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Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention

Human Services

Victoria

PRODUCED BY THE HEART RESEARCH CENTRE ON BEHALF OF DEPARTMENT OF HUMAN SERVICES VICTORIA

Background to Heart Research Centre and authors
The Heart Research Centre was established in 1989 with three year seeding funding from the National Heart Foundation of Australia. It became an independent centre in 1993 and is now affiliated with The University of Melbourne and La Trobe University. The Heart Research Centre conducts research into cardiac rehabilitation and the prevention of heart disease, especially their psychological, behavioural and social aspects. The Centre also conducts training programs for health professionals. Dr Alan Goble is a practising clinical cardiologist, with a longstanding interest in cardiac rehabilitation. He is a member of the Expert Advisory Panel on Cardiovascular Diseases of the World Health Organisation, and a member and pastchairman of the Council on Rehabilitation and Prevention of the World Heart Federation. He is Chairman of the Board of the Heart Research Centre. Dr Marian Worcester has a doctorate in social and preventive medicine and a Master’s degree in criminology. She has a particular interest in psychological responses to acute illness and social support. She has been Director of the Heart Research Centre since its establishment.

Dedication
These Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention are dedicated to the late Dr John Shaw, former director of the National Heart Foundation of Australia, for his support of the Heart Research Centre, and to cardiologists, Dr Robert Goodwin and Dr W Anthony Seldon for their contributions to the development of cardiac rehabilitation in Australia.

BEST PRACTICE GUIDELINES FOR CARDIAC REHABILITATION AND SECONDARY PREVENTION

HEART RESEARCH CENTRE

Principal Authors Alan J Goble, MD, FRCP, FRACP Marian U C Worcester, PhD, MA

Produced on behalf of Department of Human Services Victoria

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Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention Goble AJ & Worcester MUC Heart Research Centre ACN 060 479 763 A company limited by guarantee Lygon Court, 333 Drummond Street, Carlton, Victoria 3053 Australia PO Box 607, Carlton South, Victoria 3053 Australia Telephone (613) 9347 5544 Facsimile (613) 9347 6964 Email [email protected] Website http://rubens.its.unimelb.edu.au/~heart/ Published by Department of Human Services Victoria April 1999 ISBN: 0 7311 5258 1 Designed by Outsource Design (03) 9645 5220

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CONTENTS

FOREWORD FOREWORD INTRODUCTION PREFACE EXECUTIVE SUMMARY CHAPTER 1
Development of the Best Practice Guidelines
Introduction Terms of reference Clinical Practice Guideline of the United States Agency for Health Care Policy and Research Development of the Best Practice Guidelines Evidence from meta-analyses Strength of evidence rating systems United States Agency for Health Care Policy and Research National Health and Medical Research Council of Australia Consultative Committee Survey of current programs in Victoria Focus groups with health care providers Comparative study of four model programs

xiii xiv xv xvi xviii 1
1 2 3 3 5 5 6 6 7 8 8 8

CHAPTER 2
Cardiac rehabilitation and secondary prevention: definitions
Cardiac rehabilitation Secondary prevention Phases of cardiac rehabilitation Inpatient rehabilitation (Phase 1) Ambulatory outpatient rehabilitation (Phase 2) Maintenance (Phase 3)

9
9 10 11 11 11 12

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CHAPTER 3
Cardiac rehabilitation and secondary prevention: historical background
United States of America Australia Europe United Kingdom Asia Participation in programs

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13 14 15 15 15 16

CHAPTER 4
The burden of cardiovascular disease

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CHAPTER 5
Recent practice guidelines and policy statements
Scientific review United States Agency for Health Care Policy and Research Other guidelines and statements American Association of Cardiovascular and Pulmonary Rehabilitation British Association of Cardiac Rehabilitation American College of Sports Medicine British Cardiac Society American Heart Association American College of Physicians Rehabilitation Systems in Europe European Society of Cardiology National Heart Foundation of Australia World Health Organisation

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23 23 23 23 23 24 24 24 24 24 24 25 25

CHAPTER 6
Review of Clinical Practice Guideline No 17 “Cardiac Rehabilitation” (1995) US Agency for Health Care Policy and Research
Exercise training Education, counselling and behavioural interventions Organisational issues

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29 30 30

CHAPTER 7
Exercise training in cardiac rehabilitation
Meta-analyses Ambulatory (convalescent) cardiac rehabilitation trials Longterm exercise studies where exercise training alone is compared with standard medical care

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31 32 32

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Longterm multifactorial interventions compared with standard medical care Comparisons of high and low intensity exercise training The benefits of exercise training Physical performance Exercise tolerance Muscular strength Symptoms Psychological functioning Social adaptation and functioning Return to work Major risk factors Lipids Smoking habit Body weight Blood pressure Subsequent exercise habits Morbidity, recurrent events, hospital readmissions and mortality Conclusions

32 32 33 33 33 34 34 35 35 36 37 37 37 38 38 39 40 41

CHAPTER 8
The amount of exercise training
Intensity of exercise training Categorisation of exercise intensity Low intensity exercise Moderate intensity exercise High intensity exercise Measuring exercise intensity Heart rate Determination of training heart rate from exercise stress test Determination of training heart rate from formula Formula-based percentage of maximal heart rate Formula-based percentage of heart rate reserve Perceived exertion Frequency of exercise sessions and duration of program Frequency of sessions Duration of program Home exercise programs Continued exercise beyond convalescence Eligibility for exercise programs Exclusion from exercise training

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42 44 44 45 45 46 46 46 47 48 48 49 49 50 51 52 53 55 55

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CHAPTER 9
Risk stratification
High risk groups Technological assessment of risk Clinical assessment of risk Conclusions

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57 58 58 59

CHAPTER 10
Conducting exercise programs
Site of exercise program Safety protocols Equipment Content of exercise classes Staffing Staff to patient ratio Exercise testing before exercise training Patient assessment before entry to the program Time of starting the exercise program Monitoring during exercise sessions Exercise testing after exercise training High intensity exercise training

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60 61 62 62 63 64 64 65 66 66 67 68

CHAPTER 11
Exercise programs for specific groups
Patients with heart failure and transplantation Patients with pacemakers and implantable cardioverter defibrillators Patients with other forms of heart disease Obese patients and diabetic patients Unfit patients Elderly patients Female patients

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69 70 71 71 72 73 74

CHAPTER 12
Education, counselling and behavioural interventions
Knowledge Health behaviours and risk factors Smoking Lipids Blood pressure Body weight Physical inactivity

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77 79 79 82 84 85 86

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Psychosocial well-being Stress Type A behaviour pattern Return to work Conclusions

87 92 93 94 96

CHAPTER 13
Content of education and counselling groups
Core education program Medical topics Risk factors Smoking Raised lipids, nutrition and dietary fat High blood pressure Overweight, obesity and diabetes Physical inactivity Other modifiable risk factors Non-modifiable risk factors Behaviour change and adherence to regimens Mood and emotions Psychosocial risk factors and social support Stress Impact upon the spouse and family Sexual activity and activities of daily living Return to work

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97 98 99 100 100 102 102 103 104 104 105 107 109 110 111 112 112

CHAPTER 14
Structural aspects of group education and counselling programs
Group versus individual counselling Principles of adult learning Range of topics Duration and frequency of sessions Time of entry to the education program Size of groups Style and level of presentation Individual counselling and referrals Protocol for education programs Review of education program Session facilitators Training of facilitators

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114 115 115 116 116 117 117 118 118 119 119 120

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CHAPTER 15
Programs for specific groups
Patients resuming work Patients who have had percutaneous transluminal coronary angioplasty Patients with other forms of heart disease Younger patients Patients of non-English speaking background Aboriginal Australians with heart disease Patients from rural and remote areas and others unable to attend a group program Spouses of patients

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121 123 124 125 126 127 128 129

CHAPTER 16
Cardiac rehabilitation teams
Membership Roles of team members Nurse Physiotherapist Dietitian Occupational therapist Social worker Psychologist Cardiologist Cardiac surgeon General practitioner Exercise physiologist Exercise therapist Diabetes educator Welfare worker Rehabilitation physician Pharmacist Psychiatrist Vocational counsellor Community health worker Other health practitioners Program co-ordinator Regional co-ordinator Team meetings Core competencies and staff training

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131 132 132 133 134 136 137 138 139 140 141 142 143 143 143 144 144 144 145 145 146 146 147 147 148

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CHAPTER 17
Organisational issues
Establishing programs Eligibility for referral to the program Hospital discharge plan Method of invitation to the program Invitations in other languages Initiating referrals and motivating patients Invitations to spouses Selection of program Time of commencing the program Entry assessment Selection of program modules Encouraging participation in programs and monitoring attendances Discharge review Referral to maintenance program Referral to community health services and support groups Communication with doctors Longterm follow-up of patients

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149 150 151 151 152 152 153 154 154 155 156 157 158 158 159 159 160

CHAPTER 18
Program evaluation
Program evaluation Outcome evaluation Instruments assessing functional capacity Graded exercise test 6 minute walk test Shuttle walk Duke Activity Survey Index Specific Activity Questionnaire Intruments assessing symptoms New York Heart Association Canadian Cardiovascular Society Seattle Angina Questionnaire Minnesota Living with Heart Failure Questionnaire Quality of life Generic measures of health related quality of life Medical Outcomes Study Short Form 36 (SF-36)

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161 162 162 162 162 162 163 163 163 163 163 163 163 163 164 164

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The Nottingham Health Profile Profile of Moods States Sickness Impact Profile Psychosocial Adjustment to Illness Scale Specific measures of health related quality of life Quality of Life after Myocardial Infarction Questionnaire Minnesota Living with Heart Failure Questionnaire Heart Patients’ Psychological Questionnaire Instruments measuring single psychological states State Trait Anxiety Inventory Hospital Anxiety and Depression Scale Beck Depression Inventory Cardiac Depression Scale Other questionnaires Visual analogue scales Measures of other psychosocial outcomes Selecting methods of assessing quality of life Knowledge Cardiac Health Knowledge Questionnaire Coronary Angioplasty Risk Factor Inventory Victorian Cardiac Rehabilitation Questionnaire Open-ended questions Risk factors and health behaviours Smoking Cholesterol Blood pressure Body weight Physical activity Dietary habit Adherence to medication and advice Attitudes towards changing health behaviours Intention to change Attitudes towards change Self efficacy regarding change Work Outcome indicators Functional capacity Activities of daily living Physical status Quality of life Knowledge

164 165 165 165 165 165 165 165 166 166 166 166 166 166 167 167 167 169 169 170 170 170 170 170 170 171 171 171 171 171 172 172 172 173 173 173 174 174 174 174 174

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Risk factors, health behaviours and attitudes Smoking Cholesterol Blood pressure Body weight Physical activity Dietary habit Adherence to medication and advice Work Hospital readmissions Process evaluation Patient satisfaction Delivery of the program Process indicators Communication Program referrals Liaison with general practitioners Patient management Assessment of patients General practitioner follow-up Program evaluation Program attendance Program modules Consumer input Participation of general practitioners Documentation Staff issues Minimum data sets External audit or peer review Conclusion

174 174 174 175 175 175 175 175 176 176 176 176 177 177 177 177 178 179 179 179 179 179 180 180 180 181 181 181 182 182

CHAPTER 19
Cost, cost saving and cost effectiveness
Victorian public hospitals Victorian private hospitals Canada United States of America United Kingdom Cost saving Cost effectiveness

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183 185 185 186 186 187 188

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CHAPTER 20
Recommendations for future research

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REFERENCES GLOSSARY ACKNOWLEDGEMENTS TABLES

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Table 1: Deaths from CVD (1994) Table 2: Hospital separations: number of patients with a diagnosis of CHD (Victoria) Table 3: Strength of evidence ratings for benefit (AHCPR 1995) Table 4: Number of exercise studies reviewed (AHCPR 1995) Scientific basis for recommendations: exercise training Table 5: Number of studies reviewed reporting education, counselling and behavioural interventions (AHCPR 1995) Table 6: Correlation with exercise training levels (approximate)

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FIGURES
Figure 1: Age-adjusted death rates 1950–1994, and falls since 1967 Figure 2: Trends in cardiovascular death rates in males and females, Victoria Figure 3: Cardiovascular procedures in Australia, 1970–93 19 20 21

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FOREWORD

These Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention were commissioned by the Department of Human Services Victoria as part of the Victorian Government’s Cancer and Heart Offensive. Cardiovascular disease is the most common certified cause of all deaths in Victoria, as in other states of Australia and elsewhere in industrialised countries, ranging around 45% of deaths for both men and women. Many who suffer from heart attacks or who have surgical or other procedures which are undertaken to reduce symptoms and prolong life, or who have other problems related to cardiovascular disease, have some difficulties during recovery. It is now clear that such physical, psychological and social difficulties can be greatly reduced through rehabilitation programs. The costs of care after cardiovascular or coronary artery disease events are considerable, both in human and dollar terms. Subsequent episodes of heart attack, heart surgery, heart failure, stroke and other related illnesses may occur months or years later, leading to costly hospital readmissions and significant suffering for patients and families. These may all be reduced, delayed or prevented through the combined approach of medical care and cardiac rehabilitation and secondary prevention programs. The Victorian Department of Human Services accepts the recommendation of the World Health Organisation and other authoritative bodies that cardiac rehabilitation and secondary prevention programs should be available to all patients with cardiovascular disease. These Guidelines demonstrate how this can and should be achieved in the most effective and simple manner and at low cost. The Guidelines present the scientific basis and reasoning behind the recommended widespread adoption and implementation of such programs. On behalf of my department and the Victorian Government, I extend our thanks to the authors and to those who have assisted them in the generation of this very considerable and impressive scientific document.

ROB KNOWLES Minister for Health and Aged Care
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FOREWORD

While the importance of primary prevention of cardiovascular diseases is obvious, the role of cardiac rehabilitation as secondary prevention is critical. The cardiac patient who has survived an acute event or suffers from chronic heart disease needs special attention to restore quality of life to the maximum, to improve functional capacity and to lead a normal life; he or she also requires education to help prevent the recurrence of events. Appropriate cardiac rehabilitation programmes, which include a broad range of secondary prevention measures including education of spouses and families, can help the patient resume a productive life more quickly and function more efficiently. Such programmes can be among the most cost-effective aids that healthcare systems can provide. Gratitude is expressed to the authors who brought their wisdom, working knowledge, and clinical experience to a unique document on best practice guidelines. The recommendations contained in it are applicable to all countries. We trust the readers will find the suggestions contained herein to be useful in developing or complementing their own local cardiac rehabilitation programmes.

INGRID MARTIN, MD Team Coordinator Cardiovascular Diseases World Health Organization Geneva, Switzerland

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INTRODUCTION

Alan Goble and Marian Worcester have written a classic “Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention”. The Guidelines come four years after the US Department of Health and Human Services published the first evidence based guidelines on cardiac rehabilitation entitled “Clinical Practice Guideline”. Why were these Best Practice Guidelines needed and how do they differ from the US Clinical Practice Guideline? Firstly, the world has moved on. There is more evidence in some areas and new evidence in other areas. Secondly, these Guidelines also involve greater emphasis on the effectiveness of education, counselling and behavioural intervention on outcomes, as well as on organisational issues and evaluation. Unlike the Clinical Practice Guidelines from the USA, these Guidelines also involve consensus opinions derived from focus groups with health care providers, a survey of current programs in Victoria, Australia, and a comparative study of four model programs in that State. These have been integrated together with the scientific evidence to produce Best Practice Guidelines which are clear, authoritative and evidence based. They are of value to the practitioners of cardiac rehabilitation, the payers of health services and to those ultimate sceptics, the medical practitioners, who should recommend these programs to all their patients with cardiovascular disease. I commend the authors on the clarity and scholarship of the Guidelines. I recommend the Guidelines to all interested parties.

MICHAEL V JELINEK, MD, FRACP, FACC Associate Professor of Medicine President, Cardiac Society of Australia and New Zealand

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PREFACE

These Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention concern exercise training, education, counselling and behavioural interventions, as well as key organisational issues relevant to the delivery and evaluation of services. The Guidelines provide evidence and consensus based recommendations for best practice programs. The document is not intended to be a practical manual on how to set up and conduct programs. The Guidelines primarily refer to ambulatory programs conducted during early convalescence, immediately after hospital discharge (“Phase 2” cardiac rehabilitation). However, they also refer to inpatient (“Phase 1” cardiac rehabilitation) and later maintenance (“Phase 3”) programs which may best be community-based. All phases of cardiac rehabilitation aim to facilitate recovery (cardiac rehabilitation) and to prevent further cardiac illness (“secondary prevention”). The document will be useful to both purchasers and funders, agency managers, program planners and people wanting guidance on specific elements of cardiac rehabilitation and secondary prevention programs. The first five introductory chapters deal with the historical background to cardiac rehabilitation and secondary prevention, the importance of cardiovascular disease as a health care burden, and the development of these Guidelines and other published guidelines and policy statements. Chapter 6 presents a condensed review of the only existing clinical practice guideline on cardiac rehabilitation. That Guideline, which was commissioned by the US Public Health Department, produced recommendations based upon a systematic, comprehensive review of the scientific literature. Chapters 7 to 11 present a further review of evidence regarding the benefits of exercise training and assess evidence concerning the intensity of exercise, the implications arising from that evidence upon risk stratification and upon the conduct of exercise programs, and the exercise requirements of specific groups. Chapter 12 examines evidence regarding the effectiveness of education, counselling and behavioural interventions upon outcomes, both alone and together with exercise programs, thereby introducing some overlapping of evidence and references with those cited in

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earlier chapters. Chapters 13 to 17 deal with the content and structure of education and counselling groups, programs for specific groups, team roles and organisational issues, while Chapters 18 and 19 deal with program evaluation and issues of cost. Recommendations for future research are listed in Chapter 20. Strength of evidence ratings used in making recommendations were based on those devised by the National Health and Medical Research Council (NH&MRC) of Australia. Whereas recommendations provided in chapters dealing with the benefits of exercise training, education, counselling and behavioural interventions (Chapters 7 to 12) were largely made on the basis of a comprehensive review of the scientific literature, recommendations contained in Chapters 13 to 19 were mostly based upon consensus opinions and accepted practice, supported by available research findings. These chapters deal with structural issues concerning the content, organisation and evaluation of programs. Many of these issues were included in the Guidelines at the request of members of the Consultative Committee and practitioners who participated in the statewide survey and focus groups. Some material appears in more than one section of this document because some may prefer to read only specific sections of these Guidelines.

Citation
Reproduction of material in this document may be made with appropriate acknowledgement of sources. The suggested format is as follows: Goble AJ, Worcester MUC. Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention. Heart Research Centre. Melbourne, on behalf of Department of Human Services Victoria; 1999.

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EXECUTIVE SUMMARY

Cardiovascular disease remains the leading cause of death in Australia. In 1995, it accounted for 46% of all deaths, with 24% being attributed to coronary heart disease. However, while age-adjusted certified deaths from coronary heart disease are falling, increasing numbers of patients are being discharged alive from hospitals after acute cardiac events and interventions. These patients constitute the major pool of those eligible to attend cardiac rehabilitation and secondary prevention programs. Cardiac rehabilitation programs were originally introduced to facilitate recovery from acute cardiac events. In both the USA and Australia, work classification or cardiac rehabilitation units were set up in the 1950’s and 1960’s to encourage return to work among those with physical or psychological disabilities. In Australia, hospital-based programs were established in the mid 1970’s. Since that time, many programs have been established in metropolitan and rural hospitals throughout Australia, and more recently, in community settings. Australia now has a large network of programs, particularly in Victoria. As well as facilitating recovery, cardiac rehabilitation programs function as launching pads for secondary prevention of cardiovascular disease. Education, counselling and behavioural interventions to promote lifestyle change and modify risk factors have become an increasingly important part of cardiac rehabilitation programs. In 1993, the National Heart Foundation of Australia produced a document to establish minimal standards for cardiac rehabilitation to guide health care providers and policy makers. The purpose of these new Best Practice Guidelines is to provide optimal standards for cardiac rehabilitation and secondary prevention programs, particularly those conducted during convalescence. The recommendations contained within these Guidelines apply to cardiac rehabilitation programs not only in Victoria, but also elsewhere in Australia and in other countries. The Guidelines examine evidence for the effectiveness of exercise training, education, counselling and behavioural interventions upon physical, psychological, social, occupational and behavioural outcomes, risk factors, morbidity and mortality. Recommendations for best practice are based upon a comprehensive review of the scientific literature. However, where scientific evidence from clinical trials and

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observational studies is lacking, recommendations are based upon expert opinion and consensus statements derived from surveys and focus groups with practitioners in the field. These Best Practice Guidelines do not duplicate the contents of the Clinical Practice Guideline of the US Agency for Health Care Policy and Research (AHCPR), which was published in 1995. Whereas the major part of that document deals with evidence concerning exercise training, these Best Practice Guidelines focus equally on education, counselling and behavioural interventions, as well as other aspects of cardiac rehabilitation which were not extensively addressed in the AHCPR Clinical Practice Guideline. Reference is also made to the findings of studies published since the production of the AHCPR Clinical Practice Guideline.

Exercise Training
There has been extensive research into the benefits of exercise training in patients with cardiovascular disease, particularly after acute cardiac events. Physical and functional outcome measures have been well defined and it is clear that exercise training produces definite physical, quality of life and secondary prevention benefits. Available evidence confirms that exercise training produces definite improvements in physical performance (exercise tolerance, muscular strength and symptoms), psychological functioning (anxiety, depression, well-being), and social adaptation and functioning. Further, exercise training produces a demonstrable reduction in mortality, morbidity, recurrent events and hospital readmissions. In general, psychosocial outcomes have been less well studied than physical and functional effects of exercise training. Conclusions concerning psychosocial benefits, widely claimed by patients and endorsed by practitioners, have been much less well documented scientifically. It is likely that many of the psychosocial benefits of exercise training are attributable to group activities, peer support and access to professional advice rather than to the exercise itself. It is probable that exercise training has a favourable impact upon other outcomes, including modification of risk factors. These benefits are mostly apparent when exercise is provided as part of a comprehensive program including education, counselling, behavioural interventions and support. Further, evidence indicates that for such beneficial lifestyle changes to be sustained, continued physical activity and support are required. Studies have now confirmed that high intensity and low intensity exercise programs produce similar benefits. Nevertheless, some patients may prefer high intensity exercise. Those returning to heavy manual jobs may benefit from more intensive exercise training. For the majority of patients, however, low intensity exercise is sufficient. Further, low intensity exercise has some important practical advantages. It

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is more suitable for a broader population, including older men and women and patients with functional impairments, and it is more likely to be sustained in the longer term. Because low intensity programs do not require such careful supervision and use less technology and equipment, they can be conducted at low cost. Clinical rather than technological methods can be used for risk stratification, assessment and monitoring, with considerable cost savings. Exercise conducted in groups also significantly reduces costs. Further research is needed to determine best practice with regard to the frequency of exercise sessions and the duration of exercise programs. On the basis of both evidence and expert opinion, it is apparent that twice weekly group exercise programs are as effective as thrice weekly. While twice weekly group exercise is recommended, there is some evidence that once weekly supervised group exercise may achieve similar benefits to twice weekly group exercise, provided it is accompanied by an additional daily home walking program. There is no scientific evidence to indicate the preferred duration of exercise cardiac rehabilitation programs. On the basis of expert opinion, most of the aims of ambulatory cardiac rehabilitation programs conducted during convalescence should be achieved with a twice weekly program lasting four to eight weeks. It should be emphasised that individual patients vary considerably in their need for a group exercise program. Thus, it is essential to provide flexible programs to meet particular needs.

Recommendations
Exercise programs for cardiac patients should: • be based on low to moderate intensity exercise • be suitable for a broad population • be tailored to individual needs while being conducted in groups • be preferably conducted twice per week • be accompanied by a home walking program • be continued for four to eight weeks • have a ratio of no more than 10 patients to one staff member • be designed by a physiotherapist or exercise specialist • be conducted by a physiotherapist, exercise specialist or an additionally trained nurse or occupational therapist

Education, Counselling and Behavioural Interventions
Scientific evidence concerning the benefits of education, counselling and behavioural interventions is less conclusive than that concerning exercise training. Much of the research in these areas has been poorly designed. Further, the evidence base is confounded by markedly differing interventions, duration of programs and outcome

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measures. In some areas, evidence is nonexistent or scanty. For example, the application of behavioural approaches to modify risk factors has not been extensively tested to date in cardiac rehabilitation. Despite these qualifications, there is now some good evidence to support the effectiveness of education, counselling and behavioural interventions in cardiac rehabilitation, whether combined with, or provided independently of, an exercise program. Available evidence confirms that education, counselling and behavioural interventions increase patient knowledge and enhance psychosocial functioning. Further, favourable effects have been demonstrated upon reduction of smoking, lipid levels and stress. However, increases in knowledge do not necessarily lead to improved health behaviours. More emphasis upon teaching patients the necessary skills for making lifestyle changes is required. Further research is needed to develop interventions which produce measurable improvements in health behaviours and modification of risk factors.

