation, nutritional counseling, weight

management, aggressive coronary risk-factor management and psychosocial

counseling. The following table provides a detailed overview of the primary

components of the rehabilitation process:5,10,11,142,149-152

Patient

assessment

In order to guide the patient through the different aspects of cardiac

rehabilitation, to meet his individual needs and to optimize his

benefits, a risk profile of the patient needs to be established through

a complete physical and mental evaluation done at the initiation of

the cardiac rehabilitation program.

The goal is to insure a safe environment for the patient and to

facilitate patient care with minimal risk. This evaluation will help set

the goals of cardiac rehabilitation for the patient.

Before the exercise training, a symptom-limited exercise test is

undertaken for prognostic, diagnostic, and therapeutic purposes. At

the end of the participation, some centers routinely perform another

evaluation to verify if the goals have been met and to find ways to

ensure a continued patient progress in the long term.


Exercise

training

The scientific data clearly establish that exercise training results in

improvements in exercise tolerance. Appropriately prescribed and

conducted exercise training is therefore a key component of cardiac

rehabilitation.

Meyers, et al., showed that improvement of 1 metabolic equivalent

in functional capacity imparts a 12% reduction in all-cause mortality.

More recently, Jolly et al., showed that abnormal heart rate

recovery, which is a predictor of mortality, can be normalized with

exercise training with improvement in mortality.

Exercise protocols should include not only endurance but also

resistance training, as improvement in muscle strength could benefit

patients’ performance of activities of daily living. A variety of

material is used for patients’ endurance and resistance training.

These include treadmills, steppers, weights, rowers, elliptical

trainers, exercise bikes, dumbbells, etc. Swimming pools can be

very helpful for the training of highly debilitated patients.

A baseline symptom-limited exercise test is used to stratify patients’

risk for cardiac events before exercise training. An exercise

prescription is developed based on the result of the exercise test and

includes the type, the intensity, the duration, and the frequency of

the exercise.

Patients covered by health insurance, Medicaid or Medicare are

offered exercise training at a frequency of three times weekly for 8

to 12 weeks. Exercise training sessions are usually of 45 minutes

duration. In an effort to address the problem of discrepancies in

response to cardiac rehabilitation and the increasing rate of obesity

in cardiac rehabilitation participants, exercise modalities other than

the traditional moderate-intensity protocols have been studied

recently.


High-intensity interval aerobic exercise program and high-calorie-

expenditure exercise program are two such modalities recently

studied. High-intensity interval aerobic exercise training programs

have shown greater improvements in exercise performance and

hemodynamic benefit when compared to moderate-intensity

exercise training in patients with stable CAD and heart failure with

no significant increase in complications.

Exercise protocols for this modality vary. In one study, the exercise

program consisted of a 10-minute warm-up period at 50 to 60

percent of VO2max followed by four 4-minute intervals at 90 to 95

percent peak heart rate (Rate of Perceived Exertion 17±1), with

intervals separated by three-minute periods of walking at 50 to 70

percent of peak heart rate.

Ades et al., developed another variation called high-calorie-

expenditure exercise training, which they compared to the standard

cardiac rehabilitation exercise in participants who were overweight

or obese and who had ischemic heart disease. This program

achieved a much higher exercise-related energy expenditure (3000-

3500 kcal/week) compared to the usual care (700-800 kcal/week)

with patients walking at lower intensities (50-60% peak VO2) for

longer durations and more often. They showed a significantly greater

weight loss with improvement in insulin resistance and lipid profiles.

Physical activity

counseling

Regular physical activity has been shown to have many

cardiovascular benefits including weight loss, blood pressure

reduction, glycemic control and lipid profile improvements. A meta-

analysis of 11 exercise rehabilitation randomized trials including

2285 patients showed that regular exercise was associated with a

significant 28% reduction in all-cause mortality (6.2% versus 9.0%,

risk ratio 0.72, 95% CI 0.54-0.95) and a possible but nonsignificant

24% reduction in recurrent myocardial infarction (risk ratio 0.76,

95% CI 0.57-1.01).


Most guidelines recommend that exercise should be performed for a

minimum of 30 minutes per day at least five days per week and

preferably daily, should involve moderately intensive (target heart

rate of 60 to 75 percent of the average maximum heart rate or the

perception of moderate exercise 12 to 14 on the Borg scale) aerobic

activity such as brisk walking and should be supplemented by an

increase in daily lifestyle activities (i.e., walking breaks at work,

gardening, and household work).

There seems to be a dose-response relation between physical

activity and Health in general and coronary heart disease in

particular. A meta-analysis by Sattlemair, et al., found that “some

physical activity is better than none” and “additional benefits occur

with more physical activity.”

Tobacco

cessation

Smoking cessation is the most important and the most cost-effective

of all the lifestyle modifications recommended to prevent

cardiovascular disease. Several large observational studies and a

meta-analysis showed a substantial reduction in mortality [RR: 0.64

(CI: 0.58-0.71)] in patients with a history of MI, CABG, angioplasty,

or known CHD, who quit smoking compared with patients who

continued to smoke.

The overall mortality risk of smokers who quit decreases by 50% in

the first couple of years and tends to approach that of nonsmokers

in approximately 5-15 years of cessation of smoking. Nevertheless,

smoking cessation is often challenging, as tobacco dependence is a

complex phenomenon that includes not only physical and

psychological addiction but also social and behavioral components.

A personalized consultation with an emphasis on both smoking

history and the exposure to second-hand smoke is offered to

smokers to enable and consolidate smoking cessation.


Many tools are used for smoking cessation and they include

pharmacologic assistance (nicotine substitutes, bupropion,

varenicline), counseling, education and group support.

Nutritional

counseling

The aim of nutritional counseling in cardiac rehabilitation is to help

patients understand the impact of food on one’s health and make

healthy food choices. For that reason, the dietician gathers baseline

daily caloric intake and dietary information. Recommendations are

given to patients tailored on their individual diet profile. Dieticians

organize practical workshops to teach patients healthy eating habits,

label reading and cooking demonstrations.

General dietary recommendations for cardiac patients include a

reduced intake of saturated fats (<7% of total calories) and

cholesterol (<200 mg/d), increased intake of polyunsaturated (about

10% of total calories) and monounsaturated fats (20% of total

calories), an adequate repartition of calorie sources (about 50-60%

of total calories for carbohydrates, 15% for protein and 25-35% for

fat) and increased fiber intake (about 20-30 g/d).

Based on recent studies in nutrition and cardiovascular disease,

there has been specific recommendations for patients with heart

disease that emphasize moderation and plant-based food.

Weight

management

The negative effects of overweight and obesity on physical activity

and the incidence of hypertension, cholesterol and diabetes have

been confirmed in many studies. Anthropometrics measurements

are taken during visits at cardiac rehabilitation centers. Patients are

instructed on their specific weight issues and on methods that can

help achieve a healthy body weight through a combination of

decreased caloric intake and increased caloric expenditure.