Recommendations
Education and counselling for cardiac patients should: • be conducted in groups • be preferably conducted twice per week • be conducted over four to eight weeks • be supplemented by individual counselling as required • follow adult learning principles and encourage interactive discussion • apply behavioural principles, including goal setting and monitoring, to promote lifestyle changes • involve psychologists and other appropriately trained specialists to teach patients skills for making lifestyle changes • provide information relevant to the needs of particular patients or groups of patients • provide scientifically accurate information • be delivered by a multidisciplinary team of appropriately trained facilitators

Psychosocial Interventions
Cardiac patients and spouses commonly experience psychological distress following an acute cardiac event. Unfortunately, there appears to be less emphasis upon psychosocial than physical and functional aspects of cardiac rehabilitation. Participation in group exercise and education programs enhances psychological functioning. Such groups also provide social support. Cardiac rehabilitation programs conducted in groups have significant advantages over individually based programs (such as home programs) in these important respects. Stress management programs, relaxation therapy, psychosocial counselling groups and spouse groups can also facilitate psychosocial recovery. Evidence from well designed studies to support the

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value of such interventions is generally lacking, although a few recent studies have shown favourable effects from stress management and relaxation therapy. Individual counselling of patients and spouses has also been shown to be effective.

Recommendations
Psychosocial rehabilitation should offer: • brief screening to detect patients and spouses requiring special assistance • individual counselling by a social worker, psychologist, or other trained counsellor, if required • participation in a group to provide social support • additional modules, such as stress management or relaxation therapy, if required

Vocational Rehabilitation
There is limited evidence demonstrating that cardiac rehabilitation, as currently practised, has a favourable impact upon occupational outcomes. One possible explanation for this lack may be that resumption of work appears to have been set aside or forgotten as a major aim of cardiac rehabilitation in recent years. Further studies are required to test strategies to increase rates of return to work and to promote better occupational adjustment among those who successfully resume work.

Recommendations
Vocational rehabilitation should include: • supervision by the occupational therapist • discussion at entry assessment of employment plans and development of appropriate vocational goals • identification of any physical and psychological barriers to resumption of work • modules offering tailored vocational programs, including work hardening and simulated work testing • adequate liaison between patient, doctor and employer

Organisational Issues
There is considerable evidence to support the need for improved referral procedures, discharge planning and liaison between health care providers so that greater participation in cardiac rehabilitation programs can be achieved. Attention to such process issues has been inadequate in the past and now requires a greater focus. Assistance with transport and the provision of more locally based programs are also recommended. The practice of automatic referral to programs is strongly recommended. If medical contraindications exist in individual cases, the doctor should indicate in the patient’s hospital record that the patient should not be referred to a program.

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The delivery of a structured cardiac rehabilitation program involves the need for multiple skills. Such expertise is usually beyond the capacity of one or few health professionals and in several areas, specific training is required. Thus, a multidisciplinary team is recommended. A designated co-ordinator is essential. Any team member with adequate organisational and interpersonal skills and sufficient time may fulfil this role. An important function of the program co-ordinator is to ensure adequate communication between different team members, and especially with general practitioners. One health professional may suffice for small programs in poorly resourced rural or local communities, provided there is adequate back-up support. A key principle of contemporary cardiac rehabilitation programs is flexibility. Thus, while nearly all patients should be encouraged to attend exercise and education groups, the duration of their attendance and the nature and amount of rehabilitation required will vary considerably, according to individual need. Some patients will require slow progress and support through a gradual program of increasing activity, while others with little impairment of cardiac function or fitness may progress rapidly. Psychological and social support may also vary markedly in degree. While some patients may have a good understanding of their illness or procedure and have clearly defined goals for achievement in a cardiac rehabilitation program, others may have little idea of the nature of their condition or of what may be achieved or desirable from such a program. It is therefore essential that the individual needs of each patient are understood and discussed between the patient and program staff. Patients should be able to see that their particular needs are being addressed at all times in the program. A rehabilitation plan devised to suit the individual patient needs to be agreed upon at the entry assessment. Specific individual behavioural goals should also be decided so that progress can be monitored. For best practice, a variety of program components or modules should be available to patients. It is now apparent that certain patient groups, such as those who have undergone coronary angioplasty, require different kinds of programs. Some patient groups, such as those of aboriginal background, have rarely attended cardiac rehabilitation programs. Moreover, very little research has been conducted to identify their specific needs. Tailored programs for different patient populations need to be devised and evaluated. The need for flexibility in the provision and delivery of services also arises from recommendations that programs should be offered to a broad range of patients, including those with considerable physical and functional limitations. It is further advocated that family members should also attend cardiac rehabilitation programs which can offer them an opportunity for primary prevention of cardiovascular disease.

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Recommendations
Cardiac rehabilitation and secondary prevention programs should: • develop efficient referral procedures • develop effective strategies to maximise program attendance and completion • offer programs which are accessible • provide flexible, multifactorial programs consisting of several modules • offer programs which suit a broad range of patient groups as well as family members • be delivered by a multidisciplinary team with a designated co-ordinator • ensure adequate communication between hospital staff, program staff and general practitioners

Evaluation
Evaluation is becoming an increasingly important aspect of cardiac rehabilitation and secondary prevention programs. There are some suitable measures available to assess functional, quality of life and behavioural outcomes. However, there is a definite need for further research to test the applicability of some generic tools to cardiac rehabilitation and to devise more sensitive measures. Outcome indicators have been included in the Best Practice Guidelines because it is difficult to monitor a number of outcomes which require longterm follow-up. Further testing of the recommended process and outcome indicators is required to identify suitable benchmarks. More detailed costings of best practice model programs are also required. Qualitative research is required to obtain a better understanding of patient attitudes and responses in areas which are less well understood. It should be emphasised that multifactorial, comprehensive cardiac rehabilitation programs combining exercise training with education, counselling and behavioural interventions produce significantly greater benefits to patients than programs providing either exercise or education alone. Many of the studies reviewed contain education, counselling or behavioural interventions as well as exercise training and demonstrated favourable outcomes. However, it is difficult to determine which ingredients of multifactorial programs produce these benefits.

Recommendations
All programs should: • undergo outcome evaluation to determine their effectiveness upon patient outcomes • undergo process evaluation to identify inadequacies, to assure program quality and to improve program delivery • be evaluated following professional advice regarding appropriate evaluation methods

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Cost, Cost Saving and Cost Effectiveness
There is marked variation in the cost of programs throughout the world. Costs depend largely on the program duration, frequency of attendance and the intensity of rehabilitation exercise. Low cost programs are feasible provided that high intensity exercise is avoided, thereby obviating the need for technology in risk stratification and monitoring. The major cost is then related to the salaries of program staff. With a well attended program, approaching optimal size for exercise and education groups and for both group and individual counselling and support, it appears that the aims of the program may be generally achieved with twice weekly (possibly once weekly) sessions of group work lasting two hours per session over a period of six weeks. This type of twice weekly program can be reasonably conducted at a mean cost of approximately $40 per session per patient and a total cost of $480 per patient completing the program. The cost of a once weekly program would probably approach $300 per patient. There is now evidence that significant cost saving may be achieved through cardiac rehabilitation and secondary prevention programs. These savings are largely from reduced subsequent hospital admissions and reduced costs of medical care. There are additional savings that arise through pension, retirement and sickness benefits, provided that work resumption and remaining in work is achieved. These cost savings may be very large in an ageing population prone to development of preventable heart failure. While cost benefit and effectiveness studies are so far not widely reported, it is apparent that cardiac rehabilitation programs have benefits and effectiveness similar to other successful interventions in the treatment of cardiac and vascular disease.

Recommendations
Cardiac rehabilitation and secondary prevention programs should: • Avoid high intensity exercise to assure low cost • Assure educational and behavioural contents are sufficient for secondary prevention, thereby reducing future medical and hospital costs • Encourage continuation in gainful employment, thereby reducing pension, retirement and social security costs • Be directed to assure the above and, further, to improve other patient outcomes, including longer life expectancy and improved quality of life such that the gains are apparent relative to the cost. Although the primary focus of these Best Practice Guidelines has been upon producing recommendations for outpatient programs conducted during convalescence, much of the literature cited in support of recommendations was based upon longterm maintenance programs. It should be emphasised that behaviour change is a process which requires considerable time. Thus, participation in ongoing community based programs is recommended to encourage maintenance of behaviour change and modification of risk factors.
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CHAPTER 1
DEVELOPMENT OF THE BEST PRACTICE GUIDELINES
Introduction
Best practice concerns outcomes, processes and structures. The achievement of better health outcomes requires effective and efficient processes for delivering health care services, as well as appropriate organisational structures. Whereas minimal standards provide recommendations for the basic requirements of a service, best practice guidelines provide recommendations for optimal standards. They aim to achieve better health outcomes by contributing to the education of health professionals and improving their practices. Best practice guidelines also identify benchmarks for providing optimal health services, thus contributing to quality assurance. Implicit in the concept of best practice is the requirement that the recommended practices should be cost effective. Traditionally, guidelines have been based upon a consensus of expert opinion. However, expert opinion does not always reflect the current state of medical knowledge. According to the Australian National Health and Medical Research Council (NH&MRC), guideline recommendations should be evidence based, that is, they should be derived from a systematic identification and synthesis of the best available scientific evidence. While these Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention are largely based upon scientific evidence, they also reflect expert opinion and consumer input, especially in areas where little or no scientific evidence exists. The Best Practice Guidelines have been produced for ambulatory cardiac rehabilitation and secondary prevention programs conducted during early convalescence after hospital discharge (hereafter referred to as ambulatory cardiac rehabilitation programs). They apply to any hospital catering for cardiac patients, as well as to community health centres or similar venues where programs may be conducted. These Guidelines provide the basis for recommending low cost, low technology, multifactorial programs of exercise, education and support, conducted by trained health care providers, whether working with or without close medical support, as recommended in the Report of the World Health Organisation (WHO) Expert Committee on Rehabilitation after Cardiovascular Diseases1.
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The reviewed scientific evidence and authoritative opinions contained within these Best Practice Guidelines are consistent with the recommendations of the above WHO Report 1, which support the types of programs most widely available in Australia and in several other countries. While commissioned by the Victorian Department of Human Services, the recommendations of the Best Practice Guidelines should apply throughout Australia. Further, they should generally apply to any country or community throughout the world. The recommendations concerning the benefits of cardiac rehabilitation contained in the Clinical Practice Guideline No 17: Cardiac Rehabilitation, published by the United States Department of Health and Human Services through the Agency for Health Care Policy and Research (AHCPR)2 are endorsed. However, many of the recommendations contained in these Best Practice Guidelines regarding the implementation of programs are very different from current practices in the United States of America. The Best Practice Guidelines present scientific evidence to support simpler, less costly programs involving less supervision, testing and technology than those still advocated and offered in the United States of America. Such low cost programs can be readily implemented anywhere. Widespread availability of such programs is becoming increasingly important. In eastern European countries, there is already an epidemic of cardiovascular disease. It is now appearing in developing and transitional countries. The increasing burden of disability from this non-communicable disease in an ageing population can be ameliorated by providing suitable, low cost rehabilitation programs directed towards secondary prevention. These health issues facing all countries have been highlighted in the 1997 WHO World Health Report3 and the publication entitled Global Burden of Disease, produced in 1996 by WHO, the World Bank and Harvard School of Public Health 4. They are further discussed in Chapter 4.

Terms of reference
The Cancer and Heart Offensive was initiated by the Victorian Government in 1993 to strengthen and co-ordinate efforts to reduce the incidence and impact of cancer and heart disease. An important goal of the Offensive was to identify key issues for action and to enhance current service delivery through the fostering of best practice and improved linkages between services. These Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention were produced as part of the Victorian Cancer and Heart Offensive. The terms of reference for this project were as follows: To develop effective models and best practice guidelines for quality and cost effective cardiac rehabilitation and secondary prevention programs for Australia, particularly Victoria, across a range of sectors, which will be of practical value to service planners and staff working in programs and provide an important basis for informed purchasing of health services.

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Production of the Guidelines involved a review of the scientific literature, previous guidelines, policy statements and other publications. A Consultative Committee of experts in the field was established to assist in the development of the Guidelines. In addition, input from health care providers was obtained from a statewide survey of current services 5 and from focus groups 6. Finally, a pilot study was carried out to compare outcomes of patients attending four different model programs and to explore their attitudes towards cardiac rehabilitation7.

Clinical Practice Guideline of the United States Agency for Health Care Policy and Research
In Chapter 5, recent guidelines and policy statements are summarised. The only comprehensive scientific review to date remains the AHCPR Clinical Practice Guideline 2* . This scientific review merits considerable credit. The Panel which produced the AHCPR Clinical Practice Guideline researched and reviewed the available literature regarding each of the major aspects of cardiac rehabilitation. It mainly concentrated on the benefits of exercise, strongly endorsing those benefits. It further endorsed the benefits of patient education, counselling and behavioural interventions. The Clinical Practice Guideline also addressed some organisational issues. The Panel concluded that the substantial benefits of formal comprehensive ambulatory cardiac rehabilitation programs included: • improvement in exercise tolerance • improvement in symptoms • improvement in blood lipid levels • reduction in cigarette smoking • improvement in psychosocial well being and reduction of stress • reduction in mortality.

Development of the Best Practice Guidelines
In producing these present Best Practice Guidelines, each of the recommendations of the AHCPR Clinical Practice Guideline has been reviewed in the light of the 334 references cited by the Panel. The Best Practice Guidelines do not attempt to repeat a review of the contents of each of those references. However, many references cited in the Best Practice Guidelines are the same as those included in the AHCPR Guideline. The Heart Research Centre decided that it was unnecessary to repeat a scientific literature review as extensive as that undertaken for the AHCPR Clinical Practice Guideline. Further, to do so would be contrary to the recommended procedures for producing guidelines laid down by the NH&MRC, which stated that if the same work had been undertaken by others, it should not be repeated8. Nevertheless, it was necessary to undertake a careful review of the literature in several areas which were
*Single copies of the Clinical Practice Guideline may be purchased from the Government Printing Office, Superintendent of Documents, Washington DC. 20402 USA
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addressed only briefly in, or omitted from, the AHCPR Clinical Practice Guideline. These areas include the following: • the nature and amount of exercise • the nature and amount of prior testing • the nature and amount of monitoring • the content and structure of education and counselling group programs • the impact of education and counselling upon knowledge • programs for special groups • team roles and program co-ordination • organisational issues, such as referral procedures • program evaluation • relative costs and cost benefits related to outcomes The data sources used for the review for these Best Practice Guidelines were Medline, Psychlit, Cinahl, Eric and other publications not indexed in these databases. All the recommendations of the AHCPR Clinical Practice Guideline are referred to in the following chapters. However, these Best Practice Guidelines include recommendations which differ slightly from those of the Clinical Practice Guideline of the AHCPR because additional evidence, much of it unavailable in 1995, has been considered which has changed some strength of evidence ratings.

Comment
The AHCPR Clinical Practice Guideline concentrated upon the benefits of exercise training in patients with cardiovascular disease, largely because it is in this area that there has been much research. Thus, clearly defined physical outcome differences are apparent in clinical trials. The degree of exercise conducted in a class can be finitely measured, because it has been carefully prescribed. The interpretations of outcomes from educational, psychological and behavioural interventions in cardiac rehabilitation are more difficult because their ingredients are hard to define. Further, outcomes in these areas are difficult to quantify. Human variability in many parameters makes the formation of clear conclusions difficult. Hence, clear recommendations concerning best practice in these areas are difficult to make. It is in such areas that evidence for benefit is insecure, as reported in the scientific literature. However, the balance of evidence and expert opinion from many sources is quite definite about the benefits of educational, psychological and behavioural interventions. Further, such interventions are generally within the framework of explanation, reassurance and support which is considered to be the right of all patients, facilitating recovery, promoting understanding of illness, allaying anxiety and minimising possible disability. Information, explanation and support are provided to help patients accommodate to the illness or, more importantly, to lead to changes in behaviours to prevent the occurrence of further events. Thus, although the

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body of evidence concerning the benefits of exercise training by any rating is greater than the amount of evidence for the benefit from education, counselling and behavioural interventions, the strength of opinion regarding the need for supportive interventions is as great as the endorsement of exercise programs. Most past research concerning exercise has been undertaken into relatively high intensity exercise. The intensity of exercise is now being questioned, even in those places where it has been most strongly supported. Such questioning applies to physical activity levels both for the population at large and prescribed exercise training for cardiac patients.

Evidence from meta-analyses
The Panel for the AHCPR Clinical Practice Guideline2 recognised difficulties in using data from meta-analyses to support recommended practice because of the significant variability in methods used in the different randomised controlled clinical trials incorporated into the meta analyses. The Panel also recognised that evidence from more than a decade previously may or may not necessarily apply to current medical practice in the light of changes in technology and interventions. We support these views and consider that some interpretations and conclusions from the meta-analyses are open to question. Nevertheless, we agree that reported meta-analyses should be addressed.

Strength of evidence rating systems
In the review of the scientific literature, the AHCPR Clinical Practice Guideline2 followed a strength of evidence rating system based upon three grades of evidence. However, these 1998 Best Practice Guidelines have applied four levels of evidence, following the recommendations contained in the Guidelines for the Development and Implementation of Clinical Practice Guideline8 of Australia’s NH&MRC. The NH&MRC strength of evidence ratings are based upon a number rating designating the strength of the scientific evidence. These number ratings are somewhat different from the letter grading used by the AHCPR. Both ratings systems reflect the quality of the studies, including methodology and study design, and the consistency of the results reported in the scientific literature. Each strength of evidence rating cannot be regarded as absolute and may change over time. It is necessary to update such recommendations every few years in the light of accumulated evidence. Each rating system is set out below:

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United States Agency for Health Care Policy and Research2
A Scientific evidence provided by well designed, well conducted, controlled trials (randomised and nonrandomised) with statistically significant results that consistently support the guideline recommendations. Scientific evidence provided by observational studies or by controlled trials with less consistent results to support the guideline recommendation. Expert opinion that supports the guideline recommendation because the available scientific evidence did not present consistent results, or controlled trials were lacking.

B

C

National Health and Medical Research Council of Australia8
1 Scientific evidence based upon systematic review of well designed, well conducted, randomised controlled trials. Evidence obtained from at least one properly designed randomised trial Scientific evidence obtained from nonrandomised controlled experiments with statistically significant results supporting the guideline recommendations Scientific evidence from well designed cohort or case control studies from more than one centre or research group. Scientific evidence based upon observational studies with time series with or without the intervention or supported by observational studies which have sufficiently consistent results to support the recommended guideline. In the absence of scientific evidence sufficient to support a recommendation under Category 1, 2 or 3, consensus expert opinion has been used to form the basis of the guideline recommendation.

2 3.1

3.2

3.3

4

The NH&MRC rating presents a significant difficulty where there are several properly designed randomised clinical trials with inconsistent outcomes, but favouring the intervention. Systematic review may lead to acceptance on balance as indicating level of evidence = 1. To submit these trials to meta-analysis, however, would be inappropriate because of the disparate methodologies employed in the studies. Where the majority of trials or larger trials support the effectiveness of the intervention, we have elected to allocate level of evidence = 2, because there is “evidence from at least one properly designed randomised trial”. Where the evidence for benefit is equalled by failure to demonstrate benefit, a strength of evidence rating = 4 has been given. Where the evidence from randomised controlled trials is balanced, but there is

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significant evidence from controlled studies, we have given a strength of evidence rating = 3. Such inconsistency in outcomes from several trials presents no difficulty in the AHCPR rating system where, when positive on balance, the strength of evidence rating = B. In some instances, there is evidence to support strength of evidence ratings from two or three of sub-categories 3.1, 3.2 and 3.3. These three sub-categories were therefore reduced in the Best Practice Guidelines into a single Strength of Evidence Rating 3. These guidelines were developed with a view to presenting sound recommendations for the care of patients with cardiovascular disease, based upon a comprehensive literature review. Recommendations are based, where available, on published scientific literature. In those areas where the scientific literature was inconsistent or incomplete, the recommendations reflect consensus statements assessed by Consultative Committee members and consultants. In some areas it was necessary to step outside the cardiological and rehabilitation literature and to accept expert opinion or evidence from other fields such as education or behavioural psychology.

Consultative Committee
All professions involved in cardiac rehabilitation programs were represented on the multidisciplinary Consultative Committee, including the following: cardiology, rehabilitation medicine, general practice, nursing, physiotherapy, exercise physiology, occupational therapy, social work, dietetics, psychology and pharmacy. Also represented were rural health professionals and agencies such as the National Heart Foundation of Australia, the Victorian Association of Cardiac Rehabilitation and the Australian Cardiac Rehabilitation Association. In addition, consumer representatives (who had themselves had coronary artery bypass surgery or myocardial infarction) from Heartbeat Victoria and Heart Support Australia were invited to join the Committee. Members of this committee are listed in the Acknowledgements. The roles of the Committee were to provide expert advice regarding the content of the Guidelines, to facilitate the conduct of additional surveys and focus groups and to give feedback on the recommendations contained in the Guidelines. Sections of this report were submitted for review by small groups before finalising the guidelines. The complete document was then reviewed by all Consultative Committee members. During the development of the Guidelines, the Committee met on five occasions.

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Survey of current programs in Victoria
During 1996, a survey was undertaken to document currently available cardiac rehabilitation services in hospitals and community health centres throughout Victoria 5. All hospitals with monitoring facilities admitting acute cardiac patients were eligible for inclusion in the survey. Investigation of community health centres was confined to those centres which had already established ambulatory cardiac rehabilitation programs. The survey was conducted by telephone interview. Most respondents were program co-ordinators. In smaller hospitals where there were no formal programs, interviews were carried out with directors of nursing or other personnel. Services for both inpatients and outpatients were investigated and views were sought regarding perceived deficiencies in current services. Material from this survey is incorporated into discussions of current practice in later chapters.

Focus groups with health care providers
In order to identify pertinent issues for service providers, 10 focus groups were held6. Discussions lasting about one hour took place, guided by an experienced facilitator, with each of the following groups: nurses, physiotherapists, occupational therapists, dietitians, social workers, cardiologists, general practitioners, rural health workers, health insurance bodies and health fund users. These focus groups aimed to explore perceptions of cardiac rehabilitation and its aims and to uncover major areas of concern for those delivering cardiac rehabilitation services. Expectations regarding the Best Practice Guidelines were also explored and views elicited about what should be included in the Guidelines. Findings from these focus groups are referred to throughout the Guidelines.

Comparative study of four model programs
A small pilot study was conducted of 168 patients, who were consecutively enrolled into four model cardiac rehabilitation programs in Melbourne7. Three public hospitals and one private hospital were included in the study. The frequency of sessions at these hospitals varied from once per week in one hospital, twice per week in two hospitals and three or more times per week in the fourth hospital. Health attitudes and behaviours were investigated before program entry and after discharge from the programs which lasted between six and eight weeks. Patients’ perceptions of the rehabilitation programs were explored. Data were collected via self-report questionnaires. Reference to the findings of this study is made in several chapters.

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CHAPTER 2
CARDIAC REHABILITATION AND SECONDARY PREVENTION: DEFINITIONS
The traditional ingredients of formal cardiac rehabilitation programs in Australia include exercise, education, and psychological and social support. Inpatient rehabilitation is mostly undertaken on an individual basis, whereas ambulatory rehabilitation programs after discharge from hospital are usually conducted with groups of patients. Such group programs have generally been conducted in a suitable outpatient area of the treating hospital. More recently, some programs have been established in community health centres and other sites. Best practice ambulatory programs are conducted by a multidisciplinary team. However, it is recognised that a cardiac rehabilitation program can be conducted by one appropriately trained health professional, provided there is adequate external medical and other support. Many aspects of cardiac rehabilitation and secondary prevention are addressed through medical practice on a one to one basis between patients and medical practitioners. Cardiac rehabilitation and secondary prevention programs refer to structured programs of exercise, education and support additional to usual medical care. As described in later chapters, the benefits of such programs have been demonstrated through comparing the outcomes of patients enrolled in programs after an acute cardiac event with those exposed to usual medical care alone. Cardiac rehabilitation and secondary prevention programs are thus important adjuncts to the treatment of individual patients by medical practitioners.

Cardiac rehabilitation
Cardiac rehabilitation has been defined as The sum of activities required to ensure cardiac patients the best possible physical, mental and social conditions so that they may, by their own efforts, resume and maintain as normal a place as possible in the community9. Cardiac rehabilitation has also been described as The combined and coordinated use of medical, psychosocial, educational, vocational and physical measures to facilitate return to an active and satisfying lifestyle 10.

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A somewhat different definition of cardiac rehabilitation was produced by the United States Public Health Service in 198811. 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, stabilise 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. It is now recognised that cardiac rehabilitation programs, in certain circumstances, may also be delivered to 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 indeed any other form of cardiac disease. To encompass this broader definition, the Cardiac Rehabilitation Working Group of the European Society of Cardiology (ESC)12 has modified the definition of cardiac rehabilitation to be more inclusive, 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. The words “chronic” and “preserve” were added to the previous definition of the World Health Organisation (WHO) in order to stress the concept of the importance of rehabilitation in the long term care of patients with chronic disease, including those who had not had recent acute events.

Secondary prevention
For many years, cardiac rehabilitation programs have included an educational and supportive element to facilitate lifestyle change, adherence to advice and long term maintenance of change in order to promote secondary prevention of cardiovascular disease. Many studies have now demonstrated that ambulatory cardiac rehabilitation programs can be effective launching pads for secondary prevention. While the definitions of the US Public Health Service11 embraced the concept of secondary prevention, those of WHO9 and ESC 12 failed to do so adequately. The US Public Health Service definition is somewhat restrictive regarding patient entry characteristics, while the other definitions favour enrolment of all patients with cardiovascular disease. A broader definition should embrace those of the WHO and ESC and include the intentions of the US Public Health Service, as follows: Cardiac rehabilitation is the co-ordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients
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with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease. A similar definition containing the same ingredients has been generated by a European WHO working group13.

Phases of cardiac rehabilitation
There are three recognised phases of cardiac rehabilitation.

Inpatient rehabilitation (Phase 1)
Rehabilitation begins in hospital and consists of early mobilisation 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 recognised 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 mobilisation, so that self care is possible by discharge, and brief counselling 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.

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 Australia and elsewhere, 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.
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The duration of ambulatory exercise programs during convalescence also varies. In the United States of America, 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 Australia and Canada, the usual duration of programs is six to eight weeks, although in some places it may be as short as four weeks. A brief intensive program is common in Europe, particularly in Germany, where three or four week residential programs are offered. Sessions may be offered once, twice or occasionally three times per week in Australia. Programs in the United States and Continental Europe usually offer exercise of a moderate or high intensity level, whereas most exercise programs in Australia and New Zealand are of low or moderate intensity. The pattern of exercise programs in the United Kingdom is now changing from a few programs of high or moderate intensity exercise (following the practice in the United States) to widespread programs with lower levels of intensity (as practised in Australia). Most programs in Australia 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.

Maintenance (Phase 3)
A lifetime, maintenance stage follows 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 physician14 or nurse 15. Patients may receive additional medication, further education, social support, exercise classes and behavioural intervention, as required14–17 . 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 class18,19 . 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.

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CHAPTER 3
CARDIAC REHABILITATION AND SECONDARY PREVENTION: HISTORICAL BACKGROUND
The welfare of patients with heart disease, particularly those who became unemployed as a consequence of their illness, has been a concern of medical and other health professionals throughout the twentieth century. However, during the past 50 years, it was gradually recognised that disability could be controlled or avoided, that retirement was often unnecessary and that patients could live for many years after their acute events. A distinct change in attitude developed with the introduction of formal programs of cardiac rehabilitation to facilitate and support recovery of patients and to prevent further episodes.

United States of America
Cardiac rehabilitation as a systematic discipline was initially developed in the early 1940s in the United States of America. 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 recognised that there were many men capable of work who 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 Association20. 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 enjoyed21. The success of this pilot unit led to many such units being established throughout the United States. These produced a gradual change in the attitude toward medically recommended early retirement following heart attack22. Simultaneously, there occurred a slow change in medical opinion regarding mobilisation and resumption of normal activities. Whereas in the 1940s an episode of acute myocardial infarction was likely to result in some weeks of absolute bed rest and possibly three months of hospitalisation 23 or rest at home, it was later recognised that early mobilisation produced beneficial effects24. In the 1960s, progressively early mobilisation occurred amongst patients admitted with myocardial infarction. A more optimistic approach toward the future welfare of

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the patients entered into medical thinking and practice. Return to work became a significant aim of cardiac rehabilitation programs. Psychosocial recovery was recognised to accompany physical recovery25. The accepted physical and psychological benefits of early mobilisation and supervised exercise training led to the introduction of exercise training programs during convalescence 26–31 . Confirmation that early exercise testing and training could start within two to three weeks of a myocardial infarction32–33 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 29–33 . 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 recognised that more formal patient education was desirable. Therefore, group education was later grafted on to many of the group exercise programs.

Australia
In 1961 the National Heart Foundation of Australia established Cardiac Rehabilitation Units in major capital cities. Patients were referred to these centres with occupational, social or psychological problems which were causing unnecessary disability or unemployment. Patients attending the cardiac rehabilitation units received guidance and support, exercise and education, both individually and in groups. The majority returned to jobs (usually new employment) suitable to their physical capacity and their training 34–37. These Cardiac Rehabilitation Centres (or Work Assessment Centres) contributed significantly to a change in the pattern of medical management of patients with cardiovascular disease. Progressively earlier mobilisation occurred with progressively shorter hospital stay. It became recognised that it should be possible to prevent patients from requiring such late rehabilitation services if one could intervene at an early stage. Thus, in the 1970s “preventive” rehabilitation programs for patients following acute myocardial infarction were started in a number of hospitals. Initially patients were referred to these outpatient programs four weeks or more after discharge from hospital. Later, it was accepted that exercise programs could start earlier after discharge from hospital38. Thus, the pattern of outpatient ambulatory cardiac rehabilitation programs in Australia evolved. Increasingly, patients were referred to a rehabilitation program, usually based on group education and relatively light or moderate group exercise with minimal equipment and testing and limited monitoring 39. These programs lasted for six to eight weeks with once or twice weekly attendance. Family members were encouraged to participate.

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This pattern is typical of most current cardiac rehabilitation programs in Australia, although several are now shorter (4–8 weeks). A few programs, particularly in New South Wales and Queensland, use higher levels of exercise and consequently require more technology in assessment and monitoring. Results of recent surveys show a rapid growth in the number of cardiac rehabilitation programs in Australia, and especially in Victoria5,40–41 . A survey conducted in Victoria in 1996 showed that 67 outpatient group exercise and education programs and 23 inpatient group programs were available5. All major hospitals in metropolitan Melbourne and country Victoria now provide ambulatory group programs.

Europe
Support for multiple benefits arising from exercise training of patients after myocardial infarction has also been reported from studies in Europe42–46 . Most of these studies were based on hospital outpatient programs. In Central Europe some residential rehabilitation centres became cardiac rehabilitation hospitals and eventually developed into regional cardiological centres for the inpatient assessment, management, education and training of patients. Patients were referred to these centres directly from the hospital to which they had been admitted for the acute event or were called to the cardiac rehabilitation hospital some weeks after discharge from the acute hospital 47–48.

United Kingdom
Rehabilitation programs in the United Kingdom have developed rapidly in recent years. The structure of the rehabilitation program is described as “fairly consistent and follows the low level program advocated by Goble et al from Melbourne, rather than the high intensity programs seen in North America”49.

Asia
Cardiac rehabilitation programs have recently been established in several Asian countries, supported in some places by the World Heart Federation (formerly International Society and Federation of Cardiology)50. The programs follow WHO recommendations 1 and are based upon programs of low intensity exercise and group education which is the model for the great majority of programs currently available in Australia 41. However, there are a few programs in private hospitals based upon the US model of high intensity exercise training, delivered to those who can afford to pay. The introduction of cardiac rehabilitation programs in Asian countries has been facilitated by the Heart Research Centre, which has developed and conducted training programs in Melbourne and elsewhere in Australia50–51 . Health professionals from Hong Kong, Malaysia, India, Pakistan, Philippines, Indonesia and Thailand have attended these training programs and observed cardiac rehabilitation programs in

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Australia. They have then established similar programs in their own countries. Over the past five years, training programs modified to suit local needs have been conducted in these Asian countries, in conjunction with the Heart Research Centre and sponsored by the World Heart Federation.

Participation in programs
The gradual acceptance of cardiac rehabilitation as an important adjunct to medical care and an important need for patients has received support from the World Health Organisation, health departments and professional societies throughout the world. However, participation in cardiac rehabilitation programs has been relatively low in all countries 52–56 . The challenge now is to increase participation rates, as discussed in Chapter 17.

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CHAPTER 4
THE BURDEN OF CARDIOVASCULAR DISEASE
According to the 1997 World Health Report, circulatory diseases such as heart attacks and stroke kill more people than any other disease, accounting for at least 15 million deaths, or 30% of the annual total, every year3. In developing countries these diseases also account for about 25% of all deaths. In 1996, coronary heart disease accounted for more than 7 million deaths worldwide and was responsible for about one-third of all deaths in industrialised countries. In 1994 cardiovascular disease (CVD) was certified to be the primary cause of death in 43.33% of all deaths in Australia and 41.97% in Victoria (39.2% in males, 44.9% in females)57. The majority of these deaths were from coronary heart disease (CHD), also referred to as ischaemic heart disease (IHD) (Table 1). The proportion of deaths from CHD/IHD in the State of Victoria (23.0%) is similar to that of Australia generally (24.1%). It is also similar to that reported in the ‘The Global Burden of Disease 1996" 4, with CHD/IHD constituting 24.7% of all certified deaths in developed regions in 1990.

Table 1: Deaths from CVD (1994)
Australia n Estimated population Total deaths CVD deaths CHD/IHD Stroke Other 17,844,449 126,683 54,886 30,573 12,838 11,475 43.33 24.13 10.13 9.06 % n 4,477,419 32,353 13,577 7,448 3,127 3,002 41.97 23.02 9.67 9.28 Victoria %

Source: Australian Bureau of Statistics 199657

The majority of patients who die from CHD already have a past diagnosis of CHD and many have had one or more admissions to hospital. The Victorian Inpatient Minimum Database for the 12 month periods to June 1995 and to June 1996 highlights the rapid increase in the number of patients admitted to hospital with CHD and also discharged alive with a primary diagnosis of CHD (Table 2)58. In addition, there has been a rapid increase in the number of major interventions in the treatment of CHD, both coronary artery bypass graft surgery (CABGS) and percutaneous transluminal coronary angioplasty (PTCA) (Table 2).

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Table 2: Hospital separations: number of patients with a diagnosis of CHD (Victoria)
Year to June Myocardial infarction (ICD9 410) Angina pectoris (ICD9 413) Coronary bypass surgery (ICD9 36.10 - 36.19) Coronary angioplasty (ICD9 36.01, 36.02, 36.05) (Coronary stent) (ICD9 36.06)
Source: Victorian Inpatient Minimum Database 58

1995 7,956 5,633 3,972 2,622 (198)

1996 8,456 8,918 4,439 3,463 (817)

The increased number of hospital admissions and separations for angina pectoris may be partly accounted for by increased admissions for coronary angiography to determine suitability for CABGS or PTCA. The number of stents inserted concurrently with PTCA has also rapidly increased, which may explain the increasing number of PTCA procedures performed. This rise in the number of admissions and successful (living) hospital separations is occurring in the face of a falling death rate from CVD, both in Australia generally (Figure 1)59 as well as in Victoria (Figure 2)60, for both men and women. Similar patterns prevail in many industrialised countries. In Eastern Europe there is a rapidly rising prevalence of CVD with a rising death rate in all socioeconomic groups. Death rates from CVD in most Eastern European countries now far exceed those of Western Europe, USA, Australia and New Zealand 61. In Asia there is a rapidly rising prevalence of CVD, particularly among the growing professional, managerial, business and factory supervising groups62–64 .

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Figure 1: Age-adjusted death rates 1950–1994, and falls since 1967

Source: Heart and Stroke Facts, National Heart Foundation of Australia 1996 59

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Figure 2: Trends in cardiovascular death rates in males and females, Victoria

Males

Females

Source: Health Indicators: Victorian Department of Human Services, 1996 60

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In Australia, the falling death rate from CVD, particularly CHD, is leading to overall falling death rates at all ages, and consequently a progressive increase in overall life expectancy. The increase of five years’ life expectancy to 75 years in men and to 81 years in women during the past 20 years is very largely due to reduced premature deaths from CVD 65. While certified death rates from CHD, both total and age adjusted, in men and in women are falling, there is an increasing survival of persons with CHD. Modern medical and surgical treatments for acute myocardial infarction, angina pectoris, stroke and other manifestations of CVD have contributed greatly to this falling annual death rate. In addition, changes in population and patient behaviours have led to a delay in the appearance of CVD and CHD, less severity of CVD and CHD and increasing chance of survival after the disease becomes symptomatic. Thus, we have an increasing survival rate in an increasingly ageing population. It is possible that while death rates are falling, the actual prevalence of the disease is not. The ageing population means that those presenting with CHD are more likely to suffer comorbidity (for example, osteoporosis, arthritis) and to have increased chance of death from other illness (for example, cancer, respiratory disease). The development of effective but costly interventions continues to increase rapidly in Australia (Figure 3), including Victoria59. Thus, there are increasing numbers of patients discharged alive from hospital after acute episodes of CHD and also after acute interventions. These patients constitute the major pool of those eligible to attend ambulatory cardiac rehabilitation programs. Apart from the benefits to individual patients and their families, these programs should also aim to reduce recurrent events, including avoidance of subsequent interventions, and to reduce health costs by delaying or preventing dependency, disability and hospital readmissions. These are the aims of secondary prevention of cardiovascular disease.

Figure 3: Cardiovascular procedures in Australia, 1970–93

Source: Heart and Stroke Facts, National Heart Foundation of Australia 1996 59

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Another group of persons who may benefit from cardiac rehabilitation programs includes those who are at high risk of CVD who commonly have multiple risk factors. This group may need support additional to that obtained from usual medical care. In this regard, cardiac rehabilitation programs may well be a suitable means of encouraging healthier behaviours and compliance. This may apply particularly to those of high risk declared by a positive family history66. Motivation to change lifestyle may be heightened if a family member suffers an acute cardiovascular illness. The potential pool of patients with diagnoses of CHD in Victoria could be up to 20,000 new patients per year and in Australia up to 80,000 new patients per year. The possible numbers of high risk patients could be much greater. The magnitude of the burden of CHD in Australia is one reason for delivering cardiac rehabilitation and secondary prevention to patients in groups. Such group programs can be delivered at low cost, reducing the cost burden of CVD. In Australia in the year 1989–1990, the total direct costs for CVD were calculated by the Australian Institute of Health and Welfare to have been $2.2 billion and indirect costs $1.3 billion65.

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CHAPTER 5
RECENT PRACTICE GUIDELINES AND POLICY STATEMENTS
Several bodies have produced guidelines and policy statements regarding cardiac rehabilitation. Only one of these is a scientific review of the available evidence in the literature. The remainder are guidelines for practitioners, policy statements, position statements or non-systematic reviews.

Scientific review
United States Agency for Health Care Policy and Research
An extensive scientific review of the available literature was undertaken in 1995 by NK Wenger, ES Froelicher, CK Smith et al entitled “Clinical Practice Guideline No 17: Cardiac Rehabilitation”. It was published by the US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (AHCPR) and The National Heart, Lung, and Blood Institute2. “A Quick Reference Guide for Clinicians” entitled “Cardiac Rehabilitation as Secondary Prevention”67 was also produced, which summarised the review of the literature and the conclusions and recommendations arising from the review. However, the US guidelines did not address several important issues relating to program content and other aspects of cardiac rehabilitation. Moreover, publications since 1995 have modified some of their recommendations. A review of the US recommendations is provided in Chapter 6.

Other guidelines and statements
American Association of Cardiovascular and Pulmonary Rehabilitation
The American Association of Cardiovascular and Pulmonary Rehabilitation produced “Guidelines for Cardiac Rehabilitation Programs” (first edition in 199168; second edition in 1995 69). These are well referenced text books for health professionals working in the field.

British Association of Cardiac Rehabilitation
The British Association of Cardiac Rehabilitation published “Guidelines for Cardiac Rehabilitation” in 199570. The British guidelines are somewhat more clinically oriented than the AHCPR Clinical Practice Guidelines.

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American College of Sports Medicine
The American College of Sports Medicine produced “Guidelines for Exercise Testing and Prescription” (5th edition) in 1995 71. This also is not a scientific review guideline: it is a referenced instruction manual for those exercise physiologists and others who co-ordinate or participate in exercise training programs. It follows the preferred high intensity exercise programs in the USA.

British Cardiac Society
A working party of the British Cardiac Society produced a “Working Party report on Cardiac Rehabilitation” in 199272. Another working party in the United Kingdom produced “Cardiac rehabilitation in the United Kingdom: guidelines and audit standards” in 199673.

American Heart Association
The American Heart Association (AHA) produced a Position Statement “Cardiac Rehabilitation Programs: A Statement for Healthcare Professionals from the American Heart Association” in 199474. The AHA also produced a “Consensus Panel Statement: Preventing Heart Attack and Death in Patients with Coronary Disease” in 199575. The statement has been endorsed by the Board of Trustees of the American College of Cardiology.

American College of Physicians
The Health and Public Policy Committee of the American College of Physicians produced a report “Efficacy of Cardiac Rehabilitation Services” in 198876.

Rehabilitation Systems in Europe
An independent review from Europe entitled “Cardiac rehabilitation today: programs, their effects and practical guidelines” was published in 199277. The residential option for rehabilitation, common in Central Europe, is presented in a paper entitled “Cardiac rehabilitation in the Federal Republic of Germany: Klinik Roderbirken” by Jette et al in 1988 47. Such costly residential rehabilitation programs appear to confer questionable benefit to patients 48,78 .

European Society of Cardiology
The Working Group on Cardiac Rehabilitation of the European Society of Cardiology produced “Cardiac Rehabilitation: Definitions and Goals” in 199212.

Comment
While none of the above guidelines and policy statements represents a scientific literature review comparable to that contained in the AHCPR Clinical Practice Guideline 2, their recommendations are generally consistent with the AHCPR

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Guideline. They are also consistent with the following recommendations of the National Heart Foundation of Australia published in 1994 and of the World Health Organisation Expert Committee in 1993.

National Heart Foundation of Australia
In 1994, the National Heart Foundation of Australia published a Policy Statement on Cardiac Rehabilitation, which states: Secondary prevention programs, including outpatient cardiac rehabilitation, should be available to all patients in Australia who have had acute myocardial infarction, coronary artery bypass grafts, coronary angioplasty or other cardiovascular disease. Unless contraindicated, these patients should be routinely referred to hospital or community based outpatient programs79.

World Health Organisation
The World Health Organisation Expert Committee report “Rehabilitation after Cardiovascular Diseases, wit h Special Emphasis on Developing Countries” of 19931 made the following recommendations: 1 Cardiac rehabilitation should be an integral component of the long-term, comprehensive care of cardiac patients. 2 Cardiac rehabilitation programs or services should be available to all patients with cardiovascular disease, both children and adults. 3 Rehabilitation services should be provided by any trained health professional caring for cardiac patients, since no sophisticated equipment or facilities are required. Both patients and their families should participate. 4 Rehabilitation programs should be integrated into the existing health care system; this can be done at modest cost. The major requirement is for health professionals to be trained in prescribing appropriate exercise and providing health education and vocational guidance. 5 Responsibility for the implementation of cardiac rehabilitation should be given to a designated health professional at the local level, trained as a coordinator. This individual should, in turn, be responsible to an appropriate physician or to a department, hospital, or other health care facility, which may operate under the auspices of the government or a nongovernmental organisation or other agency. 6 All plans for the implementation of rehabilitative programs should include provision for evaluating the efficacy of the programs.

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Comment
The conclusion from all of the above guidelines and policy statements is that cardiac rehabilitation services should be available to all patients with cardiac and vascular disease. There is uniformity of opinion to support the view that cardiac rehabilitation should include exercise, education, social support, behavioural change, follow-up of patients and program evaluation. However, there are significant differences between regions regarding specific aspects of the content of these programs; that is “how much of what and for whom?” and in methods of delivering programs.

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CHAPTER 6
REVIEW OF CLINICAL PRACTICE GUIDELINE NO 17 “CARDIAC REHABILITATION” (1995)
US Agency for Health Care Policy and Research
The extensive scientific review undertaken in 1995 to produce the Clinical Practice Guideline on Cardiac Rehabilitation for the US Agency for Health Care Policy and Research (AHCPR) 2 generated a series of recommendations based upon consideration of evidence of over 900 reports, a review of over 400 scientific papers and analysis of 334 of these papers. The Clinical Practice Guideline consists of the following: 1 Overview 2 Effects of cardiac rehabilitation exercise training 3 Effects of cardiac rehabilitation education, counselling and behavioural interventions 4 Organisational issues. The overall conclusion of the scientific review is that Cardiac rehabilitation based upon exercise, education, counselling and behavioural interventions should be incorporated into programs of management for all patients with cardiovascular disease. This is consistent with the recommendations of the WHO Expert Committee of 1993)1. This chapter summarises the strength of evidence ratings and the number of references reviewed for each recommendation of the AHCPR Clinical Practice Guideline. Table 3 presents the strength of evidence ratings derived from the scientific review applicable to a series of outcome measures. The evidence for the benefits of exercise training is sufficient to be absolute for some outcome measures (such as the vast amount of evidence that exercise tolerance is increased by exercise training). The evidence is sufficient to make fairly strong statements in other areas (for example, psychological functioning is likely to be improved by exercise training alone and it is definitely improved by exercise training together with educational support and other measures). Although the evidence is not absolute in some areas, it is reasonable to conclude that some outcomes are neither affected by exercise training nor by comprehensive cardiac rehabilitation (for example, collateral coronary circulation and myocardial function are not improved by exercise training, while

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peripheral muscle efficiency is clearly improved). It is also highly likely that in many areas, a comprehensive cardiac rehabilitation program produces beneficial effects additional to exercise training alone.

Table 3: Strength of evidence ratings for benefit (AHCPR 1995)
Strength of evidence (A, B, C) Exercise alone Comprehensive rehabilitation Maintenance programs

Outcomes—Physical
Functional effect Improved exercise tolerance Increased muscular strength Disease progression Symptoms reduced Morbidity reduced Mortality reduced Atherosclerosis slowed Cardiac status Myocardial perfusion (reduced ischaemia) Collateral circulation (no effect) Myocardial function (no effect) Arrhythmias (no effect) Risk factors Smoking reduced Lipids improved Weight controlled Blood pressure improved Exercise habits improved Safety of exercise training A B B A B -

B A B B

A B B

B B B B B A B B -

B B B B B

B B B B B

Outcomes—Psychosocial
Psychological wellbeing improved Social functioning improved Return to work increased A A C -

Outcomes—Special Cases
Heart failure Improved symptoms & exercise tolerance Transplantation Improved symptoms & exercise tolerance Elderly As for younger patients A B -

B

B

B

Footnote: In Table 3, no evidence or insufficient evidence is indicated by a dash (-). The alphabetical letters (A, B, C) are those used in the AHCPR Clinical Practice Guideline, as set out in Chapter 1. Morbidity includes both recurrent events and hospital readmissions.

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Exercise training
Table 4 sets out the number of studies related to exercise training in cardiac patients from which the strength of evidence is derived. In some areas, the evidence is considerable and consistent. In others, it is slight or equivocal (for example, the effect of exercise training upon arrhythmias).

Table 4: Number of exercise studies reviewed (AHCPR 1995) Scientific basis for recommendations: exercise training
Outcome Exercise tolerance Muscle strength Symptoms Morbidity Mortality Atherosclerosis Myocardial perfusion/ischaemia Collateral circulation Myocardial function Arrhythmias Smoking Lipids Weight Blood pressure Exercise habits Psychological status Social functioning Return to work Heart failure Transplantation Elderly Randomised trials 46 4 12 15 17 5 6 0 9 4 12 18 11 9 10 9 2 10 5 0 0 Non-randomised trials 25 3 7 14 8 1 2 0 5 0 8 6 7 6 2 8 2 9 3 1 1 Observational studies 43 0 7 13 6 3 3 5 8 1 4 13 16 3 3 3 2 9 4 4 6

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Education, counselling and behavioural interventions
Table 5 sets out the number of studies from which the recommendations and strength of evidence ratings were derived for education, counselling and behavioural interventions in cardiac rehabilitation. The evidence is small compared with that concerning exercise, but is sufficient to demonstrate that interventions additional to, or independent of, exercise training contribute to favourable outcomes in several areas, particularly those concerning risk factors and psychological wellbeing. Hence, such interventions should either directly or indirectly affect morbidity and mortality. Rather than attempting to dissect out the benefits of interventions additional to exercise, they are included in Table 3 in the framework of “comprehensive cardiac rehabilitation”. Some incremental benefits to outcomes, apparent from exercise training alone, become more apparent when exercise training is combined with education, counselling and behavioural interventions. Some reports suggest, further, that benefits may arise from education, counselling and behavioural interventions independently of exercise training.

Table 5: Number of studies reviewed reporting education, counselling and behavioural interventions (AHCPR 1995)
Outcome Smoking Lipids Weight Blood pressure Exercise tolerance (without exercise training) Symptoms Return to work Psychological wellbeing Morbidity Mortality Randomised trials 5 12 3 0 1 2 2 7 3 8 Non-randomised trials 1 3 1 2 1 1 0 5 0 0 Observational studies 1 3 1 0 1 1 1 2 0 0

Organisational issues
In the final section, the Clinical Practice Guideline addresses organisational issues, which include intake assessment, risk stratification, alternate approaches such as home-based cardiac rehabilitation, strategies for encouraging adherence to programs, and a brief discussion about the cost and benefit of cardiac rehabilitation. They also make recommendations for additional research.

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CHAPTER 7
EXERCISE TRAINING IN CARDIAC REHABILITATION
This chapter reviews the scientific evidence for benefits from exercise training, both as the sole intervention and as a part of comprehensive cardiac rehabilitation. The term “exercise training” applies to a program of repeated exercise undertaken at a guided or prescribed intensity and frequency over a period of time, usually several weeks. The exercise training is based upon so-called aerobic or dynamic exercise, designed to improve physical performance at both maximal and submaximal levels. Such exercise may be of low, moderate or high intensity, as discussed in Chapter 8. Exercise training may also include resistance training involving the use of muscular effort against resistance, with the aim of increasing muscular strength

Meta-analyses
Reported randomised clinical trials involving exercise training in cardiac patients have been collected and submitted to meta-analyses with death as the major outcome measure 80,81 . These aggregations include trials which have been limited to convalescence (eight to 12 weeks) and continuing programs with follow-up support extending for three, five or even 10 years. In these meta-analyses, positive outcomes have been essentially attributed to exercise rather than to the comprehensive process of cardiac rehabilitation. Several of the trials in the meta-analyses have clearly been multifactorial interventions. These meta-analyses have shown benefit from exercise programs in terms of longterm mortality. The benefit is a mortality reduction of between 20% and 25%. Dissection of the major studies included in the meta-analysis by O’Connor et al81 reveals such disparate research designs that submitting them to meta-analysis is questionable. The meta-analysis has concentrated on longterm mortality reduction. Mortality reduction of statistical significance has been demonstrated in a few of the longer term trials standing alone14,17 . The study from Finland 14, which achieved a statistically significant effect on mortality, was included in the WHO Europe Study17. Aggregation of disparate studies and other problems have led some to regard metaanalysis as potentially misleading82–84 , particularly in the light of insecurity regarding methodology and outcome measures in some non-blinded randomised clinical trials85–87 .