All the other aspects of cardiac rehabilitation will also have an

impact on weight improvement and maintenance.


The American Heart Association released a Scientific Statement in

2011 regarding weight management strategies for busy ambulatory

settings.

The goal of weight management is body mass index of 18.5-24.9

kg/m2 and waist circumference of <40 inches in men and <35

inches in women. The initial goal of weight loss therapy should be to

reduce body weight by approximately 10% from baseline. With

success, further weight loss can be attempted if indicated through

further assessment.

Lipid

management

Hypercholesterolemia is the risk factor with the highest percentage

of attributable risk post myocardial infarction. Yusuf et al. showed

that every 1 mmol/L (38.7 mg/dL) decline in LDL cholesterol results

in a 21% decrease in cardiovascular events. Unfortunately this risk

factor is often overlooked. Euroaspire studies have shown that this

risk factor is not well controlled and that there have only been weak

improvements in the percent of patients attaining target LDL-

cholesterol values (33% to 41%). Many aspects of cardiac

rehabilitation will contribute to improve patients' lipid profile. These

include physical exercise, nutritional counseling and weight

management. Pharmacologic treatment is often added to

therapeutic lifestyle changes to achieve LDL-cholesterol targets.

Blood pressure

management

High blood pressure is very prevalent among patients referred for

cardiac rehabilitation. A decrease in systolic blood pressure by 10

mmHg can decrease cardiovascular mortality by 20-40% and a

reduction of diastolic blood pressure by 5-6 mm Hg results in a

reduction of stroke risk by 42% and Coronary heart disease events

by 15%.

For many patients at cardiac rehabilitation centers, medications for

high blood pressure will be a new reality they are dealing with

because those medications would have been introduced only a few

weeks earlier at the time of their cardiac event.


During cardiac rehabilitation sessions, they will learn the importance

of blood pressure control, the medications and their side effects, the

measures of therapeutic life changes that will have an impact on

their blood pressure and the use of blood pressure devices.

Understanding of the disease and its treatment will certainly improve

patients' compliance and reduce the risk associated with high blood

pressure.

Diabetes

management

About 26% of patients referred to cardiac rehabilitation have

diabetes. These patients have a particularly high cardiovascular risk

profile. The majority (93%) will have another associated risk factor

(smoking 16%, hypertension 54%, hypercholesterolemia 51%,

overweight 40%, obesity 34%).

Therapeutic education is a very important tool that helps improve

diabetes control. Because of their multidisciplinary approach and the

use of therapeutic education tools, cardiac rehabilitation programs

can help achieve a better glycemic control. This has been shown to

reduce cardiovascular morbidity and mortality.

The goal of diabetes management is to maintain glycosylated

hemoglobin (HbA1c) concentration of <7%.

Management of

Psychosocial

and

professional

issues

Patients with heart disease are often confronted with psychological

and social problems that can affect both morbidity and mortality.

Depression, anxiety, and denial occur in up to 20% of patients

following myocardial infarction. During cardiac rehabilitation follow-

up, patients undergo a routine screening to identify anxiety,

depression, substance abuse and familial or other social problems.

The social workers and others professionals involved in the

multidisciplinary team in cardiac rehabilitation centers provide

patients with the information and the help they need to plan for their

return to work and to a normal life.


Medical, psychological and social interventions tailored to individual

problems are offered and have been shown to improve outcomes.

The INTERHEART Study quite clearly demonstrated that stress was

the third most important risk factor for coronary events, following

lipids and smoking, and accounts for approximately 30% of the

population’s attributable risk of acute MI.

Psychosocial stress affect cardiovascular disease process through the

increase in blood pressure, blood glucose, lipid levels and body

weight. It also promotes the progression of atherosclerosis,

inflammation and endothelial dysfunction. Exercise training has been

associated with reductions in stress and its related mortality. Many

cardiac rehabilitation programs also offer stress management

workshops to help patients identify, avoid and deal with stressful

situations.

Cardiac rehabilitation is therefore an important therapeutic tool for

distressed cardiac patients. Besides exercise training, many cardiac

rehabilitation centers offer other stress reduction techniques training

including meditation, relaxation breathing, yoga, etc.

Alcohol drinking

Moderate alcohol consumption (1-2 drinks per day) is associated

with a reduced cardiovascular and all-cause mortality compared with

both abstinence and heavy drinking. In a pooled estimate from five

prospective cohort studies of patients with coronary heart disease,

patients who consumed small to moderate amounts of alcohol daily

had a 20 percent reduction in cardiovascular mortality (relative risk

0.80, 95% confidence interval [CI] 0.78-0.83) compared to

nondrinkers. A meta-analysis by Costanzo, et al., found J-shaped

curves for alcohol consumption and mortality, with a significant

maximal protection against cardiovascular mortality with

consumption of approximately 26 g/d and maximal protection

against mortality from any cause in the range of 5-10 g/d.


The pattern and amount of alcohol intake appears to be more

important than the type. Possible explanations for moderate alcohol

consumption benefits include: HDL increase by stimulating the

hepatic production of apo A-I and A-II, fibrinogen levels reduction,

fibrinolysis stimulation, inflammation reduction and inhibition of

platelet activation.

Medical Evaluation

Prior to beginning a cardiac rehabilitation program, patients will require a

thorough medical assessment and evaluation to determine eligibility. This

assessment will also be used to determine the level of programming required

for the patient. The rehabilitation program will be tailored to meet the

specific needs of the patient.

The following is a list of key points to keep in mind regarding the initial

patient assessment:153

Before patients are enrolled into the program, an interview and

assessment are required, either individually or together with another

family member (usually the spouse).

Approximately 30 minutes are required for assessment of each patient.

Either, or both, of the health professionals conducting the exercise

class can undertake this enrolment interview.

A referral note from the patient’s medical practitioner will best support

the entry assessment, preferably with relevant clinical information.


Hospital records should be sought to provide in-hospital data including

diagnosis, symptoms, medications, advised restrictions and perceived

patient difficulties.

The entry assessment should address the patient’s specific goals

regarding resumption of work and activities of daily living, since these

may influence the duration and pace of the exercise training. It should

also clarify needs for specific muscle strengthening related to work,

social or leisure activities.

Physical Activity Program

The physical activity program will be categorized into three groups based

upon the intensity level of the programming. In most instances,

categorization will be done using Berg’s scale, or by heart rate.

Categorization can also be based upon correlating activities with metabolic

equivalents (METs). However, when METs are used, it is important to factor

in age and cardiovascular disease status of the patient, for example:

1 MET is the oxygen consumption at rest, measured as 3.5ml

O2/Kg/min.

2 METs would be equivalent to strolling at about 3kms/hour for a

healthy person.

3.5 METs should be equivalent to walking at about 5kms/hour (the

usual walking pace for a middle-aged male).120

One could therefore suggest that 3.5 METs is light exercise; that would be so

for a healthy male. It may well be a high level of activity for an elderly


woman, for a patient with controlled or compensated heart failure or for a

patient deconditioned by a long period of immobilization in hospital. The

chart below outlines an exercise program with patient perceptions and

physical responses to varied levels of exercise.139

Exercise

Training

Level

Rate of Perceived Exertion

(BORG)

% of Maximal

Heart Rate on

Test

Increment over

Resting Heart

Rate

LOW

MODERATE

HIGH

Very, very light 6

7

8

Very light 9

10

Light 11

12

Somewhat hard 13

14

Hard 15

16

Very hard 17

18

Very, very hard 19

20

50 – 65%

60 – 75%

70 – 85%

10 – 25

20 – 35

30 - 55

The following table provides an explanation of the appropriateness of the

three categories of intensity, as well as a recommendation for a standard

program:13,77,154-157


Low intensity

exercise

Low intensity exercise is acceptable to almost all patients. It can

be managed by the elderly and by patients with incipient or actual

heart failure. It is associated with little risk and requires little

supervision. However, some monitoring is needed for the disabled

and those with congestive heart failure.

Moderate intensity

exercise

Moderate intensity exercise is acceptable to many patients. It

may prove difficult to incorporate into daily living activities on a

long-term basis and can lead to musculoskeletal injury in the

elderly. It may not initially be within the capacity of many older

patients and probably should not be attempted by those with

heart failure except with careful supervision.

High intensity

exercise

Only a small minority of patients embraces high intensity

exercise. It is a barrier to participation in cardiac rehabilitation for

the elderly, the obese and for most middle aged or older women.

It is beyond the capacity of those with heart failure or significantly

impaired left ventricular function and requires prior testing for

safety and determination of a training heart rate. High intensity

exercise requires monitoring. Further, it is unlikely to be

subsequently incorporated into the life activities of most patients.

For some patients, however, high intensity exercise training is a

desired level of activity, particularly for younger males who are

usually of higher socioeconomic status and who are in a position

to continue such activity in a social or gymnasium environment. It

may also be desirable for rapid reconditioning of those in

physically demanding work. The need for high intensity exercise

has now been questioned in and many programs now offer

moderate intensity exercise training. While high intensity exercise

represents the quickest method of achieving or regaining fitness,

it is the most demanding on resources and costs. Further, it

delivers a program with limited appeal and with poor equity of

access.


Recommendation Low to moderate levels of physical exercise training, coupled with

regular physical activity at home, approaches that of high

intensity exercise training as a mode of enhancing physical

working capacity. High intensity and low intensity exercise

training appear to be equally effective in accelerating psychosocial

recovery. Thus, low to moderate intensity exercise is

recommended as best practice for cardiac rehabilitation programs.

As well as producing comparable physical benefits to those

achieved through high intensity exercise, it is acceptable to a

larger proportion of the population with greater safety. Further,

because of the reduced need for technology and medical

supervision, low to moderate intensity exercise training programs

can be delivered at low cost.

Currently, most authorities recommend supervised exercise of

high or moderate intensity three times weekly (preferably not on

consecutive days) for 12 weeks. This is based upon acceptance

that improvement in physical working capacity tends to plateau

from 10 to 21 weeks in such programs. It has been accepted that

if high intensity exercise training lasts for longer than half an

hour, the chance of musculo-skeletal injury is increased. Further,

it has also been confirmed that the risk of injury is greater if

exercise training occurs more frequently than on alternate days.

The concept of exercising three times per week for 12 weeks (36

training sessions), with electrocardiographic monitoring, either

with telemetry or other methods (limited leads or defibrillator

paddles), has been the basis of programs throughout the United

States. It is recognized that this requirement needs to be changed

(for example, there has been no defined insurance funding for

non-ECG monitored programs, nor for education programs or

psychosocial support of individual patients who may well require

additional personal attention).


Exercise programs should be structured with the following components in

place:

Safety protocols

With low intensity exercise training programs, risk of a cardiac event is very

small. However, it is essential that staff have current training in

cardiopulmonary resuscitation. A written emergency protocol is required,

together with a telephone accessible to staff to generate assistance if

required.

Access to medical and pharmaceutical support is dependent upon the

availability of either an ambulance or a medical practitioner. A simple

manually controlled ventilator and plastic airways are desirable. Nitroglycerin

should be available for patients who may develop chest pain and it is

desirable to have an oral diuretic (furosemide) on site for patients with heart

failure. However, the administration of a diuretic should only be after

medical advice. Healthcare staff requires knowledge of the indications for

and use of nitrates for patients with angina and of diuretics for heart failure.

Additional equipment and training are mandatory for high intensity exercise

programs. The equipment includes a resuscitation cart and a defibrillator,

which must be regularly maintained and checked. Healthcare staff requires

training in the use of the defibrillator and the contents of the resuscitation

cart. Monitoring may be by heart rate, intermittent rhythm strips by

electrocardiography or use of the defibrillator panels. This applies

particularly to those assessed as being at high risk. Telemetered

electrocardiography may be required for monitoring of the occasional patient

who is thought to be subject to serious arrhythmias.


Equipment

It is possible to conduct cardiac rehabilitation exercise programs with little

equipment and maintain the principles of best practice at low cost. The

decision regarding equipment is partly secondary to the decision regarding

the level of exercise training. For low to moderate level exercise, it is

necessary to have a stethoscope and sphygmomanometer. Exercise

equipment may be limited to simple items such as buckets, bricks, boxes,

baskets, cases or weights. A set of steps to accommodate several patients,

or sets of steps to be used by individual patients, can be useful. Treadmills

for walking are expensive and unnecessary. Stationary cycles with air or

mechanical resistance occupy relatively little space and are not expensive.

An indoor walking area is desirable, but outdoor walking, if feasible, may be

preferred. High intensity exercise may be undertaken using similar

equipment, but additional safety equipment is required, as noted above.

Content of exercise classes

Low to moderate intensity exercise may be undertaken without the warm up

and cool down periods required for high intensity exercise. However, it is

generally desirable, particularly with older, obese or unfit patients who may

have reduced flexibility, to start with a warm up period of light calisthenics

and stretching of major muscle groups. Stretching may be largely limited to

the legs and spine if the activity program is based upon walking, use of

steps or stationary cycling. Patients after sternotomy should include upper

body flexibility exercise as a part of their warm-up. It is desirable to take

patients through a series of activities before starting dynamic exercise or

strength training exercise, particularly if using the arms with cranking,

pushing, pulling or lifting.


The program may be largely based upon walking, which may be maintained

for 20 to 30 minutes. A circuit of different activities may also be performed

at levels short of breathlessness, with monitoring of perceived exertion

and/or heart rate after each station where activities may be maintained for

up to five minutes at a level acceptable to the patient. Patients should be

observed and should also be requested to report any symptoms or

difficulties in performance of individual exercises.