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The trials included in the meta-analyses by O’Connor et al81 fall into four groups:

1 Ambulatory (convalescent) cardiac rehabilitation trials
Most programs were of short duration (12 weeks) or less with insufficient longterm intervention or attention to follow-up to contribute to longterm mortality studies.

2 Longterm exercise studies where exercise training alone is compared with standard medical care
In those studies in which exercise training was apparently the sole intervention, there may have been a statistically significant difference demonstrable by metaanalysis 18,43–45,88–90 . However, these exercise trials are included with, and much influenced by, the definite mortality differences reported in some long-term multifactorial interventions.

3 Longterm multifactorial interventions compared with standard medical care
Reduction in mortality, recurrent events, hospital readmissions and risk factors has been demonstrated in randomised trials from the 1970s and 1980s14,17 . The results of these trials are supported by a well designed, controlled experiment from Sweden 16,91 which produced similar results but which, not being a randomised trial, is not included in the meta-analyses. The Stanford Coronary Risk Intervention Program (SCRIP), also not included in the meta-analyses because of its recent publication date15, was more a clinical trial of continued “shared care” than strictly of cardiac rehabilitation.

4 Comparisons of high and low intensity exercise training
In one randomised controlled trial extending over four years19,92 , outcomes of recurrent myocardial infarction and death were followed in patients randomly allocated to low or high intensity exercise programs. Each group was exposed to health professionals, but without specific additional intervention other than advice to individual patients. Here no difference in events was observed over three years. In the other study included in the meta-analysis, patients were followed for one year after programs of eight weeks of high or low intensity exercise94. Here again, no difference in events was apparent at follow-up. There are two randomised controlled trials comparing other effects of high versus low intensity exercise with up to 12 month follow-up. These showed a minor difference only 94 or no difference in physical performance93. Both failed to show statistically significant differences between groups in psychological, social, occupational or other outcomes 95,96 . Another study 97 showed only trivial physical differences between groups. Psychosocial outcomes are not yet reported from this study.

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Comment
It appears likely that exercise intensity, frequency and duration may not necessarily be the keys to better survival, fewer events, fewer hospital admissions and improved risk factors. Such benefits may well arise from the multifactorial nature of interventions (either intended or accidental) offered in cardiac rehabilitation programs, including exercise. This possibility was raised by Stern in 1981 and 198398,99. A similar conclusion concerning the limitations of meta-analyses was presented in a review by Kellermann 100 .

The benefits of exercise training
There are several clearly defined benefits from exercise training of cardiac patients. Other claimed benefits are less securely based. Some may be due to aspects of cardiac rehabilitation other than the exercise component itself.

Physical performance
Recommendation
Exercise training is recommended to improve physical performance (exercise tolerance, muscular strength and symptoms) Strength of evidence = 1

Exercise tolerance
The physical benefits of exercise training in patients after acute myocardial infarction (AMI) have been extensively studied. Randomised clinical trials have repeatedly shown that functional capacity improves through exercise training, whether directly measured by maximal oxygen uptake or indirectly measured from nomograms based upon maximal treadmill exercise tests or in Watts by cycle ergometry15,17,26,42–46,101–123. Similar benefits from exercise training have been demonstrated in randomised clinical trials involving patients who have had coronary artery bypass graft surgery (CABGS)118,123–129 . Improvement in exercise tolerance continues for up to 8 or 12 weeks and possibly beyond. Most randomised trials of exercise in cardiac patients have been based upon exercise training at a heart rate of between 70 and 85% of the maximal heart rate determined by symptom limited maximal exercise testing. Most trials have been limited to “low risk or moderate risk” patients. The process of “risk stratification” 130 has led to exclusion of so-called “high risk” patients, such as those with heart failure, significant impairment of left ventricular function or arrhythmias. Patients with “residual ischaemia”, being those with angina or abnormal ST segment depression in the electrocardiogram at an exercise test or on 24 hour ECG monitoring, have also been commonly excluded from these trials. Patients in this last group have

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been classified as being at “moderate or high risk”. It now appears from the literature that most of the risk in patients with residual ischaemia is a subsequent need for revascularisation rather than a significantly greater chance of death or reinfarction. Risk stratification methods and significance are discussed in Chapter 9. Widely accepted recommendations regarding exercise training have come from many authoritative sources based upon literature review and consensus 1,2,12,31,68–77,79. It is also well recognised that physical performance spontaneously recovers through resumption of normal activities after a period of physical inactivity following AMI or other illnesses 131. However, trials have demonstrated that exercise training produces a significantly more rapid recovery of physical function.

Muscular strength
There have now been several reports, including randomised trials132–137 and observational studies 138–142 in which patients with impaired left ventricular function or heart failure have been trained in exercise of multiple muscle groups successively, with flexion and extension against resistance. All have demonstrated increased muscular strength. These findings are important because most activities of daily living involve movement against resistance or movement of objects requiring some strength. Although previously thought to have been hazardous, progressive resistive exercise training is now recommended, particularly for those who have become inactive and weakened by muscle wasting.

Symptoms
Some patients may be limited by dyspnoea or by angina. It has been demonstrated that patients with left ventricular failure enrolled in exercise training experienced less dyspnoea at the same level of exercise than did patients receiving usual care 102,106,107,111,112 . In randomised trials in patients with angina, exercise training has also been demonstrated to raise the threshold of activity at which symptoms appear17,88,114,143–145. The improvement is attributed to less cardiac work being required to deliver blood and oxygen to the exercising muscles at any given level of activity. However, no significant reduction of angina was reported in four other randomised clinical trials14,43,108,146 . In one report of a comprehensive cardiac rehabilitation program, including exercise, half of the patients with angina awaiting elective coronary artery bypass graft surgery were removed from the waiting list following abatement of their angina 147.

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Comment
There is no doubt that dynamic (aerobic) exercise training improves functional capacity. Although less studied, it is also definite that strength training, through resistive exercise, increases muscular strength. Both types of exercise training appear to lead to reduction in symptoms of dyspnoea and of angina.

Psychological functioning
Recommendation
Exercise training is recommended to improve psychological functioning (anxiety, depression, well-being) Strength of evidence = 2 There are two randomised clinical trials demonstrating improvement in psychological functioning (anxiety, depression and other measures) from exercise training alone, compared with standard medical care110,148 . The benefit is more apparent with multifactorial rehabilitation92,121,148–150 . One randomised trial failed to demonstrate benefit 146. The evidence for benefit from exercise training in randomised trials is supported by non-randomised studies98,151–156 .

Comment
While spontaneous recovery of psychological functioning occurs over many months following major illness or surgery, it is apparent that enrolment in a group exercise training program accelerates psychological recovery. Reviews and consensus statements support this benefit from exercise training. Benefits in psychological functioning are apparently greater in multifactorial rehabilitation.

Social adaptation and functioning
Recommendation
Exercise training is recommended to improve social adaptation and functioning Strength of evidence = 2 The effects of exercise training on social functioning are less well defined than those assessing other aspects of recovery. Outcome studies include social adjustment, marital adjustment, sexual recovery and occupational adjustment. Positive outcomes have been reported from two randomised clinical trials149,157 . Three observational studies produced statistically significant improvement in social functioning98,128,158 , while one controlled study showed no significant difference between groups159.

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Comment
While the attribution of better social recovery to the exercise training is generally accepted, uncertainty remains as to whether it is the exercise itself or interaction with health professionals and other patients which produces the benefit. Benefits in social functioning are more apparent with multifactorial rehabilitation.

Return to work
Recommendation
Return to work should be a specific goal of cardiac rehabilitation programs. Comprehensive rehabilitation, including education, counselling and vocational rehabilitation, is recommended. Exercise training as the sole intervention has not been shown to increase the rate of return to work. Strength of evidence = 3 There is no convincing evidence from controlled trials that exercise training alone favourably affects the rate of return to work. There is evidence that comprehensive cardiac rehabilitation is effective but that benefit appears only to be achieved when return to work is considered an important outcome measure of cardiac rehabilitation. Of three randomised controlled trials of exercise training alone, compared with usual care, none demonstrated an increased rate of return to work43,44,90 . Where education and counselling were included in the rehabilitation program, additional to the exercise, three studies reported positive results 17,155,160 , while eight showed no significant increase in return to work32,45,46,108,146,157,161,162. None of the reported interventions in these studies specifically included vocational rehabilitation. Several controlled nonrandomised and observational studies, where return to work was a major aim of the rehabilitation program, showed significant benefit in return to work (see Chapters 12 and 15).

Comment
While exercise programs may improve levels of fitness for work and enhance self efficacy and psychological functioning, they may not be enough to prove effective in increasing return to work. Education and psychosocial support may have some additional effect, but can be ineffective unless return to work is a formal aim of cardiac rehabilitation. These issues are discussed in Chapters 12 and 15.

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Major risk factors
Recommendation
Exercise training alone may possibly lead to improvement of risk factors (lipid profile, smoking, weight control, blood pressure control). However, the improvement is not apparent in the absence of a comprehensive rehabilitation program. Education, counselling and support are additionally recommended to improve risk factors. The strength of evidence is different for each risk factor. However, as indicated below, it is difficult to attribute reported improvement in risk factors to exercise alone, as many studies were of multifactorial interventions, with exercise as a major component.

Lipids
Strength of evidence = 3
A beneficial effect upon lipid levels has not been clearly demonstrated from exercise training alone in randomised trials. One showed statistically significant total cholesterol lowering in the exercise group88, while three did not 17,43,163 . This may be partly due to the relatively short period of the exercise training. Beneficial differences in lipid profiles have been demonstrated in randomised multifactorial trials of cardiac rehabilitation during convalescence, where exercise is one ingredient of the program and attention is also paid to nutritional and behavioural advice and support14,15,104,105,116,143,144,164–166. However, in others, no statistically significant benefit has been demonstrated using the same outcome measure 109,167 . Favourable increases in HDL cholesterol levels have not been reported in randomised clinical trials of exercise training in cardiac patients. Two observational studies 168,169 showed a rise in HDL cholesterol during exercise training lasting six months and five years respectively. In a randomised trial of exercise training in sedentary men and women aged 50–65 years, HDL cholesterol rose in those enrolled in exercise training of moderate intensity over a two year period170. These time frames make it unlikely that improvement (increase) in HDL cholesterol can be achieved through exercise training in ambulatory rehabilitation programs of up to three months duration.

Smoking habit
Strength of evidence = 3
Three randomised controlled trials have shown no benefit in terms of reduction in the rate of return to smoking through exercise training alone88,90,146 . Those randomised trials in which improved smoking habit has been demonstrated have included patient

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education, support and attention to behavioural change and maintenance of change, in addition to exercise training104,118 . However, four multifactorial trials showed no difference 14,143,164,171 . Non-randomised trials have shown improved smoking habits in the multifactorial intervention group16,152,172–174 and others have produced no significant difference between groups 138,175,176 . Observational studies have shown reduced smoking habits at the end of cardiac rehabilitation programs177–180 .

Body weight
Strength of Evidence = 4
One randomised controlled trial of exercise training alone compared with standard medical care documented lower body weight in the intervention group43. Another failed to demonstrate significant intergroup differences90. In randomised multifactorial cardiac rehabilitation programs, five studies reported statistically significant lower weight in the intervention group14,15,105,144,164 . Four found no difference 44,118,143,171 . Non-randomised controlled studies and observational studies are similarly divided between demonstration of benefit and no benefit2. While it may be reasonable to assume that aerobic exercise training, without increased caloric intake, should result in lower body weight, the above studies failed to show that exercise training alone is effective in reducing body weight. Further, even combined with other measures, body weight may be resistant to change. It is possible that overweight non-smokers may lose weight through exercise training and cardiac rehabilitation, but that those who cease smoking following a cardiac event may increase in weight. Thus, the group mean weight and body mass index may not change. Further, those who adhere to an increased level of activity may increase their caloric intake. Expert opinion that weight loss should be achieved by exercise training is not well supported by scientific evidence.

Blood pressure
Strength of evidence = 4
Two randomised trials of exercise training alone resulted in no significant difference in blood pressure between groups106,143 . Three randomised controlled trials have demonstrated better blood pressure control through comprehensive cardiac rehabilitation including exercise training14,15,43 , while three showed no difference between groups 118,144,165 . Some non-randomised cardiac rehabilitation programs including exercise training have produced evidence of greater reduction of blood pressure than amongst controls16,152,181–183 while one reported no intergroup difference 175. It is not possible to attribute better blood pressure control to exercise training alone in these studies, because blood pressure control may well be affected by greater

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prescribing of medication for those noted to have raised blood pressure in rehabilitation classes. Further, the level of adherence to medication may be affected by other factors. Nevertheless, based upon expert opinion, comprehensive cardiac rehabilitation is recommended as a means of favourably influencing blood pressure.

Comment
The effects of exercise training alone on major risk factors (lipid profile, smoking habit, weight control, blood pressure) appear to be statistically slight, insignificant or absent. Those studies producing favourable results have usually been multifactorial management programs, extending over months or years and including specific attention to risk factors. They have usually consisted of combined medical and other health professional care in special management clinics. This degree of intervention is beyond the scope of usual ambulatory cardiac rehabilitation programs conducted during convalescence. However, modification of risk factors is of critical importance in reduction of recurrent events, morbidity and mortality. A convalescent ambulatory cardiac rehabilitation program, including group exercise, education and support, may be regarded as a “launching pad” for secondary prevention. To achieve this aim, however, closer linkage with medical care is required.

Subsequent exercise habits
Recommendation
Exercise training is recommended to improve subsequent exercise habits. However, programs should be followed by longterm availability of support and facilities for maintenance of activity. Strength of evidence = 3 The positive effect of exercise training on exercise habits has usually been limited to the period during which patients are enrolled in the exercise training program. Return to prior levels of activity or inactivity commonly occurs after discharge from the program. In randomised controlled trials of exercise training, significant improvement in subsequent exercise habits has been reported in six trials 88,105,144–146,184 but no difference in four trials 28,44,160,185 . Some observational studies have demonstrated better exercise habits following a period of exercise training174,186,187 . Maintenance (phase 3) programs with continued availability of group exercise classes, support groups and clinical review providing advice and encouragement are likely to be required for maintenance of activity levels.

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Comment
The majority of studies concerning exercise habits involved men under 65 years of age following myocardial infarction. It is important to recognise that exercise in most of these studies was high intensity aerobic exercise training which is not embraced by the great majority of people over the age of 50 years 188–191 . Hence, abandonment of high intensity exercise is almost inevitable. It may well be that, with lower levels of exercise, an established pattern of regular walking or other increased levels of activity could be achieved. This possibility requires further study.

Morbidity, recurrent events, hospital readmissions and mortality
Recommendation
Exercise training extending beyond convalescence, with a maintenance or follow-up (phase 3) program is recommended to reduce morbidity, recurrent events, hospital readmissions and mortality. Strength of evidence = 2 The evidence for these claims for secondary prevention comes from a few studies with longterm follow-up support14,17,185 and from meta-analyses 80,81 . As suggested earlier in this chapter, it may be that some benefits arise not from the exercise training itself, but from the comprehensive nature of the interventions. The reduction of mortality is largely demonstrated in randomised trials conducted in Finland, Britain and Continental Europe in the 1970s and 80s. Longterm follow-up programs in these trials was made possible by the nature of the health care systems in the countries in which the studies were undertaken. Similar positive outcomes have been reported in the controlled study from Sweden with reports of five and 10 year follow-up16,91 . Both the Finnish 14,185 and the Swedish 16,91 studies showed improved risk factor profiles in the multifactorial intervention groups, compared with the controls, during the first three and five years respectively. The SCRIP trial from the USA showed benefits through intensive application of nurse-managed shared care15. While not as yet showing a significant mortality difference, significant differences in risk factor profiles have already been demonstrated between the treatment and control groups in this study. Reduced progression of coronary artery disease has also been shown in this study by quantitative angiography.

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Comment
Exercise training alone may account, in part, for better outcomes if it leads to improved habits and risk factors in the longterm. However, it is clear that major benefits are more apparent from long term multifactorial interventions. These outcomes include morbidity, recurrent events, hospital readmissions and mortality.

Conclusions
A comprehensive review of the scientific literature shows that physical outcomes in cardiac patients are definitely improved by exercise training. The evidence for improved psychological and social functioning is favourable, while the evidence for improvement in risk factors, behaviours and resumption of work is equivocal. The addition of education, counselling and behavioural interventions to an exercise training program produces demonstrable benefit in all outcome measures. The greater increment in maximal oxygen uptake, strength and physical functioning is directly attributable to the exercise itself. The other benefits of exercise training may possibly be attributable in part to the exercise. However, they are more likely to be due to the effects of group interaction, the availability of health professional advice and peer support. The difficulty of separating the effects of exercise from the psychosocial benefits of group activity, patient interaction and access to health professionals is a further argument for approaching cardiac rehabilitation as a comprehensive program. The major portion of a benefit may be attributable to any part of the program or to the program in its entirety. The addition of a new or modified component may produce changes in few patients, not reflected in the psychological, social or even physical outcome measures in the group as a whole. Further, any group program may have favourable effects which cannot be demonstrated by intergroup outcome measures. This could be the case, even if all patients consider the new added intervention or support to be beneficial. Many patients are fearful of possible adverse effects of various physical activities or of any form of exercise. Demonstration of the capacity to be active with safety, initially with supervision and subsequently without supervision, facilitates recovery of morale. This in turn may lead to other beneficial effects. Nearly all patients claim that they are greatly assisted, physically and psychologically, by participating in an exercise program. However, this common claim has proved difficult to demonstrate in randomised controlled trials where the primary emphasis has been upon physical measurement. Psychological and social outcomes are more difficult to measure, as discussed in Chapters 13 and 18.

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CHAPTER 8
THE AMOUNT OF EXERCISE TRAINING

In Chapter 7 the demonstrated benefits of exercise training were reviewed. In this chapter major issues are explored relating to: • the intensity of exercise training • the determination of “training heart rate” and “rate of perceived exertion” • the frequency, number and duration of exercise classes • home exercise programs • continuing exercise and levels of physical activity • eligibility for and exclusions from exercise training.

Intensity of exercise training
Recommendation
Low to moderate intensity exercise training is recommended for all cardiac rehabilitation programs. Exercise training at low to moderate intensity has effects similar to those of moderate to high intensity exercise training. Strength of evidence = 2 While most exercise training programs in the USA (and many in Europe) are based upon high intensity exercise, most in Australia (and the United Kingdom) are based upon low intensity exercise. As previously stated, nearly all past studies investigating the effectiveness of exercise have compared high intensity exercise training plus standard medical care with medical care alone. Further, most of these studies did not include high risk groups. However, there are now four randomised clinical trials which have compared the effects of high and low intensity exercise training upon multiple outcomes. Rechnitzer et al 19 compared two groups of low risk men randomly allocated to high intensity exercise (n=390) twice weekly or to low intensity exercise (n=371) once weekly for eight weeks, with continued similar exercise thereafter. There was no difference between groups in deaths or reinfarction during the four years of follow-up.

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Blumenthal et al 93,95 recruited 70 male patients up to six months after acute myocardial infarction. No differences were found in any physical, psychological or social outcomes between the two groups of low risk patients at follow-up three months after enrolment in programs of high or low intensity exercise. Worcester et al 94,96 studied 337 consecutive patients with acute myocardial infarction admitted to a single coronary care unit. Patients were randomly allocated to either a high intensity program (70–85% of maximal heart rate) thrice weekly or to a low intensity exercise program (less than 65% of maximal heart rate or less than 20 beats per minute over resting heart rate) twice weekly. Each group was encouraged to walk each day for at least half an hour. The study included high risk patients. Physical working capacity improved in both groups. After eight weeks the high intensity exercise training group had a greater physical working capacity (10.6METs) compared with the lower intensity exercise group (9.6METs). This 10% difference at the end of the eight week exercise program had disappeared at 12 months when both groups had the same physical working capacity (10.6METs). More importantly, there was no significant difference between groups in several measures of quality of life at entry to the study or at four and 12 months after the myocardial infarction. Oberman et al 97 have reported only trivial differences in maximal oxygen uptake and rest to maximal exercise ejection fraction in patients randomly allocated to high intensity (n=111) or low intensity (n=89) exercise over a period of one year. Possible differences in risk factors and psychosocial adjustments between the two groups have not yet been reported. From these trials, it appears that a higher level of supervised exercise training has a small, positive relationship to maximal physical working capacity at the completion of the exercise program, but no significant difference is achieved in the long term. Thus, while the process of reconditioning appears to be accelerated through high intensity exercise, it is not associated with any recognisable or demonstrable other benefit. It is therefore reasonable to conclude that low to moderate intensity exercise is, with the single exception of physical working capacity, as effective as high intensity exercise, provided that home activity (particularly walking) is encouraged and undertaken. Moderate to high intensity exercise training may be of additional benefit to those whose work is physically demanding. Lower levels of exercise training (heart rate less than 70% of maximal heart rate or an awareness of slight breathlessness) are considered safe and require lesser supervision than higher levels of exercise training (greater than 70% of maximal heart rate). Although ventricular fibrillation is infrequent and death rare in high intensity exercise programs 192,193 , the consensus view remains that high intensity exercise training requires prior risk stratification with a symptom limited exercise test, specific monitoring for high risk patients or exclusion from exercise training of such high risk patients 68,69,71,74,130,194 . Thus, high intensity exercise programs are usually preceded by

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risk stratification by technological methods. A symptom limited exercise test is performed to determine training heart rate. Electrocardiographic monitoring during the period of medically supervised exercise training is also recommended. There is a significant increase in costs because of such testing and monitoring.

Categorisation of exercise intensity
Categorisation of exercise intensity (low, moderate, high) may be by symptoms, perceived exertion by Borg’s scale195 , or by heart rate. Categorisation should not be by correlating levels of various activities with METs (metabolic equivalents), without due allowance for age and CVD status of each patient. 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). 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 immobilisation in hospital. Exercise three times per week for 20–30 minutes, which leads to breathlessness and sweating, is performed by 2% of men and 1% of women aged 60 to 69 years in Australia 188. Activity at this level, performed less frequently, is undertaken by 10% of men and 8% of women of the same age. The proportions are only 3% and 18% for men and 2% and 14% for women aged 50 to 59 years. Walking for exercise is undertaken by 65% of men and 57% of women in these age groups 188. Similar attitudes and sedentariness have been noted in the USA189–191 and elsewhere. As one of the aims of reconditioning through exercise training is to lead to a more active longterm lifestyle, it is preferable that the activity is enjoyable or acceptable. Prescribed high intensity exercise training involving attention to clothing, weather conditions and adherence to a regular thrice weekly time slot is likely to lead to abandonment of the physical training program. In the study by Oberman et al97, the dropout rate from high intensity exercise was twice that from low intensity exercise. This difference, however, was less apparent in the study by Rechnitzer of low risk, somewhat younger men 19,92 .

Low intensity exercise
Low intensity exercise (see Table 6) 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. Examples of low intensity exercise programs are given in Annex 1 and 2 of the Report of the WHO Expert Committee 1.

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Moderate intensity exercise
Moderate intensity exercise (see Table 6) 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
High intensity exercise (see Table 6) is embraced by only a small minority of patients. 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 the USA97,196 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.

Comment
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.

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Measuring exercise intensity
Heart rate
Moderate or high intensity exercise is commonly monitored by heart rate, aiming at a specified training (or target) heart rate. The training heart rate during exercise is usually based upon a prior symptom limited exercise test. Some have suggested that the training heart rate may be calculated from a simple formula.

Recommendation
Training heart rates for moderate to high intensity exercise should be based upon actual measurements of individual patients’ maximal heart rates from a maximal stress test. They should not be based upon calculations of heart rates from formulae devised for healthy adults. Strength of evidence = 3

Determination of training heart rate from exercise stress test
For high intensity exercise it is usual to perform a symptom-limited maximal stress test to determine what is the maximal heart rate that can be achieved by an individual at the time when it is no longer possible to continue the test. The peak heart rate achieved is that patient’s maximal heart rate. From that may be determined the percentage of the maximal heart rate at which patients exercise. With high intensity exercise this is usually between 70%–85% of the achieved maximal heart rate from a maximal stress test. Low intensity exercise is usually in the range of 50%–65% of the achieved maximal heart rate. Moderate exercise lies in the band of about 60%–75% of achieved maximal heart rate. Thus, there is a correlation between low, moderate and high intensities of exercise training and the percent of maximal heart rate. The scale devised by Borg195 also correlates reasonably well (see Table 6 and later section in this chapter entitled “Perceived exertion”). A rating of perceived exertion of 10–12 (“Light”) corresponds with low intensity exercise training. A rating of 12–14 (“Somewhat hard”) corresponds with a moderate exercise training level and a rating of 14–16 (“Hard”) corresponds with high intensity exercise training. These correlations are set out in Table 6. However, the correlations constitute a guide only and represent approximations.