Blood pressure should be checked during pauses between exercise in new

patients to note possible fall of blood pressure during activity. Blood

pressure should also be checked in those patients known to have, or who are

found in the class to have, elevated blood pressure. If significant variation of

blood pressure is noted, exertion should cease until medical clearance is

obtained.

A record of the exercise intensity, duration, heart rate or perceived exertion

should be charted for each patient at each attendance. Any problems

encountered by patients or staff related to symptoms, abnormal blood

pressure or heart rate should be reported to the patient’s doctor. A cool

down period with gradually lessening levels of activity, followed by a period

of rest, relaxation and breathing exercises, is commonly practiced and

appreciated by patients. The total duration of a low to moderate intensity

exercise training session should be between 45 to 60 minutes, including

rests between activities. For high intensity exercise, usually continuous, the

exercise time is usually 20–30 minutes.

Staffing

While a multidisciplinary team of health professionals may conduct education

groups, physiotherapists, exercise physiologists or appropriately trained


nurses, occupational therapists or other health professionals are best trained

to conduct exercise classes. Nurses and physiotherapists conduct most

exercise programs, with the exercise program usually designed by a

physiotherapist.

Low to moderate intensity exercise programs may be conducted by a single

health professional, provided there is another health professional available

as back up and provided patients have no medical contraindications to

exercise. Such programs are suitable for small communities with a small

number of patients. This represents a “basic facility.” The key to such

programs is adequate staff training and the development of a support

network for the health professional involved. Such supports are most readily

available through a community health center or local hospital.77.154.158-163

Counseling and Education

Exercise training has traditionally been the primary focus of cardiac

rehabilitation programs. However, education and counseling are now

considered as important as exercise training in facilitating recovery from

acute cardiac events and for secondary prevention of cardiovascular disease.

Exercise training, education and counseling are now universally recognized

as integral components of comprehensive cardiac rehabilitation.164

To facilitate a return to normal living, patients require guidelines about

resuming driving, sexual activity, work and other activities. In addition,

information and advice about lifestyle change are necessary for secondary

prevention of cardiovascular disease. Motivation to adhere to advice and

prescribed medication is strongly influenced by the patient’s understanding

of the disease, the acute event and the need for risk factor modification.

Behavioral and psychosocial counseling may be delivered effectively in-group


settings. However, specific instruction regarding behavior change should also

be offered on an individual basis so that interventions can be tailored to the

specific needs of each patient. Individual counseling may be required for

some patients.165

The educational level of patients will have a significant impact on their ability

to retain information. Many patients are unable to comprehend or retain

information due to a limited education or literacy skills. Age may also

influence retention of information. The specific needs of patients and their

receptivity to information must be considered, since some information may

not be thought important by individual patients. It is important for the

educator and the patient to engage in joint goal and priority setting at the

beginning of the rehabilitation process. This will help the patient maximize

the benefits of the program.166

The quality of the intervention and education program will play a crucial role

in the success of the patient. For example, educational strategies may be

unsuccessful because the information given was too advanced or too

general. In other instances, the educational counseling may be ineffective

because different health professionals often give contradictory information

and advice. If the educator is giving different information and

recommendations than the general physician, the patient will be confused

and unsure of which guidelines to follow. Clarification is therefore required to

reduce confusion. Information needs to be repeated and reinforced.160

Education and counseling programs should cover several specific, defined

topics. However, depending upon the particular groups of patients attending

and their specific needs, some subjects may be omitted, addressed only

briefly or expanded. Topics should address questions commonly asked by


patients. The following subjects represent the core content of a typical

education and counseling program for patients with cardiovascular

disease:167

Medical topics

o Anatomy, physiology and pathology of cardiovascular disease

o Coronary heart disease/ischemic heart disease

o Acute cardiac events

o Investigations and procedures

o Symptoms and their management

o Cardiac medications

Modifiable risk factors

o Smoking

o Raised lipids, nutrition and dietary fat

o High blood pressure

o Overweight, obesity and diabetes

o Physical inactivity

o Other risk factors

Non-modifiable risk factors

o Older age

o Male gender

o Positive family history

Behavioral and psychosocial topics

o Behavior change and adherence to medication and advice

o Mood and emotions

o Psychosocial risk factors and social support


o Stress

o Impact upon the spouse and family

o Sexual activity and activities of daily living

o Return to work

Many patients will require an education program that provides clear

explanations of the disease process and potential risk factors. When

describing acute cardiac events (such as acute myocardial infarction,

coronary artery bypass surgery and percutaneous transluminal coronary

angioplasty), it is important to use clear and concise language that is free

from medical jargon. This approach is also necessary when discussing

investigations and procedures including coronary angiogram, exercise tests,

electrocardiography, echocardiography and nuclear cardiography.168

It is necessary for facilitators to be aware of the benefits of frequently

prescribed drugs so that they can answer questions commonly asked by

patients. Cardiac medications, their purpose and beneficial effects should be

explained simply, noting common side effects and stressing the need for

taking prescribed medication. Patients should be encouraged to report side

effects to their doctors so that alternative medication may be prescribed.

Patients often ask for additional information concerning the following:117

Aspirin

Beta blocking drugs

Calcium channel blocking drugs

– Dihydropyridines

– Diltiazem and verapamil

Angiotensin converting enzyme inhibitors and angiotensin II

antagonists


Diuretics

– Frusemide (furosemide)

– Thiazides

– Others

Nitrates (tablets, sprays, patches)

Digoxin

Lipid lowering drugs

– Statins

– Others

Antiarrhythmic agents

Anti-inflammatory drugs

Psychotropic drugs

Hormone replacement therapy

It is important to limit discussions regarding medication to only those that a

patient is taking, or will be taking. The education process can be quite

confusing to a patient, and it is important to ensure that the patient only

receives the information that pertains to him or her. Additional medical

topics may also be discussed during groups, depending upon the medical

and surgical problems of the patients that are present.128

All major risk factors should be covered, either in separate sessions or

together with discussion of several risk factors. Both modifiable and non-

modifiable risk factors need to be addressed. The compounding of risk if

several risk factors are present should be highlighted and the possibility of

reversal of risk, coupled with stabilization or reversal of disease, explained.

Further, it should be pointed out that other common diseases, including

stroke, peripheral vascular disease and diabetes, share many of the same

risk factors as those for coronary heart disease. Providing patients with


information about heart disease and explaining risk factors will help patients

understand the importance of changing their habits and adhering to advice

in order to reduce their risk of further events.169

In addition to providing an overview of the disease and medications,

educators should also provide a comprehensive educational program on the

following topics:14,157,168-176

Diet Education and counseling programs should provide information,

explanation and practical advice regarding nutritional aspects of coronary

heart disease. Unfortunately, nutritional education presents a common

problem for many patients who are exposed to conflicting and confusing

information from advertising and the media. They also receive conflicting

advice from professional sources, including different members of the

rehabilitation team. Nutritional advice given by nurses and general

practitioners, in particular, often conflicts with advice given by dietitians.

It is therefore most important for team members to achieve consensus

regarding what constitutes accurate nutritional information. They should

also develop guidelines for specific groups of patients, such as the

elderly, the overweight and those with hypercholesterolemia, so that

advice can be individualized. Since dietary advice changes over time (for

example, the shifts between recommending polyunsaturated or

monosaturated oils), periodic expert review of nutritional guidelines is

particularly necessary.

Sessions should include discussion of total cholesterol, LDL and HDL

cholesterol levels, the nature of fat in food, hidden fat in food, the

distinction between saturated, polyunsaturated and monosaturated fats,

the importance of fruit, vegetables and fiber and the protective effects of

“traditional” diets.


Patients and families have little understanding of the role of saturated fat

in raising total and LDL cholesterol or of the difference between fat,

lipoproteins and cholesterol. They also have a poor understanding of the

role of blood lipid levels in deposition of cholesterol in the arterial

subintimal layer, the development of atheroma and its progress to

atherosclerotic cardiovascular disease. These aspects should be clearly

and simply explained, supported by visual aids. It is important to avoid

unnecessary detail and complex terminology during sessions dealing with

nutrition.

Most cardiac patients leave hospital on a low salt diet. This is usually

advised because of the desire to prevent fluid retention in those who had

had acute myocardial infarction or coronary artery bypass surgery.

Patients need to understand that a balance should be struck so that, if

they are not found to have high blood pressure or incipient heart failure,

then it is reasonable for them to consume a moderate amount of salt. A

moderate amount of salt is already present in many foods. Hence, the

general advice for all should be to avoid adding salt at the table and to

minimize the addition of salt during cooking. For those who are

hypertensive and found to be salt sensitive, then persistence with a low

salt diet is desirable. Salt excretion may be increased by diuretic

treatments, but if the intake of salt is reduced, the dose of diuretic can

be less.

Smoking Patients must be made aware of the considerable risks of continued

smoking, particularly the increased likelihood of further cardiac events

and death. The hazards of continued cigarette smoking amongst patients

with cardiovascular disease are well reported in powerful observational

studies. Patients need to understand that many benefits accrue from

stopping smoking, including a marked reduction in morbidity and the

halving of mortality from coronary heart disease and stroke. While

smoking usually ceases with acute events and hospital admission,

resumption of smoking commonly occurs soon after hospital discharge

and occasionally before the patients leave hospital.


In some patients, relapses occur after months or even years. The

proportion of patients who continue to smoke, or who lapse after initially

ceasing, has been reported to be as low as 10–20% in some studies and

as high as 60% in others.

Continued advice and support should be offered to current or former

smokers. The effect of the culture to which the patient returns is likely to

be an important influence upon adherence to non-smoking advice.

Encouragement to stop smoking is especially important during

convalescence when patients are most motivated. In addition to

providing information about the dangers of smoking and the potential

benefits of ceasing, patients should also be shown how to use simple

behavioral strategies for stopping smoking and for maintaining the

status of a non-smoker.

Patients should be encouraged to discuss any barriers they perceive to

stopping smoking and techniques for quitting which they may have

found helpful in the past. The use and benefits of nicotine replacement

therapy should be explained. Information should be provided about

sources of further assistance and counseling. Referral to smoking

cessation programs should be recommended for those unable to stop

smoking on their own.

High blood

pressure

Education and counseling sessions should include explanations of the

role of high blood pressure in causing coronary heart disease and stroke.

The added risk from hypertension in patients with established

cardiovascular disease should be discussed. The considerable benefits

arising from good blood pressure control in these patients should be

emphasized.

Many patients with previously raised blood pressure have a fall in both

systolic blood pressure and diastolic blood pressure following acute

myocardial infarction and coronary artery bypass graft surgery. A

gradual recovery towards previous or higher levels then occurs over

some months.


This rise in blood pressure is most marked amongst those patients

whose hypotensive medication was changed or stopped while they were

in hospital. The most effective method of controlling this rising blood

pressure is resumption of medication. Additional lowering of blood

pressure, possibly with lesser dosage of medication, may be achieved

through weight reduction, exercise, salt restriction and dietary change

with the addition of fruit and vegetables.

The importance of adherence to advice regarding hypotensive

medication and the need for regular blood pressure checks should be

stressed. The benefits of blood pressure control through physical activity,

weight control and salt restriction should also be pointed out. Further,

patients should understand that it is possible that the lower the blood

pressure, the better. Since stress, especially work-related stress, is

thought by many patients to cause high blood pressure, this issue also

needs to be addressed.

Physical

inactivity

A sedentary lifestyle, with little or no physical activity during leisure or at

work, is a risk factor for the development and progress of cardiovascular

disease, almost as potent as raised blood pressure or lipid levels. The

role of a sedentary lifestyle as a risk factor for the development and

progression of cardiovascular disease should be explained and the

benefits of physical activity emphasized. Education is required

concerning the need for lifetime physical activity, in addition to

participation in exercise sessions during the rehabilitation program.

Patients should be reassured regarding the safety and ease of

undertaking physical activity outside the rehabilitation class. It should be

emphasized that major health benefits can be achieved through light to

moderate activity and that high intensity exercise is not necessary.

Weekly utilization of 1,500 to 2,200 kilocalories above the caloric

utilization of sedentary living achieves considerable protective benefit.

Patients readily embrace low or moderate levels of daily activity during

convalescence after acute cardiac events, as well as by patients with

past or controlled heart failure, the obese and older men and women.


Alcohol

Excessive consumption of alcohol should be recognized as a contributor

to hypertension and therefore as a risk factor for stroke. Patients also

need to understand that alcohol may adversely affect myocardial

function, particularly amongst those who are hypertensive and those

who have suffered myocardial infarction. Further, alcohol may be a basis

for resumption of smoking, physical inactivity or a previously

unsatisfactory diet. Patients who are aware that alcohol (whether it be

red wine or any other alcoholic drink) protects against subsequent

myocardial infarction may use that information to increase their alcohol

consumption.

It is important to emphasize the multiple other hazards of exceeding the

recommended daily maximum of two to four standard alcoholic drinks for

men and one to two drinks for women.

Age,

gender,

family

history and

existing

disease

Education and counseling sessions should address non-modifiable risk

factors, including the increased risks of age, male gender and positive

family history. The older the patient with cardiovascular disease,

irrespective of gender, the greater the risk of death and disability from

cardiovascular disease. The hazards of premature cardiovascular disease

are greater amongst males than females. However, late onset

cardiovascular disease and death from cardiovascular disease are now

more common amongst females

A positive family history of cardiovascular disease is a powerful marker

of risk for the development and accelerated progress of cardiovascular

disease. It has been clearly demonstrated that those with a positive

family history for cardiovascular disease commonly have worse risk

factor profiles in terms of lipids, blood pressure, obesity, diabetes and

smoking habit, in addition to their non-modifiable genetic background.