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Table 6: Correlation with exercise training levels (approximate)
Exercise training level Rate of perceived exertion (Borg) Very, very light 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 % of maximal heart rate on test Increment over resting heart rate

Very light LOW MODERATE HIGH Light Somewhat hard Hard (heavy) Very hard Very, very hard

50–65 60–75 70–85

10–25 20–35 30–55

Note: Chronotropic dysfunction (refer below), present in many cardiac patients, may result in a lower maximal heart rate, thereby permitting a higher percentage of maximal heart rate at any given workload. Further, the possible blunting of heart rate response in some patients generates a wide range of increment over resting heart rate. In addition, the different levels of exercise training and of perceived exertion may be accompanied by significant overlapping of percentage of maximal heart rate and increment over resting heart rate.

Determination of training heart rate from formula
There are some who consider that the formula 220 minus years of age is a suitable method of calculating the maximal heart rate for cardiac patients. This could expose individual patients to unnecessary risks. This risk applies whether the training heart rate is based upon a calculated percentage of the maximal heart rate, or upon a calculated percentage of heart rate reserve. Following acute myocardial infarction, coronary artery bypass graft surgery, or other acute cardiac illness, heart rate response to exercise may be affected by chronotropic dysfunction of variable degree197–199 , possibly further modified by medication. Thus, the normal increment in heart rate at increasing levels of exercise may not be followed. Further, the maximal heart rate achieved by a symptom limited maximal exercise test may fall far below that expected from any formula devised for normal subjects.

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Formula-based percentage of maximal heart rate
Example Consider the case of a 52 year old male three weeks after AMI. From the formula (220 - age), the maximal heart rate (HR max) is 220 - 52 = 168 beats per minute. A calculated training heart rate of 70% of HR max (70% of 168) = 118 beats per minute A calculated heart rate of 85% (85% of 168) = 143 beats per minute. In one series of 238 male patients at mean age of 52 years, who underwent symptom limited maximal treadmill testing three weeks after acute myocardial infarction94, the achieved HR max was 147 (± 20 SD) beats per minute. Only 12% of these patients were taking a beta blocker and 15% were taking a calcium blocker. In this group of patients the calculated 70% of HR max (118 beats per minute by formula) would actually be 80% of the achieved HR max on treadmill test. The calculated 85% of HR max (143 bpm by formula) would actually be 97% of achieved HR max from a maximal stress test. Fortunately, most patients cannot achieve such a level of activity, being limited by breathlessness, fatigue or profound distress. This level of activity, if attempted, could prove fatal. Further, it must be noted that individual variation is great (for example, SD ± 20 beats per minute).

Formula based percentage of heart rate reserve
The other manner in which the formula has been used is to determine the training heart rate based upon a percentage of “heart rate reserve” as suggested by Karvonen 200, say 65% of the difference between resting heart rate (measured) and the HR max (calculated from the formula). Example Consider the case of a 52 years old man three weeks after AMI. The formula based maximal HR max of 220 - 52 = 168 beats per minute. Assume a resting heart rate of 83 beats per minute (the mean resting heart rate of the above group of 238 patients with mean age of 52 years). The heart rate reserve would therefore be, calculated from the formula, 168 - 83 = 85 beats per minute. 65% of heart rate reserve (65% of 85 beats per minute) = 55 beats per minute. This would give a training heart rate (resting heart rate 84 + 55) = 139 beats per minute 139 beats per minute is estimated to be 95% of the HR max determined by test - a dangerous level of exercise.

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The concept of using a formula to obtain maximal heart rate based upon 220 less the patient’s age in years should not be considered as having a place in exercise programs in cardiac rehabilitation.

Perceived exertion
Studies conducted by Borg195 have resulted in a scale of rates of perceived exertion. The scale ranges from “no exertion at all” or “very, very light” exertion at one end to “very, very hard” or “maximal” exertion at the other end of the scale (see Table 6). These rates of perceived exertion have been correlated with heart rate, presented as the percentage of the maximal heart rate determined by a symptom limited maximal exercise test. Based upon this correlation, it has become common practice for patients to exercise at a given rate of perceived exertion, which correlates with their advised or prescribed training heart rate. This correlation may also be applied to the increment in heart rate over the resting heart rate. Thus, it is possible for patients to monitor their own exercise levels, based either upon heart rate or rate of perceived exertion (see Table 6). One should refer to the note at the foot of Table 6 which highlights and explains the greater range of heart rates amongst cardiac patients than amongst normal subjects.

Frequency of exercise sessions and duration of program
Currently, most authorities and consensus statements in the United States of America still recommend supervised exercise of high or moderate intensity three times weekly (preferably not on consecutive days) for 12 weeks69,71,74 . This is based upon acceptance that improvement in physical working capacity tends to plateau from 10 to 21 weeks in such programs 113,201 . 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 202,203 . 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 for funding of programs throughout the United States. It is recognised 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).

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Frequency of sessions
Recommendation
Supervised twice weekly group exercise programs are recommended during convalescence as they achieve similar benefits to group exercise training conducted three times per week. Supervised once weekly group exercise training may possibly be similarly effective. Supervised exercise should be coupled with a home activity/exercise program. Strength of evidence = 2 Similar increments in physical working capacity have been reported in exercise training programs where patients attend thrice or twice weekly for supervised exercise 2. The study by Worcester et al96, comparing high and low intensity exercise, also included a comparison of thrice weekly (high intensity exercise) versus twice weekly (low intensity exercise). In view of the absence of significant differences between the two groups in all measures other than physical working capacity (attributed to the higher level of training in the high intensity exercise training group), it is reasonable to conclude that twice weekly group supervised exercise is almost as efficient in achieving desired outcomes as is three times per week during convalescence. This appears to have been accepted in some Canadian exercise rehabilitation programs where funding is not the basis for the structure of the program19,121. In the Swedish controlled study, which demonstrated considerable benefits from a comprehensive rehabilitation and follow-up program after acute myocardial infarction, group exercise was also conducted twice weekly16. One randomised clinical trial specifically investigated the relative benefits of frequency of supervised exercise sessions less than thrice weekly204. The increment in maximal physical working capacity, estimated by treadmill testing, was equal in those randomised to two or three training sessions per week. One training session per week resulted in increased treadmill time compared with the control group but less than was found in those who attended two or three sessions per week. In another randomised trial, thrice weekly hospital based exercise training was compared with once weekly hospital based exercise training, coupled with two equivalent home based exercise sessions, and further compared with an unsupervised home activity program 205. Physical performance increased in each of the supervised programs, with little difference between them. All three were superior to the totally unsupervised home program. There was little relationship between levels of depression at entry and on completion of each of the four programs. In the groups
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with home walking (rather than home cycling), anxiety was less. This study suggests once weekly supervised activity, coupled with home walking, may be as effective as more demanding and costly thrice weekly hospital based supervised exercise programs. Thus, while it is probable that one supervised group exercise session per week is beneficial, it has not been adequately demonstrated to be as effective as two supervised exercise sessions per week. However, coupled with home exercise (as it should be), it may prove equally effective. Patients commonly report considerable satisfaction with their exercise programs, irrespective of the number of sessions they attend each week 7.

Duration of program
Recommendation
It is recommended that most patients should attend a twice weekly program for six to eight weeks (a total of 12 to 16 sessions) and a minimum of six to eight group discussions. Strength of evidence = 4 The basis of 12 weeks of exercise training is as set out earlier in this chapter. This duration of supervised exercise training is not universally accepted. In studies in Canada19,121 and Australia 94,96, an initial eight week program was considered sufficient. Six to eight weeks has also been considered adequate in most other Australian programs 5–7,10,39–41 . In these programs, the exercise training component is usually perceived by patients as an important part of their convalescent care. The educational and support aspects of the program are commonly perceived by staff as of equal or greater importance. Hence, the duration of the program may be more likely determined by the educational and behavioural needs of patients. It is considered that a longer program may delay return to work and possible loss of work in consequence. These issues have not been adequately studied. It is not known for how long a regular supervised group exercise program should continue. The consensus in Australia would suggest that eight, six or even four weeks may be enough to facilitate recovery from an acute cardiac event and to initiate behavioural change. The Minimal Standards document of the National Heart Foundation is in line with this consensus79.

Comment
It is important to recognise that there is no mean or average patient. Some patients require little support, education or advice about activity. Some may have only one or few questions about activity, health behaviours or other matters which they seek to gain from a program. Such matters may well be asked and resolved during exercise

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classes. On the other hand, there are some patients whose needs appear to be impossible to meet. They are frequently seeking additional advice, often on matters upon which they have already been advised. In terms of best practice guidelines, one seeks to find a reasonable mean for the duration of programs with the recognition that some patients will require less, others will require more, but the majority will be satisfied and will have achieved the aims of the ambulatory program within a defined period of time. Patients who are unfit, frail, elderly or who have heart failure need continued, longterm support with both dynamic and resistive exercises (including in groups) to encourage and help the maintenance of muscle strength and fitness. For these patients, longterm community-based activity programs are therefore required. Such programs are not perceived as standard ambulatory cardiac rehabilitation during convalescence, but the linkage is apparent between cardiac rehabilitation and supportive care for the aged and infirm.

Home exercise programs
Recommendation
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. Strength of evidence = 2 Trials conducted in the USA have compared home versus hospital ambulatory group exercise 206,207 . 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 co-ordinator 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 behaviour
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change, as well as support. Simple verbal and written instructions to such patients are required, together with discussion about activity and behaviour while in hospital (inpatient rehabilitation) and as part of discharge planning. Follow-up by telephone may be possible 208. 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 (Borg scale 10–12: Table 6)195 . 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 (ref 205), 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.

Continued exercise beyond convalescence
Recommendation
Following ambulatory rehabilitation, a multifactorial program of longterm follow-up should be offered to all patients as a part of their continuing management. All patients should maintain a continuing level of activity, including 30 minutes of walking or its equivalent each day, and should maintain muscular strength to manage all activities of daily living. Strength of evidence = 1 For a low or moderate activity exercise program, half an hour per day of activity at a level of awareness of breathing is sufficient to achieve progressive improvement in physical functioning and is sufficient to achieve psychological benefits similar to those claimed to be achieved by high intensity exercise training three times per week93–97. Randomised and controlled trials have shown that multifactorial cardiac rehabilitation programs (including exercise, education, support, behavioural change and review) induce a wide range of benefits if continued over several months or extending out to a few years14–16,91,209 . These trials indicate the desirability of continued support, as required or on a regular basis, until the changed behaviours have become part of the patient’s lifetime pattern. Such trials have demonstrated major benefits

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through improvement in risk factors, fewer recurrent episodes, fewer readmissions to hospital, fewer myocardial infarctions and fewer deaths. Further, one trial has demonstrated, through multifactorial programs of this type on a continuing basis, slowing or reversal of coronary artery lesions15. While another trial of a comprehensive program successfully demonstrating lesion reversal, the intervention was extremely time consuming and costly and required considerable dedication of both patients and staff144 . It is therefore unlikely that such an intervention would be acceptable to many patients. More trials are required to define the ingredients and duration of effective programs to encourage maintenance of regular physical activity. One longer term study has shown that, in a multifactorial rehabilitation program, increased physical activity up to a total caloric utilisation of 1500 kilocalories (during training and leisure time) results in slowing of lesion progression, while physical activity at a level of 2200 kilocalories per week leads to reversal of lesions 105. This raises the possibility that the more leisure time physical activity undertaken by patients, the better. This suggestion is similar to that which has been recommended by some, based upon epidemiological and observational studies in normal subjects 210,211 but which is not supported by others 212–214 , who appear to have demonstrated that most of the benefits of physical activity are achievable by moderate levels of exercise and fitness. It is possible to achieve a level of 2200 kilocalories per week through moderate intensity exercise such as walking, with awareness of increased breathing, for a period of one hour each day of the week, either singly or in broken periods. Further, it may not be necessary that the physical activity be evenly divided throughout the week. Additional research is required in this area. However, it is important to recognise that the majority of middle aged or older people are not prepared to exercise regularly at a higher level 188–191 . A further issue is whether exercise training will raise HDL cholesterol as an additional protective factor in lipid profiles. There is little evidence for this but one study showed that regular moderate daily activity extending over many months led to a gradual increase in HDL cholesterol 170.

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Eligibility for exercise programs
Recommendation
Group cardiac rehabilitation, including exercise, should be offered to all patients with cardiovascular disease (with the proviso that some may be incapable of participation in group activity and should be offered individual assistance). Cardiovascular disease includes special groups of patients described in Chapter 11. Strength of evidence = 1 Until recently, it was recommended that high risk patients should not be enrolled in exercise training programs (based upon moderate to high intensity exercise). Several trials and observational studies have now shown, however, that low levels of exercise lead to improvement in physical functioning and quality of life. This applies to patients with impaired ventricular function, with controlled cardiac failure and with symptomatic or asymptomatic residual ischaemia1,2,215–217 . According to one report, patients with heart failure awaiting transplantation who followed a program of low intensity exercise were removed from the transplantation waiting list because they achieved improvement in their physical functioning218. It has been demonstrated that improvement in physical functioning usually occurs without any demonstrable improvement in cardiac function; that is, there is no significant change in ejection fraction or wall movement abnormalities. The improvement lies in peripheral muscle efficiency with greater extraction of oxygen, increased peripheral muscle strength and improved muscular efficiency, so that patients may function at the same level of physical activity, but with lesser cardiac work (lower systolic pressure, lower heart rate, lower rate/pressure product)219–225 . Thus, it has now been confirmed that patients who were previously excluded from programs can be enrolled and do improve with graded low intensity exercise, with slow progression. Therefore, there should be few exclusions on physical grounds from cardiac rehabilitation programs. Physical problems are no longer a barrier to participation. However, those who require significant attention may be better supported and encouraged on an individual basis rather than in a group.

Exclusion from exercise training
A sizeable list of exclusions from exercise training in cardiac patients has been prepared by the American College of Sports Medicine 5th Edition (1995)71. Most of these exclusions are reasonable for high intensity exercise and many apply to low intensity exercise.

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One exclusion, apparently fit and healthy patients, is meant to indicate that some require no exercise training. However, such patients could well obtain other benefits from undergoing exercise training, including reassurance, psychological support, reinforcement of the need for behaviour change and adherence to regimens, additional education and better understanding of the illness. Another exclusion from exercise training (unstable angina) is reasonable for high intensity exercise. However, such patients may achieve considerable benefits from light exercise and from education and support. A third exclusion (no recent exercise test) would apply to those patients who are to be enrolled in a high intensity exercise program, and who, on clinical assessment, are at high risk and for whom a training heart rate prescription has not yet been prepared. All of the other exclusions are serious conditions requiring attention before exercise is commenced. These are: • Significant hypertension or hypotension • Severe aortic stenosis • Uncontrolled arrhythmias • Uncontrolled congestive heart failure • Uncontrolled diabetes or metabolic disturbance • High grade atrioventricular block without a pacemaker • Current pericarditis or myocarditis • Recent pulmonary or other embolism • Recent stroke or transient ischaemic attack • Recent major surgery • Terminal illness or severe disabling concurrent illness • Acute febrile or systemic illness • Physical or psychological disability preventing participation An additional reason for exclusion is physician or patient refusal.

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CHAPTER 9
RISK STRATIFICATION

The concept of risk stratification in cardiac rehabilitation is related to the possible hazards of exercise in cardiac rehabilitation programs. Risk stratification as a guide to level of exercise becomes relatively unimportant if the exercise training component of the cardiac rehabilitation program is conducted at low or moderate intensity.

High risk groups
It is recognised that during high intensity exercise there is an increased chance of sudden death through ventricular fibrillation226 and possibly myocardial infarction227. However, available evidence shows that overall, those who are active are less likely to die than those who are physically inactive210–214 . Thus, it is desirable that patients should be active and that they should acquire some fitness228, but without exercising at a level at which ventricular fibrillation could occur226. Risk of ventricular fibrillation is greatest in those who have significantly impaired left ventricular function, namely, those who have had large myocardial infarction, past multiple myocardial infarctions or impairment of ventricular function from other causes. These other causes include valvular heart disease, cardiomyopathy, myocarditis and hypertension.

Recommendation
Clinical risk stratification based upon history, examination and resting electrocardiogram is usually sufficient. Technological investigation of patients should be limited to specific tests to answer specific clinical questions applicable to individuals. Strength of evidence = 3 If a patient is to be enrolled in a high intensity exercise program, then risk stratification is necessary74,130 . High intensity exercise may be regarded as exercise at a level which is greater than 75% of the maximal heart rate (HR max) which the patient can achieve either on a treadmill or a cycle ergometer. HR max is variable between patients. As death is a possible outcome from high intensity exercise, calculation of maximal heart rate from tables related to age and sex is not adequate. Further, it could be misleading and dangerous. Thus, a symptom limited maximal exercise stress test is

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required from which to calculate the target training heart rate. These issues are discussed in Chapter 8. While poor ventricular function is the major marker of risk of death229–232 , there are other markers, including myocardial ischaemia and the occurrence of arrhythmias233. Myocardial ischaemia may be demonstrated by the production of angina during a stress test or may be inferred from the degree of ST segment depression which occurs during a stress test even in the absence of pain (so-called silent ischaemia). The possible production of arrhythmias, particularly ventricular tachycardia (which could be subsequently associated with ventricular fibrillation), may also be provoked by a stress test 234. A 24 hour ambulatory electrocardiogram may also reveal arrhythmias or reveal ST-T wave abnormality, indicating a tendency to arrhythmia or ischaemia235,236 . It appears, however, that induction of arrhythmia during a stress test, when it occurs as a single phenomenon, does not herald the likelihood of fatal ventricular fibrillation 237. It further appears that angina or ST-T wave abnormality during a stress test does not herald risk of death230,238,239 . It heralds angina during exertion of normal daily activity or of exceptional activity and, in consequence, foreshadows likely coronary angiography and coronary revascularisation240.

Technological assessment of risk
The major value of a treadmill test in assessing risk is to determine the level of physical activity which the patient can accomplish before cessation of the test. The greatest risk is to those who are considered clinically unfit to undergo the test241. The next level of risk is those who perform poorly on the test. Those who perform well on the test can be considered as having tolerable or good left ventricular function and therefore are of relatively low risk during high intensity exercise. Technological risk assessment was developed in the 1980s as investigative technology progressively improved. Some still recommend that patients entering an exercise rehabilitation program should undergo investigations including a symptom limited maximal exercise test and an assessment of the left ventricular ejection fraction, both for risk assessment within the program and for overall prognostication242. The ejection fraction could be determined from radionuclide left ventriculography, from two dimensional echocardiography or from angiographic left ventriculography, depending on circumstances . However, ejection fraction and exercise capacity need not correlate well in individual patients. Ambulatory Holter monitoring has recently been considered of doubtful additional prognostic value243–246 .

Clinical assessment of risk
Prior to the development of the technologies, clinical correlates of risk were well recognised, including clinical evidence of past heart failure complicating myocardial infarction or occurring at other times, shortness of breath and fatigue on exertion, the

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reporting of chest tightness or angina and the recognition of clinical arrhythmias. The site and size of infarction were indicated by both clinical measures and standard electrocardiography 238,247,248 . Abnormalities in the resting electrocardiogram are regarded as a marker of significant myocardial damage. The age of the patient was incorporated into the assessment. Weighted indices were developed which accurately reflected prognosis based upon clinical observation249–253 . In the 1990s it is accepted that clinical recognition of heart failure is a powerful marker of prognosis, more powerful than the ejection fraction231,232 . Recent studies have also demonstrated that while the resting electrocardiogram is a good indicator of mortality, stress test ischaemia is not a good indicator of mortality238–240 . It is an indicator of the possible need for revascularisation.

Conclusions
It is possible for risk stratification to be undertaken by clinical means and this has now been recommended by some bodies 1,238. It is of some importance to the physician and cardiologist to make an assessment of prognosis. Such assessment can be made on clinical grounds, although technological testing may well be required in specific instances to answer specific questions regarding a particular patient. If a low or moderate intensity exercise program is undertaken rather than a high intensity exercise program, technological risk stratification is not required. Determining the clinical state of the patient in terms of presence or absence of angina, the presence or absence of shortness of breath, the recent presence or absence of heart failure and other clinical indicators of the size of infarction or impairment of ventricular function is sufficient 1,238,248,250,254 . This pattern of risk stratification removes much of the cost applicable to technological investigation without any apparent increase in hazard for the patients. It does, however, necessitate adequate clinical training and retention of clinical skills, which may be deteriorating, as costly testing supplants clinical judgement 255. A stress test and/or echocardiogram may be undertaken to assess residual ischaemia or ventricular function in individual patients. This is a clinical decision. Such tests are not a necessary part of cardiac rehabilitation. However, if these tests have been performed, it is desirable to forward the results to the cardiac rehabilitation program co-ordinator. In patients who have had myocardial infarction or who have been admitted to hospital with unstable angina, it is now common to perform coronary arteriography with a view to possible early revascularisation. Informing the cardiac rehabilitation co-ordinator of the results of angiography is also desirable, together with a statement regarding whether revascularisation for that patient is planned or is under consideration. Observation of the patient in the cardiac rehabilitation program could prove of value to the cardiologist in reaching a decision. The occurrence of chest pain or of breathlessness during exercise and the level of activity to produce the symptom can be of considerable clinical value.

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CHAPTER 10
CONDUCTING EXERCISE PROGRAMS

Many thousands of patients have passed through low to moderate intensity exercise programs in Australia without mishap. The adequacy and safety of such low cost, low equipment programs is accepted in Australia, New Zealand and the United Kingdom1,5,39,40,41,49,79 . These types of program are recommended by the WHO Expert Advisory Committee for both basic and intermediate cardiac rehabilitation facilities1. High intensity exercise training programs are thought best limited to centres where research and development in exercise physiology is being undertaken. Chapter 8 presents evidence which shows a similarity in outcomes from low and high intensity exercise programs. Recommendations in this chapter are based upon observed outcomes from low to moderate intensity exercise programs, giving strength of evidence ratings = 4.

Site of exercise program
Recommendation
Cardiac rehabilitation exercise programs should be established in all sizeable hospitals treating cardiac patients. In addition to these early ambulatory outpatient-based programs, cardiac rehabilitation programs should be established in other appropriate facilities to facilitate patient access. Strength of evidence = 4 To date, most cardiac rehabilitation exercise programs have been developed in the outpatient areas of hospitals. Referral to such programs should be organised 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. 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.

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Another disadvantage is the centralisation 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 centres. This latter case becomes more feasible if the intensity of exercise is at a low to moderate level. The ideal appears to be the establishment and maintenance of programs inn both hospitals and community centres. This approach has authoritative support1 and is rapidly being developed in Australia, particularly in Victoria 5,40,41.

Safety protocols
Recommendation
A written emergency protocol is required for all programs, together with ready access to a telephone to summon assistance. Staff require current training in cardiopulmonary rescusitation . Strength of evidence = 4 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 oral diuretic (frusemide) on site for patients with heart failure. However, the administration of a diuretic should only be after medical advice. Staff require 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 trolley and a defibrillator, which must be regularly maintained and checked. Staff require training in the use of the defibrillator and the contents of the rescusitation trolley. 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.

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Equipment
Recommendation
Low to moderate intensity exercise training can be undertaken using little equipment and at low cost. Strength of evidence = 4 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
Recommendation
Low to moderate intensity exercise training is recommended for most patients, with a short warm up, that is, calisthenics and stretching exercise segments. These are followed by either a walking program and/or a light training circuit with rests between. A cool down and rest segment should complete the sessions. Limited patient monitoring by observation, perceived exertion or heart rate is maintained throughout the exercise. Strength of evidence = 4 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

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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 practised 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
Recommendation
Exercise training sessions should be conducted by suitably trained health professionals. Strength of evidence = 4 While education groups may be conducted by a multidisciplinary team of health professionals, exercise classes are best conducted by physiotherapists, exercise physiologists or appropriately trained nurses, occupational therapists or other health professionals. In Victoria, most exercise programs are conducted by nurses and physiotherapists, with the exercise program usually designed by a physiotherapist 5.

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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” 1. 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 centre or local hospital.

Staff to patient ratio
Recommendation
The recommended staff to patient ratio is one staff member to 10 patients. As it is desirable to have two health professionals in each exercise session, classes should contain no more than 20 patients per class. Strength of evidence = 4 The exercise class is usually conducted by two persons who, together, can supervise the activities of up to 20 patients. In addition, about 10 family members commonly attend to observe the class. While it is desirable to conduct a program for all patients twice weekly (or once weekly), the numbers of patients may be sufficiently large to dictate the need for a second parallel program. This is preferred to having more than 20 patients in a single group and to having a “waiting list” for entry into the program.

Exercise testing before exercise training
Recommendation
An exercise test is not necessary before entry to a low to moderate intensity exercise program. High intensity exercise training necessitates a prior symptomlimited maximal exercise test. Strength of evidence = 4 In Australia, where the preferred model program of low to moderate intensity exercise training is the norm, a prior exercise test is not performed nor is it needed. In the few programs where high intensity exercise is offered, a symptom limited treadmill or cycle ergometer test is required to determine the training heart rate74,130 and for risk stratification (see Chapter 9).

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Exercise stress testing and other investigations which may reflect prognosis can also reflect the safety of high intensity exercise for an individual patient. However, these tests contribute little to risk stratification not already obtained by simple clinical measures. Such testing may be of value in medical decision making, but is not a prerequisite for entry into a cardiac rehabilitation program with low to moderate intensity exercise training.