Hence, risk factor modification is of greater importance in patients with a

positive family history than it is for those with identified modifiable risk

factors without a family history.


A past history of stroke, other vascular disease or diabetes mellitus is

also a powerful marker of risk for coronary heart disease and an

indicator of the need for attention to all risk factors.

Facilitators should define overweight and obesity and explain their role in

the etiology of cardiovascular disease and diabetes. They should also

explain their role as risk factors for further cardiovascular events and

mortality, the development of Type II diabetes and raised cholesterol

and blood pressure. Reduced caloric intake, particularly reduced fat

intake, together with regular, maintained or increased physical activity,

has been shown to be effective and should be encouraged for all

overweight patients and those with non-insulin dependent diabetes.

In some patients, obesity may be coupled more with physical inactivity

than with a high caloric intake. However, weight loss is hard to achieve,

especially in those who have a long history of obesity. The difficulties

faced by overweight and obese patients in achieving and maintaining

lower weight should be recognized and discussed. Gradual weight loss

should be recommended, with limited targets over time. Psychological

factors associated with overweight and obesity should be explored and

the development of a supportive environment encouraged for those

seeking to lose weight.

Depression,

anger,

stress

Patients need to understand the typical emotional responses to an acute

cardiac event. It is usual for patients to pass through a period of anxiety

after their acute event, especially upon transfer to the ward and on

discharge from hospital. Common concerns include a fear of death, a

further cardiac event, physical disability and unemployment. Physical

symptoms such as palpitations, breathlessness and chest pain may be

caused by anxiety, although patients may not recognize such symptoms

as manifestations of anxiety. Anxious patients usually have little

concentration and often fail to comprehend, accept or recall information

provided in hospital. Further, anxiety may lead to a delay in resuming

activities.


Depression is also common after an acute cardiac event and has been

associated with increased mortality and morbidity and increased costs

associated with rehospitalization. In most cardiac patients, such

depression is more a grief or bereavement reaction rather than a

depressive illness. It is best referred to as a “depressed mood” in which

a sense of real or imagined loss is experienced. Symptoms are mostly

mild and transient and their manifestations are usually subtle. A

depressed mood may be experienced first in hospital. However, it

typically peaks during convalescence. Common symptoms of a depressed

mood include an inability to concentrate, restlessness, disturbed sleep,

early waking, irritability, a sense of fatigue, loss of interest and

motivation, sentimentality or even tearfulness. Patients may become

pessimistic about their recovery and fearful of a recurrence. They may

equate fatigue and weakness with heart damage greater than

anticipated.

They may then become preoccupied with the supposed limitations of the

illness. Withdrawal and irritability during convalescence are frequent

symptoms of a depressed mood. Concerns are increased if there is

awareness of heart action, ectopic beats or palpitation, non-cardiac or

cardiac chest pains, breathlessness from hyperventilation or unfitness or

of any other symptoms of physical and psychosomatic origin. It is

important to explain and discuss such symptoms during group sessions.

Forewarning patients that a depressed mood commonly occurs during

convalescence can also be most valuable. Anxiety and depression often

coexist. Several symptoms, including irritability, reduced concentration

and sleep disturbances, are common to both conditions.

Patients may cope with their anxiety, depression or other symptoms by

denial, convincing themselves that any problems they have are not

serious and that they are not at risk of future problems. While denial

may be a useful defense mechanism in the short-term for coping with

anxiety and a depressed mood it can exert a negative influence upon

outcomes if patients cease to adhere to regimens regarding lifestyle,

medication and other advice.


It is usual for anxiety and depression to decrease spontaneously during

the months after the event, although they may persist for up to a year

or more. Studies suggest women have poorer psychological outcomes

than male patients. Early detection and management of psychological

difficulties can prevent persisting disturbances. Facilitators of group

sessions need to identify those at risk of continuing psychological

problems and, if necessary, refer them to appropriate team members for

individual assistance.

Psychological difficulties persisting for several months are usually

attributable to an unrecognized and untreated depressed mood, which

can lead to nonadherence with advice, occupational difficulties, and

marital and sexual dysfunction. Moreover, as already stated, depression

is a powerful predictor of mortality after acute myocardial infarction. A

further loss or crisis can intensify or prolong the depressed mood. In

some patients, the onset of depression may be delayed. In these cases,

the acceptance of loss and the need for change have usually been denied

earlier. Those who do not display some signs of depressed mood early

will often become depressed at a later stage of their recovery.

Psychological responses can be effectively addressed during group

sessions by a skillful facilitator. When patients are able to disclose

feelings during group sessions, identification with others who are

experiencing similar problems can be a major benefit. Recognition that

problems are not unique is reassuring. Facilitators of group discussions

should explain that anxiety and a depressed mood are typical after acute

cardiac events but that they are usually mild and transient. Fear of

further cardiac episodes, anxiety about resuming work and concern

about overprotectiveness in spouses may be successfully shared with

others in the group. In addition to identifying with others who have

similar problems, patients also gain from observing positive changes and

a rapid recovery in others. Thus, a group should ideally contain patients

at all stages of recovery, including “elders” who often adopt a preceptor

role for the newer group members.


Discussion groups for patients can also benefit from the occasional

attendance of former patients who have made a favorable adjustment.

The practice of introducing successfully rehabilitated postsurgical

patients to those awaiting the operation is based on the same premise.

Patients commonly attribute their cardiac illness to stress. Stress and

perceptions of the causal role of stress in the patient’s illness should be

explicitly addressed during group sessions, possibly together with

discussion of mood and emotions. While life stress, as discussed above,

has been shown to be a factor leading to adverse outcomes, this type of

stress is not necessarily that which most concerns many patients. The

perceived stress, which patients typically describe, arises from external

pressures and demands, time constraints, work problems or adverse

personal interactions and low levels of control over these stresses.

There is some evidence that such stress may worsen prognosis.

Patients often perceive such “job stress” to be the main cause of their

disease. However, there is no substantial scientific evidence to support

these views. While “strain” may not be a significant risk, poor “control”

may be so. Such poor “job control” may be another reflection of less

education, reduced job opportunities and lower socioeconomic status.

Nevertheless, since these concerns regarding occupational stresses are

so widely held by patients, the topic needs to be discussed during group

sessions.

Failure to address the issue can have adverse consequences. Concern

about the effects of “work stress” may lead to unemployment, whether it

is the concern of the patient, spouse, other family members, workmates,

foreman or employer. Patients should be encouraged to talk about how

they feel about resuming work and to raise any anticipated problems.

Many problems can be resolved by discussion with the patient and close

family members or in the group where others may have similar concerns

about their work.


Facilitators should explain the two aspects of stress: the stressor and the

response to the stressor. Most important is recognition that the response

to the stress may influence the progression of the patient’s disease.

Thus, for some, occupational or domestic stress may lead to resumption

of smoking or consumption of more cigarettes, food and alcohol and to

physical inactivity. Alternatively, patients may handle such stress by

walking or exercising during work breaks, pacing up and down rather

than sitting while working and by increasing leisure time physical

activity. Some patients can face stress by “switching off” or by avoiding

situations, which they are aware, will induce a sense of stress.

Patients need to understand that the evidence for stress being directly

harmful is insecure. There is some evidence that it does not contribute

directly and independently to the progression of cardiovascular disease.

Patients may therefore accept the presence of stress, but be led to

modify their responses to embrace favorable rather than harmful

behaviors. Some may also be able to modify their perception of stress

and their responses to stress through stress management techniques.

Cardiac Rehabilitation Timeline

There are three distinct phases of cardiac rehabilitation. Each phase has

specific activities and guidelines associated with it. While there are

suggested and estimated amounts for the duration the patient should spend

in each phase, it is important to note that the actual amount of time spent

will depend on the individual patient. Some patients will only require a brief

period on one or more of the phases, while other patients may require more

intensive treatment as part of one or more phase. The physician will work

with the individual patient to determine an adequate timeline, with the

understanding that the timeline may change as the patient progresses. The

phases of cardiac rehabilitation are outlined below.


Inpatient Rehabilitation: Phase 1

Rehabilitation begins in hospital and consists of early mobilization and

education. It is delivered on an individual basis and, additionally, in some

hospitals, to groups of patients. The degree of structure of inpatient

programs varies from one hospital to another. The shorter hospital stay

(now commonly four to six days after acute myocardial infarction, five to

seven days after coronary bypass surgery, and one day after coronary

angioplasty) makes it extremely difficult to conduct formal inpatient

education programs. Further, inpatients commonly undergo time consuming

comprehensive investigations. Thus, inpatient cardiac rehabilitation

programs are now much more limited in scope than in the past. Moreover, it

is recognized that inpatient education may be ineffective because of the

psychological state and concerns of patients soon after their acute event.

Inpatient rehabilitation is now mostly limited to early mobilization, so that

self-care is possible by discharge, and brief counseling to explain the nature

of the illness or intervention, to increase the patient’s awareness of his or

her risk factors and to reassure the patient about future progress and follow-

up. A discharge plan usually incorporates a discharge letter to the general

practitioner and/or cardiologist or cardiac surgeon and assurance that the

patient is aware of the need for continued medication. Appointments are

usually made for follow-up review and, ideally, referral to a formal

outpatient cardiac rehabilitation program. The effects of such restricted

inpatient programs upon patient outcomes have been little studied.177,178

Ambulatory Outpatient Rehabilitation: Phase 2

Most cardiac rehabilitation is based upon supervised ambulatory outpatient

programs conducted during convalescence. Attendance begins soon after

discharge from hospital, ideally within the first few days. In most instances,


ambulatory cardiac rehabilitation programs usually end within two to three

months of the acute event. Formal outpatient cardiac rehabilitation

programs vary widely in content. Almost all contain an element of group

exercise, which is conducted by allied health professionals. Therefore, an

educational and supportive element is inevitably delivered together with the

exercise.

The duration of ambulatory exercise programs during convalescence also

varies. In some programs, funding is available for exercise classes

conducted three times per week for 12 weeks for those who are covered by

health insurance, Medicare or Medicaid. In other programs, the usual

duration of programs is six to eight weeks, although in some places it may

be as short as four weeks.

Sessions may be offered once, twice or occasionally three times per week.

Many programs offer exercise of a moderate or high intensity level, although

some will offer low or moderate intensity. Most programs include group

education, but the content and method of the delivery of such education

programs varies greatly. Different facilitators in the one program also vary

considerably in their approach to running group discussions. Psychological

and social support may be given on an individual basis, as required, or may

be provided to groups of patients and family members.179-181

Maintenance: Phase 3

A lifetime, maintenance stage will follow the ambulatory program in which

physical fitness and risk factor control are supported in a minimally

supervised or unsupervised setting. Maintenance programs are even more

varied in content and structure than ambulatory programs. The exact


content of maintenance programs is often not clearly defined. They may

consist of regular recall and review by physician or nurse.

Patients may receive additional medication, further education, social

support, exercise classes and behavioral intervention, as required. Some

patients may be enrolled in special groups for specific reasons (for example,

diabetes, obesity, smoking, lipid disorder, hypertension, heart failure) if

clinics are established for the management of these particular risk factors or

conditions. In other programs, patients may be enrolled in an ongoing

exercise class. Relatively few maintenance programs have been established

or adequately evaluated. Most of the evidence for improved prognosis is

derived from combined ambulatory and maintenance programs, which have

been hospital-based. Individual studies and meta-analyses have reported

benefits in terms of reduced mortality, recurrent events and

readmissions.77,127,166,180

Innovations In Cardiac Rehabilitation

In recent years, some innovative programs have emerged with the intent of

providing patients with a wider range of cardiac rehabilitation options.

These programs are provided as alternatives to traditional cardiac

rehabilitation programs, and are not suitable for all patients. Prior to utilizing

one of these alternative options, the physician must assess the patient to

determine if it is appropriate.

In-Home Exercise

In recent years, some doctors have begun allowing patients to engage in

home-based exercise programs. These programs are offered in place of

facility-based programs, not in addition to them. Patients complete their


exercises within their own home. This new option provides a more feasible

option for patients who do not have access to regular transportation, or for

those who have difficulty leaving their homes. However, these programs

must be closely monitored to ensure that the patient is performing the

exercises properly, and completely.182 The following is the recommendation

that has been established for home-based exercise programs:

“A home exercise program is recommended for those patients who

are unable to attend a group exercise program. A daily home

walking program is recommended as a supplementary activity for

all patients enrolled in a group program.

Trials have compared home versus hospital ambulatory group

exercise. These have shown benefits in physical working capacity

and psychosocial outcomes approaching those achieved by patients

randomly allocated to a hospital based group program. While

home-based programs reduce patient travelling time, patients who

undertake exercise training at home may still require careful

assessment before an exercise prescription is offered them, if they

are to undertake moderate or high intensity exercise. Further, in

the reported trials, patients had a cycle ergometer at home for

their prescribed exercise session, telephone communication with

the nurse program coordinator and facilities for telephone

electrocardiographic transmission during exercise. While this

extends the opportunities for individual patients to participate in

supervised high or moderate intensity exercise, it is not of low

cost. Further, it could be irrelevant. If lower levels of exercise are

accepted, telephonic monitoring would become unnecessary for the

great majority of patients. It may not be possible for all patients to


attend a group cardiac rehabilitation program. Such patients

require guidance regarding exercise, education and behavior

change, as well as support. Simple verbal and written instructions

to such patients are required, together with discussion about

activity and behavior while in hospital (inpatient rehabilitation) and

as part of discharge planning. Follow-up by telephone may be

possible. General practitioner follow-up should be assured.

Ideally, patients receiving a home-based program should attend at

least one group exercise session for guidance regarding home

exercise and to learn the level of exercise recommended for them.