Patient assessment before entry to the program
Recommendation
Before entering the exercise program, each patient should have an assessment of physical and psychological status and of the patient’s perceived needs for the rehabilitation program. It is desirable for the patient’s spouse to attend the entry assessment. Strength of evidence = 4 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. This enrolment interview can be undertaken by either or both of the health professionals conducting the exercise class. Entry assessment is best supported by a referral note from the patient’s medical practitioner, preferably with relevant clinical information. Alternatively, a hospital record should be sought to provide inhospital 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. Entry assessment is further discussed in Chapter 17.

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Time of starting the exercise program
Recommendation
The optimal time for the patient to begin the ambulatory exercise program is within a week of discharge from hospital. Strength of evidence = 4 Patients may enter at any point in the program. However, it is desirable for patients attending an ambulatory program to start the exercise and education program as soon as possible after leaving hospital. Ideally, this should be within four to seven days unless ongoing physical symptoms preclude early attendance. The reason for early attendance is to reduce the patient’s and family’s insecurity and possible depression following the acute event. It is also to start physical reconditioning as soon as possible. Many patients and spouses remain fearful of activity until its safety is demonstrated by participation in a supervised exercise class.

Monitoring during exercise sessions
Recommendation
With low to moderate intensity exercise training, it is recommended that monitoring is by one or more of the following: • patients’ symptoms • observation of patient’s responses • patient’s rate of perceived exertion • observer measured heart rate • patient measured heart rate Strength of evidence = 4 Patient monitoring in programs of high intensity exercise commonly includes at least occasional or intermittent electrocardiographic strips or telemetry. However, because most cardiac rehabilitation programs in Australia offer low to moderate intensity exercise training, it is unnecessary to undertake electrocardiographic monitoring, whether continuously by telemetry or intermittently by use of ECG rhythm strips. Patients are encouraged to be active in the group to a level where they are just aware of breathing (low intensity exercise) or aware of some breathlessness, without sweating (moderate intensity exercise). Patients are observed during group exercise to assure that they do not exceed these limits. They are also warned to cease activity and to advise staff, should unsteadiness, fatigue, muscle strain, significant breathlessness, chest pain or other symptoms develop.

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Observation of each patient by the staff and the patient’s own perception of the rate of exertion may be coupled with intermittent brief counting of heart rate. In many group programs, this is done by the exercise class leader. In some programs patients are trained to measure the heart rate themselves. There is no evidence as to which is the preferred method of heart rate monitoring. Some patients like to follow their own heart rate. Others prefer to have closer contact with the class leader when the leader palpates the patient’s pulse. In low intensity exercise programs, most patients require only occasional heart rate monitoring. Even with moderate to high intensity exercise training, monitoring may not be required for up to 60% of patients (the so called “low risk” patients), with good performance and no abnormality on a maximal symptom limited exercise test performed prior to enrolment in the exercise group2.

Exercise testing after exercise training
Recommendation
An exercise test (treadmill, cycle ergometer, steps, six or 12 minutes timed walking test) is valuable towards the end of an ambulatory rehabilitation program. The test will demonstrate the level of recovery, fitness and physical capacity to resume work and will usually reassure the patient, family, medical practitioner and, if necessary, employer. Strength of evidence = 4 A symptom limited exercise test after several weeks in an exercise training program or on completion of the program is valuable as a part of comprehensive patient assessment 39. It is best coupled with a detailed medical review. This review of the patient’s recovery and risk factor status should be undertaken by the patient’s physician, cardiologist or other medical officer. Regimens should be clarified and reinforced. Any concerns of the patient should be discussed. An exercise test at this time may reveal impaired physical performance, with shortness of breath and fatigue at a lower than expected exercise workload. It may also possibly indicate residual ischaemia, with development of angina or ST segment change in the ECG. These changes may lead to modification of management. The performance on the treadmill is reassuring for most patients, because performance is commonly greater than expected by the patient and spouse. As the intended test is maximal and symptom limited, the remote chance of cardiac arrest must be recognised; therefore, due safety precautions must be observed33,74 . Many patients may have already demonstrated significant recovery of fitness and their physical status will be quite clear to both physician and patient without an exercise test. Thus, exercise testing at this stage remains optional. It may be limited to a small proportion of patients to clarify a specific clinical question.

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High intensity exercise training
Recommendation
Patients with physically demanding work or leisure time activity may achieve added benefit from high intensity exercise. Strength of evidence = 4 Some patients seek rapid recovery of high levels of physical functioning. This usually involves a prior symptom limited maximal stress test before entry to the program to determine a training heart rate of 70–85% of HR max, close monitoring of heart rate, consideration of clothing, temperature and of safety protocols and equipment (see other sections of this chapter and also Chapter 8). Further study is required to determine whether selected patients could attend a separate session of high intensity exercise training within a program based on low to moderate exercise or whether a centralised high intensity exercise program should be available to which selected patients may be referred.

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CHAPTER 11
EXERCISE PROGRAMS FOR SPECIFIC GROUPS
Patients with heart failure and transplantation
Recommendation
All patients with heart failure should be enrolled in an exercise program as a part of comprehensive rehabilitation, including before and after transplantation. Strength of evidence = 1 Traditional past management of patients with heart failure included a period of bed rest, which was sometimes prolonged. This led to rapid deconditioning, with muscular wasting, dependency and institutionalisation and probably contributed to early death. It is now recognised that definite benefits can be achieved through early mobilisation and early exercise, both passive and active, which is gradually progressive. Dynamic exercise such as walking and using the arms is recommended to maintain activities of daily living, as well as resistive training to increase muscular strength. Such an exercise program should be gradually introduced and may start in hospital or at any point in the patient’s illness. It should lead to significant improvement in physical functioning and increased maximal oxygen uptake 102,106,219–221,225,256,257. These physiological and functional improvements are coupled with increase in muscle bulk and histological and chemical changes, demonstrable in the skeletal muscle222–224,258 . Randomised controlled trials, all showing similar benefit, have been accompanied by multiple observational studies. Preliminary findings of meta-analysis of seven published randomised clinical controlled trials of exercise compared with usual care in patients with congestive heart failure have demonstrated a mean 18% increase in physical working capacity 259 . The available evidence significantly strengthens the view that exercise training of low intensity, tailored to each patient’s capacity, has a clear benefit with a very low risk. As mentioned in Chapter 10, 31 out of 38 patients on a transplantation waiting list in one study were removed from that waiting list following improved functional capacity, through gentle progressive exercise training 218.

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There is no clear demonstrated central effect of exercise on the apparent function of the heart and lungs. The benefits have been demonstrated to be in skeletal muscle function. However, two studies failed to show improvement in a subset of highly disabled patients, with the suggestion that severe cardiac dysfunction may prevent peripheral muscle conditioning260–261 . Patients with heart failure still have a serious and potentially “malignant” disease and view their future with continued concern. One recent study showed that patients with heart failure have significantly greater levels of depression compared with patients who have had an acute myocardial infarction or who have undergone coronary artery bypass surgery 262 . However, even small increases in exercise capacity have been associated with improvements in well-being and satisfaction with daily life263,264 . The same principles which apply to patients with heart failure are used in the preparation of patients for transplantation. There is observational evidence that similar benefits from exercise training are achieved by patients who have undergone cardiac trans-plantation265–270 .

Patients with pacemakers and implantable cardioverter defibrillators
Recommendation
Patients with pacemakers and implantable cardioverter defibrillators (ICDs) should be enrolled in a comprehensive program including low to moderate intensity exercise programs. Strength of evidence = 4 Patients with implanted pacemakers or ICDs are often insecure about the safety of exercise. Depending upon the characteristics of the implanted pacemaker, there may be no increase in heart rate or only a small increase in heart rate with increasing levels of activity. Hence, heart rate may not be a suitable guide for control of exercise levels. In these patients, the rate of perceived exertion (Borg 10 to 12, light exertion; Borg 12 to 14195, somewhat hard exertion) may be followed (see Table 6). As most patients with implanted pacemakers are elderly and as many patients with ICDs have heart failure or impaired left ventricular function, the lower level of perceived exertion and progress in small increments is usually preferred.

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Patients with other forms of heart disease
Recommendation
All patients with heart disease or vascular disease are suitable for enrolment in programs of exercise, education, counselling and behavioural intervention. Strength of evidence = 4 Patient with other forms of disease include those with cardiomyopathy, those who have had past surgery for congenital heart disease, those with non-surgical and postsurgical rheumatic heart disease and patients with cerebral or peripheral vascular disease. While these groups have not been adequately studied, there is little doubt that they can achieve the same skeletal muscle benefits of exercise training as those with manifestations of coronary heart disease1. The educational needs of these groups are discussed in Chapter 15.

Obese patients and diabetic patients
Recommendation
A cardiac rehabilitation program, with exercise, dietary education and behavioural interventions, is effective and essential for all patients with cardiovascular disease who are overweight or obese. These patients may include those with type 2 diabetes. Strength of evidence = 3 Interventions involving exercise alone or education alone have been reported to be relatively ineffective in achieving and maintaining weight reduction in patients with cardiovascular disease who are significantly overweight or obese, including patients with adult onset (Type II) diabetes. Achievement of mean weight loss has been reported in some randomised trials and not in others (see Chapter 7). Such trials present several difficulties. Most have been trials involving moderate or high intensity exercise, which is generally unacceptable to obese patients. Education and counselling alone may result in some subjects losing weight, but not the majority of patients. Some patients who cease smoking increase in weight. This may obscure the successful weight loss of other patients so that no significant reduction is shown in the mean weight of patients in the intervention group. Obese patients need careful counselling, understanding and enhancement of self esteem. Limited goals which may change over time should be set for these patients. The usual short-term ambulatory program for cardiac patients is insufficient in duration and intensity to achieve significant weight loss. Longer term, multifactorial

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interventions with continued participation in a light to moderate exercise program, together with education and support for behaviour change, have been demonstrated to be effective in some studies271,272 . Successful weight loss is critically important for the overweight, diabetic patient at high risk of developing cardiovascular disease. Reduction of weight is further discussed in Chapters 12 and 13.

Unfit patients
Recommendation
Exercise training as part of a comprehensive rehabilitation program is indicated for all patients with cardiovascular disease who have become physically deconditioned or who are otherwise unfit. Strength of evidence = 1 Physical decondition occurs rapidly in many patients where bed rest or limited mobility are enforced through illness. This period of rest may be enforced because of complications following myocardial infarction or coronary bypass surgery, an episode of congestive heart failure or other manifestations of cardiovascular disease. Weakness and unfitness become apparent after a few days of inactivity. They may be recognised by overt muscular weakness, fatigue, unsteadiness or breathlessness with effort. Levels of fitness may be assessed more objectively by exercise stress testing with treadmill, cycle-ergometer, step test, or a six or 12 minute walk test. Performance may be compared to norms from nomograms. It must be recognised, however, that this same measure of unfitness is also a measure of cardiac function which interacts with the muscular deconditioning to determine test performance. Spontaneous recovery of fitness occurs during the ensuing few weeks following myocardial infarction or coronary bypass surgery through resumption of normal activities of daily living. The recovery may be accelerated and facilitated by graded supervised exercises, starting from a low level, during inpatient mobilisation and continued through convalescence. For most patients, irrespective of the patient’s age or gender, a low level activity program with gradually increasing levels is indicated, within the limits of shortness of breath and fatigue. Patients who are habitually inactive and who are unfit in consequence commonly have reduced muscle mass as well. Slow reconditioning with graded activity leads to progressive increase in fitness in these patients who may be regarded as similar to any other cardiac patient. Such unfit and deconditioned patients have been included in randomised controlled trials comparing the effects upon exercise performance of exercise training and standard medical care. They are those patients who have lower levels of exercise

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tolerance reported on entry to the studies. Patients with relatively reduced functional capacity demonstrated by exercise testing at entry improve in a degree similar to those with higher functional capacity at entry42–46,101–129,225,257.

Elderly patients
Recommendation
Exercise, as a part of comprehensive cardiac rehabilitation, is indicated for all elderly persons with any form of cardiovascular disease. Strength of evidence = 2 The benefits of group exercise in elderly patients, both men and women, have been demonstrated in randomised trials and observational studies 273–275 . Older patients have a special need for a cardiac rehabilitation program. They are more likely to have symptoms such as dyspnoea, fatigue or angina. Co-morbidity, especially from arthritis and respiratory disease, is common. Physical strength is less in older patients because of progressive muscle loss with ageing. There is a reduced ability to increase cardiac output, because of a lesser capacity to increase heart rate and stroke volume. There may also be impairment of balance and judgment. Elderly patients are aware of their relative and increasing incapacity to accomplish physical tasks with speed, strength and accuracy. They are also aware of the risks of injury. It has been reported that attempts to induce high levels of exercise (the past traditional 20 to 30 minutes of exercise at greater than 70% of HR max, three times per week) lead to musculoskeletal injury in the majority of older patients 202,203 . To offer such patients a high intensity exercise program is unwise. This pattern of cardiac rehabilitation exercise may be one reason for nonattendance and early dropout from programs among older patients. Common sense is supported by evidence showing that high intensity exercise is practised by less than 10% of healthy persons over 60 years of age. Moreover, less than 3% are prepared to undertake such activity on a regular basis 188–190 . Cardiac rehabilitation programs for elderly patients need be little different from those offered to younger patients. A program based upon group light exercise and home walking is recommended. Individual patients can set their own pace or be encouraged to increase their level of activity gradually within the group. However, the program should include circuit exercises particularly directed towards retention of muscle strength in the arms for the execution of activities of daily living. High impact activities should be avoided. Daily walking from or at home for a minimum of 30 minutes, either in a single segment or intermittent segments, is the ideal basis for general conditioning and mobility. This is consistent with recent authoritative recommendations of the Centre for Disease Control and Prevention and American

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College of Sports Medicine191 for all Americans and is also applicable to all adults in all communities. Past studies have shown that older patients, especially older women276, are significantly less likely to attend cardiac rehabilitation programs than younger patients 277. However, increasing numbers of patients aged over 65 years of age are now being enrolled in programs, including many in their 70’s and some in their 80’s. As well as achieving improvements in functional capacity276, older men and women can also achieve considerable psychosocial and educational benefits from all components of a rehabilitation program. Since many or most older patients are retired, they can usually attend programs over a longer period than younger patients who have work or domestic commitments. However, transport is more likely to be a problem for the elderly and it is therefore desirable to have the cardiac rehabilitation program close to home. Continued access to group exercise programs is desirable for older patients. This could best be achieved through community exercise and support programs. The integration of cardiac rehabilitation programs into community health centres or other local community activities is therefore recommended. Maintenance of capacity for self care, self respect and independence is critically important for the elderly and their families. It is also important to those responsible for health care planning. The ageing of the population presents an expanding reservoir of patients with cardiovascular disease, ultimately with congestive heart failure (whether controlled or uncontrolled). Physical independence and capacity for self care outside hospitals and nursing homes offer great potential to control health care costs.

Female patients
Recommendation
All women with cardiovascular disease should be referred to a comprehensive cardiac rehabilitation program including exercise training. Strength of evidence = 2 Most studies in cardiac rehabilitation have been undertaken in middle-aged men. Outcomes in women have not been extensively investigated. However, clinical data indicate that the problems facing women with cardiovascular disease are considerable. In general, women have been shown to have more adverse outcomes than men following an acute cardiac event, including greater morbidity and mortality during the first year of278,279 . The older age of women at the onset of their first acute cardiac event is coupled with greater degrees of co-morbidity, including osteoporosis and arthritis 280–282 . Nevertheless, improvements in functional capacity and psychological wellbeing amongst women enrolled in cardiac rehabilitation programs

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are equivalent to those demonstrated in men, although they have been less well reported 276,283 . Women who do not attend programs have been found to report fewer lifestyle changes and to be less successful in controlling stress284. Studies investigating the relationship between gender and attendance at cardiac rehabilitation programs generally report that women are less likely to attend54,55,276,285,286 , and are more likely to drop out from programs early287. As previously stated, most women with cardiovascular disease are older than men and hence are usually less mobile. Further, they are more likely to have less access to transport 276,288 and to be widowed. If widowed, they may be more socially isolated and unwilling to seek help with transport. Thus, older women who are socially isolated are more likely to be nonattenders. Gender differences may be less apparent for younger women and women who have adequate social support289. However, other motivational and psychosocial factors may also inhibit women from attending programs. As pointed out in Chapter 3, cardiac rehabilitation programs were originally devised for working men. Studies suggest that cardiac rehabilitation needs and preferences of women differ from those of men280,290 . Currently available programs are unsuitable in many ways for women, especially older women and those from different ethnic backgrounds. Older women dislike higher levels of exercise and hence exercise programs of low to moderate intensity suit them better 290. Further, one study suggests that women want a range of exercise choices at the program and prefer to participate in goal setting for themselves 290. In that study, it was also found that women desired more encouragement from team members, more frequent discussion of their progress, more social interaction and more emotional support from staff 290. Unfortunately, few studies have addressed the rehabilitation needs of women171,290–292 . Major studies are now in progress to study attendance patterns and attitudes of female patients towards rehabilitation52,53 . A careful review of programs, especially of the exercise component, is recommended to determine their suitability for women.

Comment
It must not be overlooked that the secondary (“quality of life”) benefits of exercise in these special groups of patients may be greatly facilitated by the better understanding and support obtained through the comprehensive nature of the rehabilitation program. While there are special problems associated with specific groups of patients with various forms of heart disease, it is apparent that all can obtain benefits from exercise training. For each of the above special groups, low levels of exercise training are preferred for the reasons given. These reasons, however, also apply to the great majority of patients with cardiovascular disease. There remain a few who prefer to exercise at high levels to achieve high levels of fitness for occupational, sporting or other purposes. High intensity exercise is addressed briefly in Chapter 10. Additional information is available elsewhere31,69,71,194 .

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CHAPTER 12
EDUCATION, COUNSELLING AND BEHAVIOURAL INTERVENTIONS
Exercise training has traditionally been the primary focus of cardiac rehabilitation in the USA. However, in Australia, education and counselling have been considered as important as exercise training in facilitating recovery from acute cardiac events and for secondary prevention of cardiovascular disease. Exercise training, education and counselling are now universally recognised as integral components of comprehensive cardiac rehabilitation. More recently, interventions specifically designed to modify behaviours of cardiac patients have been introduced and tested. We embrace the definitions of the Clinical Practice Guideline which states that education is systematic instruction and counselling is the provision of advice, support and consultation. Behavioural interventions consist of systematic instruction in techniques to modify health related behaviours. To facilitate a return to normal living, patients require guidelines about resuming driving, sexual activity, work and other activities. 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 patients’ understanding of the disease, the acute event and the need for risk factor modification. Further, discussion and explanation about the recovery process and anticipation of possible psychological problems facilitate psychosocial adaptation. Education and counselling of inpatients is undertaken on an individual basis and, at some hospitals, in groups as well5,40,41. However, because of shortened hospital stays, inpatient education is now less comprehensive than in the past 293. Education is addressed in greater detail during ambulatory cardiac rehabilitation programs. Most ambulatory group programs in Australia, and all in Victoria, include education groups5,41. Behavioural and psychosocial counselling may be delivered effectively in group settings. However, specific instruction regarding behaviour change should also be offered on an individual basis so that interventions can be tailored to the specific needs of each patient. Similarly, individual psychosocial counselling may be required for some patients.

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While there is a vast amount of literature demonstrating benefit from exercise training in cardiac rehabilitation, evidence from controlled trials to confirm the effectiveness of education, counselling and behavioural interventions is less conclusive. However, some well designed controlled studies, observational studies, expert opinion and patient perceptions confirm the benefits of providing education, counselling and behavioural interventions as essential ingredients of comprehensive cardiac rehabilitation programs. This chapter discusses the available evidence concerning the impact of education, counselling and behavioural interventions upon knowledge, health behaviours and risk factors, psychosocial well-being and return to work. In Chapters 13 and 14, recommendations are made regarding the content and structure of programs, including methods of conducting group sessions. Chapter 15 describes additional interventions for specific groups.

Knowledge
Recommendation
Education and counselling increase knowledge and understanding of heart disease and should be an integral part of comprehensive cardiac rehabilitation programs Strength of evidence = 2 Several studies, in various settings, have investigated whether education and counselling increase knowledge294–303 , including eight randomised controlled studies 294,295,297–302 . Only three of these studies were conducted after hospital discharge 295,297,300 , while others were conducted during hospital admission. Only one of these reported trials involved patient education conducted in groups300. Increases in knowledge have been reported in four randomised controlled trials comparing interventions with usual care294,295,297,300 and in another study in which historical controls were used296. Other studies have compared different types of educational approaches. Some reported benefits favouring one intervention298,300,301,303 , while others found no differences between interventions299,302 . One study comparing the effectiveness of a slide tape unit, programmed instruction and traditional lecture presentation during an outpatient program produced significantly higher knowledge scores from the slide tape approach and the programmed instruction 300. In contrast, a further study found similar levels of knowledge between patients allocated to a group receiving traditional (instructor centred) and collaborative (patient centred) educational approaches299 . The author recommended that in educating cardiac patients, collaborative approaches might nevertheless be preferable to traditional approaches in order to facilitate the

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achievement of other important goals of education, such as reducing anxiety or improving self-efficacy299. The educational level of patients can significantly influence retention of information. Many patients are unable to comprehend or retain information because of limited education 171,304–306 . Age may also influence retention of information. In one study, a greater increase in knowledge was found in younger patients compared with older patients 296. Failure to understand or recall information and advice may also be due to excessive anxiety, particularly during heightened phases of anxiety305,307 . Even where adequate advice has been given, cardiac patients often deny knowledge of important information about their illness 308. The specific needs of patients and their receptivity to information must be considered, since some information may not be thought important by individual patients. Joint setting of priorities for educational content by the patient and educator is recommended to maximise learning305 . The quality of the intervention rather than characteristics of the patients may determine the effectiveness of educational and counselling programs. For example, educational strategies may be unsuccessful because the information given was too much or too general 171. Further, educational counselling may be ineffective because contradictory information and advice are often given by different health professionals 6,309 . Clarification is therefore required to reduce confusion. Moreover, information needs to be repeated and reinforced. Telephone follow-up after discharge from hospital has been shown to increase patient knowledge and decrease anxiety295,297,310 . The teaching ability of the educator and the manner in which information is delivered are critical to patients’ acceptance of the material. In one study, increased knowledge was found in the group receiving education from a primary nurse compared with a group taught by a nurse educator 303. These results were attributed to greater familiarity and trust between patients and primary nurses. Further, more informal teaching was undertaken by primary nurses in response to patient enquiries, suggesting that teaching by the primary nurses may have been more relevant to patients and provided at a time of greater motivation. However, in another study, cardiac surgery patients receiving education from more academically qualified nurses had significantly higher test scores at discharge than did patients taught by nurses with lesser academic qualifications298 . The relevance of knowledge gain as an outcome indicator has been often questioned because increased knowledge has not been shown to significantly influence behaviour change and reduction of risk171,294,311 . Nevertheless, knowledge empowers patients to become involved in their own health care and has been shown to influence coping and social and emotional recovery after a major cardiac event312. Knowledge gain is considered by patients to be a major benefit from attending cardiac rehabilitation programs 6,7,313.

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Comment
Relatively few well designed studies have clearly demonstrated improvements in knowledge from educational interventions offered during cardiac rehabilitation programs, especially group programs conducted during convalescence. However, the evidence from three small randomised controlled trials is consistent with improved knowledge. More rigorously designed studies are required involving larger patient numbers. In particular, studies are needed which compare the effectiveness of different educational and counselling interventions. Such interventions should be tested with a variety of patient groups.

Health behaviours and risk factors
There is evidence to show that comprehensive cardiac rehabilitation programs, including exercise training, can reduce smoking, alter lipid profiles, reduce blood pressure, favourably alter body weight and increase physical activity. Improvements in psychosocial outcomes have also been shown. The following discussion examines the impact of education, counselling and behavioural interventions alone upon risk factor modification and behavioural change.