They should learn self-monitoring based upon observation of heart

rate during activities or recognition of symptoms to the level of

awareness of breathing. They should be advised to continue

activity at that level on a daily basis, preferably for half an hour

each day. Home exercise programs generally involve daily walking

at a low or moderate intensity, as well as other physical activities

with gradual progression to achieve an increase in muscular

strength for activities of daily living. Patients who are enrolled in a

group exercise program should also follow a home activity

program, accumulating at least 30 minutes of activity daily at a

similar level of perceived exertion or heart rate. To date, most

cardiac rehabilitation exercise programs have been developed in

the outpatient areas of hospitals. Referral to such programs should

be organized prior to the patient’s discharge from hospital.

Monitoring of attendance and follow-up should be readily achieved.

A further advantage of hospital-based programs is the potential for

continued support from the health professionals involved in both


inpatient care and ambulatory rehabilitation, with a heightened

sense of security for both staff and patients.”148

Disadvantages

A potential disadvantage is the possibility of patients considering that they

need to be closely linked to the hospital upon which some may develop a

sense of dependence.

Another disadvantage is the centralization of services at the hospital, with

consequent problems for patient attendance, transport and distance. Thus,

there is a good case for programs being sited in community centers. This

latter case becomes more feasible if the intensity of exercise is at a low to

moderate level.183

Job-specific Rehab

Some cardiac rehabilitation programs have been developed to provide job

specific rehabilitation. In these instances, the patient will only focus on

areas that will aid in the transition back to work. These programs will not

include the components that are not relevant to the patient’s occupation.

However, job-specific rehabilitation programs will still include a variety of

components that address the physical, lifestyle, and emotional needs of the

patient.184

Web-based Programs

Web-based programs are a new development in the field of cardiac

rehabilitation. They are currently being limited to a very specific set of

patients who can benefit the most from the program. They are most suited

for patients who are self-sufficient enough to manage the different


components of their rehabilitation program. Web-based programs provide

the content remotely to the patient, thereby reducing the amount of time

the patient will have to spend in doctor’s offices and therapy centers. With a

web-based program, all treatment guidelines and activities are delivered

electronically to the patient. The patient tracks progress electronically and

provides regular updates to the treatment provider.185

Summary

Approximately 14 million persons suffer from some form of coronary artery

disease. In the past, cardiac rehabilitation was used to treat lower-risk

patients who had the physical capacity to exercise without the risk of

additional complications. However, in recent years, cardiac treatment and

management has evolved, thereby expanding the demographic of patients

who can participate in cardiac rehabilitation programs. A substantial

component of this new demographic includes approximately 400,000

patients who undergo coronary angioplasty. In addition, there are

approximately 4.7 million patients with congestive heart failure who can

participate in a modified program of rehabilitation.

The primary goal of cardiac rehabilitation is to reverse limitations

experienced by patients who have suffered the adverse pathophysiologic and

psychological consequences of cardiac events. Just as a serious leg injury

requires rehabilitation to return the patient to optimal performance, the

heart also requires serious rehab in order to function at its best after a

trauma. Additionally, when a cardiac event occurs, the patient may suffer

emotional difficulties and challenges in accepting and overcoming the events

that caused the issue. Cardiac rehabilitation is a whole-body approach to

restoring health that incorporates a multi-dimensional approach to address

body, mind, and spirit. Exercise, counseling, and physical therapy combine


with medical management to ensure that as much normal function as

possible is restored to each patient, and that every patient is able to adapt

to lifestyle changes that reduce the risk of a repeat occurrence.

Please take time to help the NURSECE4LESS.COM course planners evaluate nursing

knowledge needs met following completion of this course by completing the self-

assessment Knowledge Questions after reading the article.

Correct Answers, page 75.


1. In the United States, cardiovascular disorders are:

a. proven to be the leading cause of mortality and morbidity.

b. responsible for approximately fifty percent of annual deaths in the United States.

c. present in approximately 14 million people who suffer from some

form of coronary artery disease or its complications.


2. True or False: Overall, modern cardiac rehabilitation is safe and

well tolerated with a very low rate of major complications such as death, cardiac arrest, myocardial infarction or serious

injuries.

a. True.

b. False.

3. The following is/are true about cardiac rehabilitation exercise

training for patients with coronary heart disease or congestive heart failure (CHF):

a. Adverse outcomes or complications of rehabilitation exercise

training are common.

b. Cardiac rehabilitation exercise training for patients with CHF leads to objectively verifiable improvement in exercise capacity in men

and women, regardless of age.

c. The benefits decrease in patients with diminished exercise

tolerance.

d. The benefits persist long-term after completion of cardiac rehabilitation even without a long-term maintenance program.


4. The American Heart Association and other organizations have

outlined the core components of contemporary cardiac rehabilitation and secondary prevention programs. They include

which of the following?

a. exercise training and physical activity counseling

b. tobacco cessation

c. nutritional counseling and weight management


5. Healthcare team members have different tasks related to cardiac rehabilitation. The task of the nurse is:

a. to confirm referral to the program at the patient’s first visit and

encourage the patient to attend.

b. define the medical parameters of the rehabilitation program from the outset.

c. detect medical and other problems, and to refer patients to other

health care providers, when required.

d. prepare the patient for resuming work by assisting the patient with

work conditioning and, if required, conducting simulated work tests and visit the worksite.

6. When categorizing the intensity level of a physical activity

program, it is important to factor in age and cardiovascular disease status of the patient when:

a. using the Berg’s scale.

b. metabolic equivalents (“METs”) are used.

c. categorization is done using heart rate.



7. With low intensity exercise training programs,

a. it is essential that staff have current training in cardiopulmonary resuscitation.

b. the administration of a diuretic should always be given to avoid

constipation caused by exercise.

c. the mandatory equipment includes a resuscitation cart and a defibrillator.


8. Blood pressure should be checked during pauses between exercises:

a. in patients after a significant variation in blood pressure is noted.

b. in all patients during low to moderate intensity exercise.

c. in new patients to note possible fall of blood pressure during activity.

d. but only during the cool down period.

9. Home-based exercise programs are a new option for heart

patients:

a. They are usually in addition to and in conjunction with facility-based

programs.

b. One of the benefits of home-based exercise programs is the program does not need to be closely monitored since the patient

self-monitors the program.

c. Patients receiving a home-based program should attend at least one group exercise session for guidance and to learn the level of

exercise recommended for them.

d. Home-based exercise programs do not require careful assessment before an exercise prescription is offered to the patient.


10. True or False: Some cardiac rehabilitation programs have been

developed to provide job specific rehabilitation. In these instances, the patient will only focus on areas that will aid in the

transition back to work.

a. True.

b. False.

CORRECT ANSWERS:

1. d

2. a

3. b

4. d

5. c

6. b

7. a

8. c

9. c

10. a


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The reference section of in-text citations include published works intended as

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