Smoking
Recommendation
Education and counselling programs for smoking cessation and relapse prevention are enhanced by behavioural strategies. Comprehensive cardiac rehabilitation programs should combine these approaches to reduce smoking rates. Strength of evidence = 2 Several controlled studies have been conducted to determine whether education, counselling and behavioural interventions modify risk factors, including reduced smoking, in cardiac patients 15,104,162,171,310,314–316. A behavioural intervention was highly effective in a randomised controlled study of 173 consecutive patients who were smoking within the six months of myocardial infarction 314. The intervention, which was provided to patients individually, was initiated in hospital and involved strong advice to quit smoking, a workbook, relapse prevention strategies and follow-up phone calls from a nurse, initially weekly for two to three weeks and then monthly for four months. Nicotine gum was provided for those who relapsed. The biochemically confirmed cessation rate in the intervention group at 12 months was 71% compared with 32% in the usual care group. Patients who had resumed smoking within three months were unlikely to have stopped by

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12 months. Intentions to cease smoking were found to be highly predictive of successful quitting. A later and larger randomised controlled trial by the same group evaluated the efficacy of a nurse-managed, home based program of exercise training, smoking cessation strategies and dietary and drug management of hyperlipidaemia104. Strategies to encourage smoking cessation consisted of physician advice, relapse prevention strategies, nicotine gum for those who relapsed and reinforcement of advice by nurses delivered by telephone. This study of 585 myocardial infarction patients found significantly less smoking at 12 months in the intervention group than in the usual care group. However, a further randomised controlled trial of a multifactorial intervention failed to reduce the smoking rate15, but since the number of smokers in that study was very low, it may have been difficult to demonstrate a benefit from the intervention. Strong advice from physicians to stop smoking, especially in hospital, has been shown to be important 317–319 . In one uncontrolled study, such physician recommendations, coupled with follow-up advice from nurses, were associated with a one year selfreported quit rate of 62%317. In another study of patients who had undergone coronary bypass surgery, reduced smoking rates were found at one year in the group randomly allocated to a program of exercise training and education, coupled with physician advice to stop smoking, compared with the control group162. Spousal support has been shown to facilitate smoking cessation in cardiac patients. In a randomised controlled study of inpatient group education followed by weekly telephone calls for six weeks after discharge from hospital, results showed a significantly greater decrease in smoking and unhealthy eating habits, and a significantly greater increase in physical activity, among patients whose partners also participated in the program310 . While there were no overall differences at 12 months between the intervention and control groups, a greater rate of smoking cessation was found in the intervention group among patients whose partners had participated. Two randomised controlled trials of group interventions failed to show benefit171,316 . In one of these studies which compared exercise, exercise plus education and counselling, and usual care, no differences were found between the three groups in smoking cessation at three and six months171. All groups showed high rates of quitting and reduction in the number of cigarettes smoked. Attrition rates in this study were 25% at 3 months and 34% at six months and, and as noted by others, dropouts were more likely than participants to have been smokers320 . In the second study, a six week outpatient program of group education for post myocardial infarction patients found smoking rates were somewhat higher in the intervention group after six months compared with a control group receiving standard individual education316.

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In another randomised study of the effectiveness of a mail-out intervention supplemented by telephone contact, no significant differences were found between the intervention and usual care groups, with both groups reporting a substantial decrease in smoking 315. In general, evidence suggests that interventions to reduce smoking are more likely to be effective if they are initiated in hospital when patients are more highly motivated rather than after discharge from hospital171,314,317 . Further, a meta-analysis of controlled trials of cardiac patient education concluded that while interventions, on average, showed no significant impact on smoking behaviour, behaviourally oriented interventions generally produced better outcomes321 . Behavioural strategies, such as regular reinforcement of advice to stop smoking and continuing support, appear necessary 314. The positive studies described above indicate that follow-up telephone contact by nurses is a convenient, inexpensive and effective method of reinforcing physician advice to stop smoking. Lapses tend to occur when interventions cease. Instructing patients in relapse prevention methods before they lapse is therefore of critical importance 314. Nicotine replacement treatment is important adjunctive therapy for cardiac patients 104,314 . A review of studies of nicotine patches in the general population found that they were effective, especially when coupled with a comprehensive program which included counselling and group support322.

Comment
Unfortunately, there have been few well designed studies testing interventions to reduce smoking in cardiac patients. However, a few studies indicate that traditional methods of educating patients, either individually or in groups, are less successful in encouraging smoking cessation than behaviourally oriented approaches, especially those which provide longterm follow-up to reinforce advice and offer support. Interventions combining multiple components are likely to be more successful but the specific components which produce beneficial effects have not been well defined314. According to the meta-analysis by Mullen, better outcomes are achieved when smoking behaviour is the focus of the intervention, rather than being incidental to an intervention such as exercise321. Further research in this area is clearly required. Given that resumption of smoking after an acute event markedly increases the risk of reinfarction and death, the development of effective interventions to reduce smoking should be accorded a high priority.

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Lipids
Recommendation
Intensive nutritional education, counselling and behavioural interventions lead to lower dietary fat and cholesterol intake and, with or without pharmacological lipid-lowering therapy, result in significant improvement in blood lipid levels and should be provided as part of comprehensive cardiac rehabilitation. Strength of evidence = 2 Several studies have investigated the benefits of education, counselling and behavioural interventions upon lipids, either alone or as part of comprehensive cardiac rehabilitation and with or without pharmacological therapy. Of 13 randomised controlled trials15,104,116,144,162,164,171,315,323–327, five reported statistically significant differences in dietary fat and cholesterol intake favouring intervention groups compared with control groups15,144,323,325,327 . One study reported differences in dietary fat intake 315 and two studies produced negative results 104,171 . Favourable changes in lipid or lipoprotein levels occurred in seven randomised controlled trials15,104,116,144,164,323,325,327, compared with control patients and no significant changes were reported in four studies 162,315,324,326 . In two studies involving group exercise and education during convalescence, no significant differences in the degree of improvement in lipid levels were found between intervention and control groups162,171 . However, a multifactorial intervention in which individual and group counselling were provided for three months followed by a continued intervention lasting three years 325, a significant decrease was reported in the intervention group in dietary fat intake and serum total cholesterol levels at follow-up after one and two years. At the six and 10 year reviews, the intervention group continued to show decreased dietary fat intake but there was no significant difference between groups in total cholesterol levels. A controlled study of extremely intensive dietary restriction, stress management, exercise and social support produced significantly reduced total cholesterol levels and dietary fat intake in the intervention group at one year144. An earlier study by the same group with short-term follow-up also reported favourable outcomes in lipid levels in the intervention group116. Another study of strict diet, stress management, relaxation, exercise and medication reported significant differences in mean dietary fat intake and serum cholesterol levels between the intervention and control groups after one year 323.

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Patients who participated in an educational program by mail and telephone reported a significant decrease in dietary fat intake after six months compared with a control group receiving usual care, but no significant differences were found between groups in cholesterol levels 315 . Beneficial effects upon lipid levels have been reported from interventions combining education and behavioural strategies with the use of lipid lowering drugs. A large study of a home-based multifactorial intervention combining education, counselling and lipid lowering medication achieved a significant mean reduction in total cholesterol and dietary fat intake in the treatment group after four years, compared with the control group 15. Another multifactorial intervention which included lipid lowering medication also reported a significant reduction in serum cholesterol levels in the intervention group compared with the control group104. A recent randomised controlled trial studied the effects of diet alone, a combination of diet and exercise, exercise alone and usual care in men and postmenopausal women with low levels of HDL cholesterol and raised LDL cholesterol327. This study showed that the Step 2 diet of the US National Cholesterol Education Program was ineffective in lowering LDL cholesterol unless it was coupled with exercise training. Similarly, a nonrandomised controlled study reported significant improvements in lipid levels from a combination of education, counselling and exercise compared with exercise alone328.

Comment
Some reports show that education, counselling and behavioural interventions which are intensive and sustained over a long period have independent effects upon lowering lipid levels. While studies from nonrehabilitation settings support the efficacy of dietary intervention alone, it appears that many patients require pharmacological therapy in addition to dietary and exercise management to achieve their goals related to lipid levels. The degree to which studies have shown a lowering of mean total cholesterol and LDL cholesterol without the use of lipid lowering drugs is not great.

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Blood pressure
Recommendation
Education, counselling and behavioural interventions alone have not been shown to control elevated blood pressure levels. However, a comprehensive program of education, counselling, behavioural interventions and exercise training can be effective in the management of hypertension and should be available as an integral part of cardiac rehabilitation programs, in addition to pharmacological therapy. Strength of evidence = 2 The effectiveness of antihypertensive drugs in lowering blood pressure is well established. Further, beneficial effects upon blood pressure in cardiac patients have been reported from two multifactorial interventions including exercise training14,15 . One randomised controlled trial of a multifactorial intervention including lifestyle advice, which was reinforced during the four year follow-up, produced significant benefits in reduction of blood pressure in cardiac patients in the intervention group compared with the control group15. A significant reduction in blood pressure was also reported in a multifactorial intervention involving exercise, education and support14. However, in another randomised controlled trial of exercise training and education, there was no impact upon blood pressure levels162. A further multifactorial intervention of stress management, exercise, intensive dietary restriction and support produced no significant impact on blood pressure levels, with both the intervention and control groups showing a decrease in blood pressure at one year 116. There is little evidence to suggest that education, counselling and behavioural interventions without exercise training are effective in controlling blood pressure in cardiac patients 2. However, their effectiveness in changing behaviours and thus lowering blood pressure in other populations has been reported329. A meta-analysis of studies conducted between 1954 and 1985 showed that a 1kg fall in weight achieved a 1.6 mmHg reduction in mean systolic blood pressure and a fall of 1.3 mmHg in mean diastolic blood pressure330. The reduction was more prominent when the blood pressure was higher. In the MRFIT study, a reduction in blood pressure was also shown with reduction of body weight331. In another study, a reduction in alcohol consumption alone achieved a reduction of 4.8 mmHg and 3.3 mmHg in systolic and diastolic blood pressures respectively, and together with a reduction of weight of 7.5kg, systolic and diastolic blood pressures were reduced by 10.2 mmHg and 7.5 mmHg respectively 332. Similarly, reduced sodium intake has been shown to be effective in reducing blood pressure333.

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According to scientific evidence and expert opinion, relaxation and biofeedback alone have not been demonstrated to be effective in controlling blood pressure and stress management is not recommended as the sole intervention for hypertension control 329.

Comment
Education and behavioural interventions for weight reduction, physical activity and moderation of dietary sodium and alcohol consumption are recommended as definitive or adjunctive therapy for hypertension. They are important components of a multifactorial approach to reduce hypertension in cardiac patients.

Body weight
Recommendation
Dietary education, counselling and behavioural interventions designed to reduce body weight can help patients lose weight and should be provided as part of comprehensive cardiac rehabilitation. Education as a sole intervention is unlikely to achieve and maintain weight loss. Strength of evidence = 2 Several studies have reported a reduction in body weight as a result of comprehensive cardiac rehabilitation programs which include exercise, education, counselling and behavioural interventions14,15,43,144,275,334. A randomised controlled trial conducted over four years demonstrated a statistically significant body weight reduction of 4 % in the intervention group compared with the control group 15. Patients in the intervention group received individual advice regarding lifestyle modification which incorporated goal setting, a monitored home exercise program, follow-up by mail, telephone contact and regular visits to the clinic for follow-up. Considerable weight loss occurred amongst the dedicated subjects enrolled in a study of a one year intervention including a low fat vegetarian diet, group discussion for social support, stress management and exercise144. Significantly greater weight loss was also reported in the treatment group in two further studies 14,43 , and in another study, a reduction in body fat was achieved in subjects receiving the intervention163. In all three studies, however, the mean weight loss was less than 3 kg. A significant reduction in body mass index, percentage of body fat and other measures was reported in one study 274 and in another, in percentage of body fat in women275. Other studies involving exercise reported no changes in body weight 45,90,143 . A randomised controlled study comparing exercise training alone, exercise training plus group education and counselling, and a control group found no significant differences between groups in weight loss after three and six months 171.

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Positive results were reported from three studies which did not involve exercise. A randomised controlled trial reported a significant reduction in mean body weight at one to 10 year follow-up in patients in the intervention group receiving nutritional counselling compared with the control group325. In that study, the intervention was intensive for the first three months, followed by a continued intervention for three years. One observational study based on self-report achieved a reduction in body weight in overweight patients 177, while a nonrandomised trial involving counselling reported a significant reduction in body fat335 . Studies conducted in other settings confirm that educational and behavioural interventions to reduce weight can be effective334–336 . According to a review of 21 studies involving obese patients, a mean weight loss of 7 to 9 kg was achieved immediately after treatment, with weight loss being related to the length of the program rather than the technique used336 . While weight gain is common after interventions cease, eight of the studies reviewed reported a 75% maintenance of post treatment weight loss at one year follow-up.

Comment
Education, counselling and behavioural interventions are necessary components of a successful weight reduction intervention. However, they may not be sufficient as the sole intervention to produce sustained weight loss. Mutifactorial interventions including exercise are recommended to achieve weight loss in cardiac patients.

Physical inactivity
Recommendation
Education, counselling and behavioural interventions are recommended, in addition to exercise training, to encourage and facilitate regular continued physical activity. Level of evidence = 3 In a multifactorial trial of education, counselling, exercise and pharmacological treatment with regular follow-up, the intervention group reported higher levels of physical activity than the control group after four years 15. However, education, counselling and behavioural interventions have not been shown to improve exercise tolerance and physical activity levels in the absence of exercise training2,15,116,337,338 . Such programs added to exercise training may nevertheless improve morale, self esteem and adherence to exercise.

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Comment
Education, counselling and behavioural interventions to increase exercise tolerance and physical activity are best delivered as part of a comprehensive cardiac rehabilitation program including exercise training.

Psychosocial well-being
Recommendation
Education, counselling and behavioural interventions, either alone or as part of multifactorial interventions, improve psychological well-being and improve quality of life. They should therefore be integral parts of comprehensive cardiac rehabilitation programs. Strength of evidence = 2 Psychological disability has long been recognised as a greater barrier to recovery than physical impairment 14,25,34,36 . Thus, an important aim of cardiac rehabilitation programs should be to improve the psychological well-being of patients. The psychological benefits of exercise training are widely acknowledged. An important issue is whether specific education, counselling or behavioural interventions enhance psychological well-being, additional to those benefits achieved through exercise training. Table 3 in Chapter 6 lists the number of studies reviewed by the US Agency for Health Care Policy and Research for each psychosocial outcome2. These studies involved a range of different interventions, including individual counselling, group counselling, Type A behaviour modification programs, relaxation therapy, stress management, telephone follow-up and home visits. In some of these studies, exercise training was also provided. In this section, a further review is undertaken of studies investigating the impact of education, counselling and behavioural interventions upon psychosocial well-being. Two recent meta-analyses321,339 included several of the studies cited below. Studies specifically addressing stress management programs and the Type A behaviour pattern are separately addressed later in this chapter. Several randomised controlled trials have been undertaken to investigate the effects of education, counselling and behavioural interventions upon psychological outcomes, including anxiety, depression, quality of life and psychological distress 99,121,217,294,310,316,326,340–353. A number of nonrandomised trials354–357 and observational studies 156 have also been conducted. Some studies included exercise as a part of comprehensive cardiac rehabilitation121,156,342,344,352,354,355,357, or as one of two interventions being compared99,346 .

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Most of the above studies involved group interventions99,121,156,294,310,316, 326,340–345,354. Statistically significant benefits in some psychological outcomes were reported in eight studies favouring the intervention group121,294,340,344,354 or in subsets of patients in the intervention groups 99,156,310,345 . Negative results were reported in five trials 294,316,326,341–343. Ten reports involved interventions with individual patients, with or without spouses297,347–353,356,358, with statistically significant benefits being found in seven studies in the intervention groups or in subsets of patients in the intervention groups297,347, 349–352,356. Two studies 348,353 reported no statistically significant differences in psychological outcomes between intervention and control groups. An inpatient program of individual education and counselling delivered by nurses to 60 male patients produced significantly less anxiety and depression in the intervention group compared with control subjects. These benefits were sustained for six months after leaving hospital 351. Another smaller study involving counselling of individual inpatients and their spouses also reported a favourable impact upon psychological well-being 350. A further, similar study of psychological counselling of couples in an outpatient setting reported an improvement in psychosocial adaptation, although the sample size was very small356. However, in a recent large study in which 1,173 patients were randomly allocated to secondary prevention programs conducted by nurses in general practice, no differences were found between treatment and control groups in anxiety or depression at one year follow-up348. However, eligible patients for this study included many with coronary heart disease who had not recently experienced an acute event. Only 14% of subjects were defined as anxious or depressed at baseline, leaving little room for improvement. Studies of group interventions have produced conflicting results, as mentioned earlier. A significant reduction in anxiety among inpatients was produced in one study, compared with a usual care group294 but not in another brief outpatient program to which spouses were also invited326 . In a further trial, patients in the workforce at the time of acute myocardial infarction were randomised to a three week cognitive behavioural intervention to reduce psychological distress and encourage return to work 340. Those patients in the intervention group were significantly less distressed psychologically at three months, compared with the control group. An Australian study, however, found no significant benefit from a program of group exercise and behavioural education in patients who had undergone coronary bypass surgery 342. A recent, large multicentred trial in the United Kingdom also failed to demonstrate significant differences in levels of anxiety or depression between the intervention and control groups at six months343. In this study, 2,328 patients were randomly allocated to standard medical care or to an intervention group which received education about heart disease and the recovery process, as well as instruction in relaxation skills. Conducted in both group and individual settings, the program lasted seven weeks.

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Exercise training and advice regarding risk factor modification were not included in the program. Despite the absence of a measurable impact upon psychosocial outcomes, those enrolled in the rehabilitation program had somewhat less anginal frequency, requirement for medication and physical disability and reported greater leisure time physical activity. Possible explanations suggested by Mayou for the disappointing psychosocial outcomes in this study are that many patients in the control group achieved a good outcome and did not require further support. Further, the intervention may have been inadequate for those patients who did have substantial psychological problems359. Another deficiency in this study may well have been the absence of exercise training, which has been universally recommended in cardiac rehabilitation programs. Further, it should be noted that, of the 792 patients receiving the intervention, 72–80% described the relaxation training, cardiac education, group discussion and individual counselling as helpful or very helpful and rated the programs highly. Two studies which have included exercise training as well as counselling and behavioural interventions produced favourable results. In one such study, a program of group exercise, counselling and education was compared with usual care in patients who had undergone coronary bypass surgery344. Results showed a significant decrease in depression scores in the intervention group but not the control group after eight months compared with baseline measures. In another study, significant improvements in affect and well-being were reported in male patients who attended a group program of exercise and psychosocial rehabilitation, including those experiencing minimal distress354 . In contrast, another study comparing group exercise, individual counselling of patients together with spouses and usual care found no significant differences in psychological outcomes after one year346. Some studies have tested interventions specifically targeting anxious or depressed patients. The effectiveness of exercise training and group counselling was compared in one controlled study of anxious and depressed patients with acute myocardial infarction 99. Although similar decreases in levels of anxiety and depression were noted for those participating in either the 12 week exercise program or group counselling program compared with control subjects, counselling significantly decreased mean depression scores and significantly increased measures of sociability. In an observational study, Milani also found depressed subjects achieved greater benefits in some behavioural and quality of life parameters following a 12 week exercise and education group program during convalescence compared with nondepressed subjects 156. Individual counselling has also been shown to be beneficial in introverted or neurotic patients347. In a study of 201 patients who were either anxious or depressed after acute myocardial infarction, a small but significantly greater improvement in quality of life and decreased anxiety was found upon completion of a six week early outpatient program of group exercise and behavioural counselling compared with a usual care
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group121. However, both groups improved significantly and by 12 months, no differences were found between the groups. In this study, it is possible some patients with psychological problems may not have been identified at baseline, since assessments of psychological state were made in hospital rather than during convalescence when psychological problems commonly occur 360. Further, many patients in the control group were later recognised by their general practitioner to be anxious or depressed and, in consequence, were referred to readily available comprehensive rehabilitation programs in their city (Hamilton, Ontario), thereby possibly contributing to improvements in that control group. The effectiveness of telephone follow-up after hospital discharge has been evaluated in several studies. In one study, telephone support provided during the first six weeks after discharge for patients who had undergone coronary artery bypass surgery produced significantly less anxiety in patients receiving the intervention297. In a randomised controlled study involving education, counselling and weekly telephone follow-up for six months, the intervention group reported significantly greater physical activity and improved dietary habits but no effects were found on anxiety, depression and smoking cessation310. In this trial, benefits were significantly greater after two months if partners had participated in the program together with the patients. A recent study involving a nurse-managed, home based multifactorial risk factor reduction program compared outcomes of 585 men and women after myocardial infarction who were randomly allocated either to the intervention or a usual care group349. Patients in the intervention group received counselling in hospital, followed by monthly telephone calls for six months, or more frequently, as required. Separate analyses of levels of psychological distress were undertaken. Results showed similar levels of improvements overall between groups, except for those with low levels of anxiety at baseline in the intervention group who improved significantly by 12 months. The authors suggested that the subjects enrolled in the trial (working, middle class whites with uncomplicated disease and a good prognosis) may not experience the same rate of depression and other types of psychosocial distress after myocardial infarction as other less economically advantaged populations. A further study in which psychosocial support was delivered by telephone and individual home visits, with an average 20 contacts per patient, only a small impact upon anxiety and depression was reported353. Moreover, there was a poorer overall outcome in the intervention group, including a higher mortality rate, among the women participating in the study. The authors speculated that the monthly telephone screening to monitor psychological distress and repeated home visits for those experiencing psychological problems may have been intrusive and harmful. Serious clinical and methodological flaws in the study have been asserted by others361,362 . One weakness concerns the failure of the reported harmful effects upon women in the study to reach conventional levels of significance. Another concerns the use of nurses
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rather than appropriately trained psychologists to deliver the program. Further, an intervention requiring frequent telephone contacts and an average five to six home visits cannot be considered cost effective as standard care. Caution should therefore be exercised in generalising the findings of this study to other more common and more effective forms of cardiac rehabilitation. In this regard, it should be noted that a meta-analysis, which included 23 trials involving 3,180 patients, found that the addition of a psychosocial intervention to cardiac rehabilitation programs produced a greater reduction in psychological distress, as well as a 41% mortality reduction over two years in those receiving the additional intervention compared with those who did not339. Home-based self-help programs have also been tested for their effectiveness. In one such study, a rehabilitation program based upon a heart manual and tape dealing with exercise, information and stress management produced psychological benefits among patients in the intervention group compared with a control group receiving standard care 352. Rehabilitation patients were significantly less anxious and depressed at follow-up, with the greatest improvement being noted in those in whom anxiety and depression were greatest upon discharge from hospital. Moreover, patients in the treatment group used health services less frequently than control subjects. The authors recommended that all patients should receive rehabilitation because of the difficulty in predicting while in hospital those patients who will later experience psychological distress.

Comment
A small number of randomised or controlled trials support observations of numerous clinical papers which claim the effectiveness of various interventions upon psychosocial well-being. Moreover, patients attending rehabilitation programs, as well as the health care providers delivering them, state that the psychosocial benefits of comprehensive cardiac rehabilitation programs are considerable. However, while some studies have demonstrated improvements in psychological well-being, it is difficult to make firm recommendations about the most effective education, counselling and behavioural interventions for facilitating the psychosocial recovery of cardiac patients. Current methods of psychosocial rehabilitation remain extremely variable because of a lack of adequate scientific bases for recommending particular approaches. Many studies suffered from poor research designs, using samples of insufficient size and vaguely described interventions. Moreover, interventions varied considerably in duration, frequency and intensity. Nonuniform outcome measures and different measurement tools were used, making comparisons between studies difficult, and interventions were delivered by personnel with varying degrees of expertise. Further, there was considerable variation between studies in follow-up periods and the types of patients included in the studies. These weaknesses limit the value of the findings of some studies. More rigorous investigations are essential. In particular, additional research is required to assess the effectiveness of interventions,

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such as group counselling, as sole modalities or in conjunction with other interventions. An equally important area for further research is the identification of particular interventions which can benefit specific subsets of patients. A range of different model programs is required to cater for the varying psychosocial needs of different patient groups.

Stress
Recommendation
Stress management programs, including relaxation training, may be useful adjuncts to other methods of psychosocial rehabilitation in selected patients. Strength of evidence = 3 The aims of stress management programs are to assist the patient to identify stressors, to recognise characteristic emotional and physical responses to stress, to decrease levels of general arousal and to develop effective coping strategies. Through the use of various techniques including relaxation therapy, meditation, cognitive therapy, anxiety management and biofeedback, the patient is taught how to reduce stressful reactions by altering stress inducing perceptions of situations. By acquiring more effective coping skills, maladaptive responses to stress may be reduced. Several studies have reported benefits from relaxation therapy99,363–366 . In one study, patients who received cognitive training early after myocardial infarction had greater confidence in their ability to control their stress than those who received relaxation therapy 364. In another, relaxation training was found to enhance the psychological effects of exercise training365. In a recent randomised controlled study366, 50 post infarction and 50 post bypass surgical patients who received a 10 week program of stress management and relaxation therapy three months after their events showed significant improvements six months later, compared with the control group, in emotional well-being, activities of daily living, satisfaction with health and perceptions of family members of the patients’ emotional state. However, these patients had not attended a formal rehabilitation program and it may be that similar benefits could have been achieved from a program of group exercise and education offered during convalescence. In a study involving monthly monitoring of stress levels of patients and home nursing visits for those with high stress scores, a significant reduction in stress scores was found as well as a significantly reduced rate of longterm recurrence of acute myocardial infarction and a marginal impact on cardiac mortality during the first year after infarction 358. Little impact was observed on those with low levels of stress in hospital. The authors concluded that patients who can benefit from such an intervention may be identified in hospital.
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Comment
Stress management and relaxation classes may help patients to feel better and less tense, and in consequence, avoid lapses in recommended behaviours. While there is some evidence to support the effectiveness of stress management programs and relaxation therapy, specific programs are not routinely required during cardiac rehabilitation programs. Further research is required to identify which patients could benefit most from such interventions.

Type A behaviour pattern
Recommendation
Specific interventions to modify Type A behaviour are not recommended as part of comprehensive cardiac rehabilitation programs . Strength of evidence = 2 The Type A behaviour pattern was defined initially by Friedman367 and further developed by Rosenman 368 and Jenkins 369. It is characterised by rapid response to perceived time pressure, by competitive or even aggressive behaviour and by hostility. The major evidence that the Type A behaviour pattern was an independent risk factor for coronary heart disease came from the Western Collaborative Study368. In this prospective cohort observational study, a clear association was demonstrated between the Type A behaviour pattern and mortality from coronary heart disease. A possible correlation was also found in a sub-study of the Framingham Study370. Review of this material led to the conclusion by a working party that the Type A behaviour pattern was probably an independent risk factor for coronary heart disease 371. After the first major report368, a subsequent review of the Western Collaborative Study data and subjects showed a reversal of risk. Thus, Type B subjects who had lived beyond the first survey report were found to be at greater risk of cardiovascular disease than Type A subjects372. As a result of this finding, the manner in which patients were originally classified as either Type A or Type B subjects has been questioned. A clinical trial conducted by Friedman and colleagues 367 demonstrated improved outcomes from a program to modify Type A behaviour. However, the randomisation process in that study has also been questioned. Meanwhile, several other prospective cohort studies have failed to demonstrate that the Type A behaviour pattern contributes any additional risk beyond the normal recognised risk factors for coronary heart disease or its complications. This applies to those patients who do not have coronary heart disease as well as to those who have

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already had acute myocardial infarction (see Chapter 13). Thus, it appears that Type A behaviour may well not be a risk factor for coronary heart disease. More recent studies are examining the possible link between hostility, a component of the Type A behaviour pattern, and coronary heart disease (see Chapter 13). Hostility is close to aggression and aggression is possibly related to maleness and testosterone levels or sensitivity. As a possible risk factor, it may be of no greater significance than other characteristics of maleness and hence not may not be amenable to significant change through psychosocial interventions.

Comment
Although a fashionable concept in the past, recent research has brought into question the robustness of the concept of the Type A behaviour pattern373. Thus, attempts to modify Type A behaviour probably have little or no place in current cardiac rehabilitation programs.

Return to work
Recommendation
Resumption of work should be recognised as a major aim of cardiac rehabilitation programs. Education, counselling and behavioural interventions focusing on vocational rehabilitation are recommended to facilitate return to work. Strength of evidence = 3 In randomised controlled trials, exercise training alone has not been demonstrated to be effective in increasing the rate of return to work. Further, in randomised controlled trials, the addition of education and counselling to exercise training has also proved generally ineffective in facilitating return to work (see Chapter 11). However, in controlled studies where return to work was an aim of the cardiac rehabilitation program, significant increases in return to work and retention of working status over time have been well demonstrated 16,91,159,160,172,174,374. In one randomised controlled trial, the addition of vocational counselling to a comprehensive cardiac rehabilitation program was reported to have produced an increased rate of return to work161. Observational reports conducted from the 1940s to 1970s in Australia (where resumption of work has traditionally been a major outcome) and the United States support the beneficial effects of cardiac rehabilitation programs upon return to work and continuing in work20,21,25,34–37 . The emphasis in Australia on return to work is illustrated by one study of 169 unselected men who were in the workforce at the time of onset of myocardial infarction. At four months, 89% of these patients were working and after one year, 87% were working, irrespective of whether they were randomly

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allocated to a high or low intensity exercise program94,96. These results may be contrasted with findings of a recent study in the United Kingdom343 where, of 838 patients who were in the workforce before their acute event, only 41% of patients in both the intervention and control groups returned to work within six months. In that study, it appeared that return to work was not a major aim of the intervention and specific vocational interventions were not provided. Such an adverse occupational outcome is amongst the worst in the literature, implying that patient medical management and support, or the health care and social security system, were seriously inadequate in supporting patients in returning to work. It has been suggested that the benefits of a cardiac rehabilitation program may lie in fostering perceptions of improved health and greater physical mobility, which, in turn, may motivate patients to continue working after their acute event. In one randomised controlled study of a comprehensive cardiac rehabilitation program including exercise, education and counselling followed by booster sessions, an increase was found in the proportion of patients allocated to the intervention group following coronary bypass surgery who were working after three years 375. However, no differences between the intervention and control groups were evident at other follow-up points, except for those aged under 55 years who returned to work more frequently if they received a program of cardiac rehabilitation. This study found that favourable perceptions of capacity for working and a desire to work were among the most significant factors influencing return to work by one year. A large study undertaken to identify predictors of return to work in 1,252 patients with coronary heart disease, subsequently validated in a prospective study, concluded that those at high risk of leaving the workforce prematurely can be prospectively identified at a time when it might be possible to intervene376. Findings of this study supported the results of other studies which showed that traditional medical factors, such as the severity of illness, have a relatively small impact upon employment outcomes. Barriers to resuming work may be more cognitive than physiological377,378 . Thus, behavioural interventions designed to enhance self-efficacy, provide constructive coping strategies and modify perceptions could improve employment outcomes 379–383 . This recommendation is supported by Shanfield in a review of studies concerning return to work after acute myocardial infarction384.

Comment
The paucity of firm evidence that cardiac rehabilitation, as currently practised, favourably influences resumption of work needs explanation. The initial basis for the establishment of cardiac rehabilitation programs was to facilitate physical, psychological and social recovery, with resumption of work as one of the important outcomes. However, there are few randomised controlled trials where resumption of work has been a major outcome measure. In most cardiac rehabilitation programs

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conducted in the United States, using high intensity exercise as the major intervention, the physical benefits of exercise represent the primary endpoint, with resumption of work an almost incidental possible outcome. In the USA and Canada, resumption of work has been considered largely dependent upon social, economic and occupational factors not related to the rehabilitation program itself2,121,161 . It may be that, if resumption of work is not regarded as a primary or important outcome measure of a cardiac rehabilitation program, then attempts to help patients to resume work will assuredly fail. For resumption of work, maintenance in work and satisfaction with work not to be major aims of cardiac rehabilitation is to deny part of the definition and purpose of cardiac rehabilitation as set out in Chapter 1. Return to work is dependent upon multiple factors including attitudes of the patient, family and employer and confidence in being able to resume work. Comprehensive programs including exercise, education, counselling and behavioural interventions may improve a patient’s potential for resuming work but they may be ineffective without directly addressing return to work as a major aim of cardiac rehabilitation. These issues are further discussed in Chapter 15.

Conclusions
Unfortunately, many studies investigating the effectiveness of education, counselling and behavioural interventions in cardiac rehabilitation have been poorly designed, with inadequate sample sizes and without explicit reference to a theoretical model2,171,299,385–387. Few studies have investigated outcomes of group programs conducted during convalescence. Further, most investigations have been limited to male patients, particularly those who have had acute myocardial infarction. Thus, clear recommendations regarding appropriate interventions for a broader range of patients are difficult to make. With regard to risk factor modification, it should be emphasised that changing health behaviours is usually a process rather than a single event. The process of change may take considerable time, especially if multiple changes are required. Thus, it is unrealistic to expect that ambulatory programs of six to eight weeks’ duration will produce significant and sustained changes in most health behaviours. Nevertheless, ambulatory programs should help patients to initiate steps to begin the process of change by fostering a positive attitude towards change, motivating them to change, increasing their self-efficacy and teaching them skills to help them adopt and maintain healthier lifestyles. Longer programs are required to reinforce the need for change and ultimately to bring about changes successfully. Thus, maintenance programs are highly recommended, in addition to repeated, supportive advice from medical practitioners. Longterm telephone followup by well trained nurses or other health professionals is also recommended to monitor health behaviours and to identify those requiring referral for further assistance with psychosocial, occupational or other problems.

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CHAPTER 13
CONTENT OF EDUCATION AND COUNSELLING GROUPS
In this chapter, recommendations are made regarding the content of group education and counselling sessions. The scientific literature to which reference is made is to underpin the statements in the text and is not meant to represent a comprehensive review.

Core education program
Recommendation
Education and counselling groups should cover pre-determined core topics. Strength of evidence = 4 The education and counselling program should cover several specific, defined topics. The core topics are supported by many authoritative bodies1,10,69,70,74,79,388 . However, depending upon the particular groups of patients attending and their specific needs, some subjects may be omitted, addressed only briefly or expanded. For example, a session on return to work may be omitted if all the patients attending are retired. Similarly, sessions dealing with explanations about cardiac procedures, investigations and medications should be confined to those aspects relevant to the patients in the group. Topics should address questions commonly asked by patients. The following subjects represent the core content of a typical education and counselling program for patients with cardiovascular disease.

Medical topics
• • • • • • anatomy, physiology and pathology of cardiovascular disease coronary heart disease/ischaemic heart disease acute cardiac events investigations and procedures symptoms and their management cardiac medications

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Modifiable risk factors
• • • • • • smoking raised lipids, nutrition and dietary fat high blood pressure overweight, obesity and diabetes physical inactivity other risk factors

Nonmodifiable risk factors
• older age • male gender • positive family history

Behavioural and psychosocial topics
• • • • • • • behaviour change and adherence to medication and advice mood and emotions psychosocial risk factors and social support stress impact upon the spouse and family sexual activity and activities of daily living return to work

Medical topics
Patients require simple and clear explanations of the disease process and possible causal factors. Simple and clear descriptions are also essential when explaining acute cardiac events (such as acute myocardial infarction, coronary artery bypass surgery and percutaneous transluminal coronary angioplasty) and investigations and procedures including coronary angiogram, exercise tests, electrocardiography, echocardiography and nuclear cardiography. Drawings, models and videos are helpful. Perceptions of individual patients regarding causes of their disease and the nature of the acute event should be explored so that any misconceptions can be addressed 389–391 . The distinction between heart attack and stroke should be explained and the ongoing and chronic nature of cardiovascular disease emphasised. The typical recovery process should be discussed. Symptoms and their management should also be part of these sessions. 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

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medication may be prescribed. Patients often ask for additional information concerning the following: • 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 • antiinflammatory drugs • psychotropic drugs • hormone replacement therapy It is only appropriate to discuss the drugs about which patients enquire. Most patients are properly interested only in their own medications. Better understanding of medications is thought to facilitate compliance (both acceptance and adherence) with prescribed medications. Additional medical topics may also be discussed during groups, depending upon the medical and surgical problems of the patients present. For example, other kinds of cardiac surgery including cardiac transplantation may be relevant, as well as heart failure and cardiomyopathy.

Risk factors
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 stabilisation 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.

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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 studies392,393 . 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 stroke392–396 . 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 studies66,397 and as high as 60% in others 395,398 . 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. In Australia, with its current anti-smoking culture, advice and support during a cardiac rehabilitation program, reinforced by advice and support from others, will usually be effective66. Encouragement to stop smoking is especially important during convalescence when patients are most motivated399. 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 behavioural 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 322,400,401 . Information should be provided about sources of further assistance and counselling. Referral to smoking cessation programs (such as QUIT) should be recommended for those unable to stop smoking on their own.

Raised lipids, nutrition and dietary fat
Education and counselling 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 6,309 . 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 hypercholesterolaemia, so that advice can be individualised. Since dietary advice changes over time (for example, the shifts between recommending polyunsaturated

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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 fibre and the protective effects of “traditional” diets 402. 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. During acute cardiac episodes, falls in total and LDL cholesterol occur, coupled with loss of appetite and loss of weight403. During convalescence, appetite recovers. Weight then increases and lipid levels gradually rise. This pattern occurs with both attenders and nonattenders of cardiac rehabilitation programs. The aim of dietary advice and counselling is to induce behavioural change (reduced fat intake, increased physical activity and control of kilojoules) to minimise or reverse the natural trend to rising lipid levels. Studies have demonstrated that the trend to reversion to previous habits, with loss over time of the beneficial effects of counselling during convalescence, can be prevented or reduced if patients are reviewed and if advice and support continue over years 14,15,16,91 . Thus, nutritional advice to cardiac patients during convalescence needs to be followed up and reinforced continuously by the patients’ doctors and other health care providers. Patients need to be motivated to continue adhering to nutritional advice and should be helped to acquire the necessary skills for making dietary changes 404. They should also be advised that, in general, the lower one’s total and LDL cholesterol levels, the better405,406 , rather than aiming to fall below specific cutpoints for levels of cholesterol. Patients should be informed of the need to continue adhering to any prescribed drug treatment and dietary advice. The benefits of following dietary regimens can now be supported by firm evidence of reversal or slowing of coronary atherosclerosis through long term dietary self control and adherence to medication15,407–410 . This effect is associated with reduction of recurrent cardiovascular disease events and mortality15,411. While much of the necessary learning may be achieved in one group session, patients and family members commonly cite a need for additional education about diet and nutrition 7. Further, during open discussion on other subjects, dietary and nutritional questions are commonly asked. Topical issues are often raised such as the role of red wine, the “French paradox”, antioxidants, fibre, vitamins, fish oil, coffee and garlic. To ensure that nutritional issues are adequately addressed, it is preferable to include

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at least two sessions which deal with nutrition during the program. One should focus upon practical aspects of shopping, food label reading, preparing food and cooking. Where necessary, group sessions should be supplemented by counselling of individual patients and couples by the dietitian. Simple written nutritional information should be available, both in English and other languages.

High blood pressure
Education and counselling 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 412–417 . The considerable benefits arising from good blood pressure control in these patients should be emphasised418,419 . 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 94. 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 vegetables420. 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 421. Since stress, especially work-related stress, is thought by many patients to cause high blood pressure, this issue also needs to be addressed.

Overweight, obesity and diabetes
Overweight (body mass index 25–30kg/m2) and obesity (body mass index > 30kgs/m2) are significant risk factors for cardiovascular disease. Facilitators should define overweight and obesity and explain their role in the aetiology of cardiovascular disease and diabetes. They should also explain their role as risk factors for further cardiovascular events and mortality422–424 , the development of Type II diabetes 425,426 and raised cholesterol and blood pressure427. 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 diabetes428,429 . In some patients, obesity may be coupled more with physical inactivity than with a high caloric intake 430–432 . 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 recognised and

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discussed 336,433–436 . 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. Behavioural interventions can be effective for overweight cardiac patients, as discussed in Chapter 12. Such interventions are probably best implemented by a psychologist.

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 191. 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 emphasised. 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 emphasised that major health benefits can be achieved through light to moderate activity and that high intensity exercise is not necessary 191,212,214,437 . Weekly utilisation of 1,500 to 2,200 kilocalories above the caloric utilisation of sedentary living achieves considerable protective benefit105. Low or moderate levels of daily activity are readily embraced by patients during convalescence after acute cardiac events, as well as by patients with past or controlled heart failure, the obese and older men and women generally (see Chapter 8). The cumulative benefit from all common physical activities, whether as sports, social activities (such as dancing), work or activities at home (such as housework and gardening), should be discussed. Patients should be advised that physical activity which is undertaken in several short bursts during the day (such as three walks each of 10 minutes) is as beneficial as one longer session of activity (such as a walk lasting 30 minutes) 191. Activities which are enjoyable and which may be undertaken in company should be recommended because they are more likely to be maintained in the long term. Advice regarding physical activity should be individualised to take into account the patient’s age, past habits, personal preferences and co-morbidity. For those patients who seek it, a maintained high level of activity should assure greater levels of fitness and may supply added health benefits210,211,438 . Unfortunately, patients tend to revert to their previous sedentary habits over time. Patients need to be forewarned of the risk of such relapses. They may occur gradually or they may happen abruptly following an incidental event which may be of physical, social or psychological origin. Patient education is therefore important regarding the benefits of activity, how it may be achieved and the need for its lifelong continuation. Barriers to physical activity should be explored during group discussions and alternative approaches suggested. The level of unfitness parallels physical inactivity

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as a risk 213,439,440 . Those who are unfit but who successfully increase their activity and fitness improve their prognosis compared with those who remain unfit228.

Other modifiable risk factors
Alcohol
Excessive consumption of alcohol should be recognised as a contributor to hypertension and therefore as a risk factor for stroke441–444 . 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 445,446 . Further, alcohol may be a basis for resumption of smoking, physical inactivity or a previously unsatisfactory diet447,448 . Patients who are aware that alcohol (whether it be red wine or any other alcoholic drink) protects against subsequent myocardial infarction441,449–452 may use that information to increase their alcohol consumption. It is important to emphasise 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.

Salt
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 minimise 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 desirable333,453–457 . Salt excretion may be increased by diuretic treatments, but if the intake of salt is reduced, the dose of diuretic can be less.

Non-modifiable risk factors
Age, gender, family history and existing disease
Education and counselling 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 278,458 . The use of hormone replacement therapy to reduce the risk of cardiovascular disease in women has been widely canvassed in recent years. The role of hormone

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replacement therapy with oestrogen alone, as in the earlier studies in the United States of America 459–462 , or with combined oestrogen/progestin regimens 463–465 , should be addressed. Many female patients are aware of the reduction of mortality, cardiovascular disease episodes and acute myocardial infarction in postmenopausal women who are taking hormone replacement therapy. They are also aware of the possible benefits of hormone replacement therapy in the prevention of osteoporosis 466,467 . For many patients, these potential gains are offset by concerns regarding the increased risk of cervical cancer 463,468 and, possibly, breast cancer 469. The mechanism whereby cardiovascular disease events and mortality are reduced through hormone replacement therapy may be largely through the beneficial effects of hormone replacement therapy on lipid levels (reducing total and LDL cholesterol, raising HDL cholesterol and other changes) and reducing fibrinogen levels, with consequent reduction in the progress of atheromatous lesions and the tendency to thrombosis 278,470 . It is further suggested that oestrogen reduces the uptake of LDL cholesterol in the arterial wall278,471 . It is yet to be defined which patients should be treated with hormone replacement therapy, but current thinking suggests those postmenopausal patients with known cardiovascular disease who have low HDL cholesterol levels or high LDL cholesterol levels should take hormone replacement therapy 278,470 . A positive family history of cardiovascular disease is a powerful marker of risk for the development and accelerated progress of cardiovascular disease472–475 . 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 66,476–481 . 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 482, other vascular disease or diabetes mellitus 423,424,483,484 is also a powerful marker of risk for coronary heart disease and an indicator of the need for attention to all risk factors.

Behaviour change and adherence to regimens
Providing patients with information about heart disease and explaining risk factors should help patients to accept the need for changing their habits and adhering to advice in order to reduce their risk of further events. However, imparting information and increasing patients’ knowledge do not necessarily produce behavioural change311. Skills need to be acquired to help patients make and maintain changes 404. It is useful during education and counselling sessions to explain the usual stages of behaviour change 485,486 and to stress that lifestyle changes are difficult for many and can take some time. Education and counselling sessions can facilitate behaviour

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change by increasing the patient’s motivation to change, fostering positive attitudes towards change and strengthening intentions to make changes487. Attitudes and predictions regarding health behaviours correlate well with subsequent behaviours 488. It is important to ask participants in the group about those aspects of their lifestyles which they are finding difficult to change. Common barriers to change should be discussed and possible ways of overcoming them explored. It is usually found during discussions that several patients face the same difficulties. Perceptions of causal factors in the development of the disease may also be relevant. For example, a belief that factors outside the patient’s control (such as heredity or fate) are responsible for the disease may stop patients from addressing any lifestyle factors which may have contributed to the illness. Factors which exert a negative influence upon behaviour should be discussed, as well as perceived costs and benefits of making the recommended changes 383. Such perceptions may significantly influence adherence to advice regarding the modification of health behaviours. It is important to challenge patients’ erroneous beliefs and negative perceptions. Patients’ beliefs about causal factors and the course of the illness are important predictors of adherence385. Self-efficacy or confidence has also been shown to exert a powerful influence upon successful behaviour change314 and other outcomes, including resumption of work489,490 . Psychological functioning and support from others are further important determinants of compliance491. In particular, spousal support increases compliance 303,309 . The benefits of social support should be addressed during group discussions 491. For example, activities which patients can do together with their spouse or friends, such as daily walking, can facilitate adherence. Simple behavioural strategies should be explained in lay terms. These may include determining realistic goals for change, planning ways of coping with any lapses and learning how to alter thoughts and feelings about habits which require change404,492 . A depressed mood or perceived stress, for example, can lead to lapses, such as resumption of smoking 493. Thus, patients need to become aware of factors which trigger mood change and plan strategies for handling such stress in a more positive way. Patients should be forewarned that lapses become more common with the passage of time 309,397 . Individual behavioural counselling may be necessary for some patients, especially those who have several changes to make. Unfortunately, nonadherence to advice regarding behaviour change and medication is common in cardiac patients. For example, resumption of smoking among former smokers has been shown to be as high as 40–50% six to 12 months after the event319,397,494 . Longterm nonadherence with lipid lowering medication is also high495. A recent Australian study showed that up to 60% of patients who had been prescribed lipid-lowering medication ceased taking their medication496. Fifty percent of these patients discontinued their medication within three months and 25% within one month. Common reasons for abandoning the medication were a belief that the

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drug therapy was not needed or that it produced unpleasant side effects. Nonadherence with medication among heart failure patients ranges from 20% to 60%264 and is commonly a cause of rehospitalisation. Such hospital readmissions are potentially preventable through improved patient education and comprehensive discharge planning 264. Adherence to medication is especially important, since it has been demonstrated that nonadherence with medication has an independent effect on mortality in both men 497 and women 498. Continuing medical supervision to encourage adherence is essential. Patients need to understand the importance of regular visits to the doctor for this reason.

Mood and emotions
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 499–504 , especially upon transfer to the ward and on discharge from hospital505. 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 recognise such symptoms as manifestations of anxiety. Anxious patients usually have little concentration and often fail to comprehend, accept or recall information provided in hospital 305,307 . Further, anxiety may lead to a delay in resuming activities. Depression is also common after an acute cardiac event360,493,502 and has been associated with increased mortality and morbidity358,506–509 and increased costs associated with rehospitalisation510. In most cardiac patients, such depression is more a grief or bereavement reaction rather than a depressive illness511,512 . 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 513. 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. Fatigue and weakness may be equated by them with heart damage greater than anticipated504. 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 coexist513 . Several symptoms, including irritability, reduced concentration and sleep disturbances, are common to both conditions.
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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 defence mechanism in the short-term for coping with anxiety and a depressed mood514 it can exert a negative influence upon outcomes if patients cease to adhere to regimens regarding lifestyle, medication and other advice515. It is usual for anxiety and depression to decrease spontaneously during the months after the event 342,349,516–518 , although they may persist for up to a year or more36,501,502,519 . Studies suggest women have poorer psychological outcomes than male patients520–524 . 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 unrecognised and untreated depressed mood520,525, which can lead to nonadherence with advice, occupational difficulties, and marital and sexual dysfunction309,360,385,507,520,526. Moreover, as already stated, depression is a powerful predictor of mortality after acute myocardial infarction527–529. A further loss or crisis can intensify or prolong the depressed mood530. In some patients, the onset of depression may be delayed531. 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 recovery530,532. Psychological responses can be effectively addressed during group sessions by a skilful facilitator. When patients are able to disclose feelings during group sessions, identification with others who are experiencing similar problems can be a major benefit 7,309 . Recognition that problems are not unique is reassuring7,533,534 . 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 others7,309 . 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 favourable adjustment. The practice of introducing successfully rehabilitated postsurgical patients to those awaiting the operation is based on the same premise. Small groups of about six to eight are more effective than large groups for uncovering more complex emotions and concerns of patients and spouses. Where possible, small group discussions should be available as adjuncts to the larger education and counselling sessions. It is preferable for small group discussions to be facilitated by a social worker, psychologist or other qualified counsellor with appropriate training.
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Psychosocial risk factors and social support
Education and counselling groups should address psychosocial risk factors, including life events, social stresses, social isolation and depression. The ways in which social support from friends and family can minimise the impact of psychosocial stress should also be discussed. Several observational and cohort studies have demonstrated that social isolation (for example, living alone, particularly without a close friend or confidant) has a marked adverse effect upon outcomes after acute myocardial infarction, including recurrent events, cardiovascular deaths and deaths from all causes535–538 . Social stresses and life events (for example, bereavement, loss of job, movement of home) have also been shown to have a negative impact upon outcomes 535,539 . Such increased morbidity and mortality are largely independent of other risk factors and other physical indicators of prognosis. Social support has been associated with improved quality of life in cardiac patients540,541 . The mechanisms whereby psychosocial factors affect outcomes are not known. It has been suggested that a sense of loss associated with isolation may lead to despair, depression, nonadherence with advice and abandonment of a healthy lifestyle. These patterns of psychosocial deprivation and depression are now recognised as powerful risk factors 528,529,535–538,542. Patients with lower levels of education, occupational and socioeconomic status and income, coupled with limited control over their lives and working conditions 537,543–545 , or those who live in a poor area 546, have a greater risk of poor outcomes. The role of depression and how best to develop support structures within a community for patients with cardiovascular disease and for others in an ageing population and a deteriorating family structure is an area for significant concern and research. Potentially effective interventions remain under investigation. Patients need to understand the importance of their life’s circumstances upon their health outcomes. They should be encouraged to develop personal or community linkages to acquire or maintain friendships and support547. Group sessions during cardiac rehabilitation programs can provide patients with considerable social support by helping them to be less self-absorbed and by giving them a feeling of being among others who are successfully coping with their illness. Participation in a group can lessen the sense of helplessness, particularly in patients who are depressed 548. Friendships are often formed during cardiac rehabilitation programs which may be long lasting309. Thus, groups may be a significant source of psychosocial and motivational support549. Indeed, it has been suggested that much of the psychological benefit demonstrated to arise through group exercise programs may be due to the supportive effect of group activity99. The emotional and social support which patients receive as members of consumer groups can be invaluable during early convalescence and for many months after ambulatory programs cease.

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Stress
Patients commonly attribute their cardiac illness to stress309,385 . 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 550–554 . Patients often perceive such “job stress” to be the main cause of their disease96,309 . However, there is no substantial scientific evidence to support these views555,556 . While “strain” may not be a significant risk, poor “control” may be so544,545 . Such poor “job control” may be another reflection of less education, reduced job opportunities and lower socioeconomic status557. 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 disease556. Patients may therefore accept the presence of stress, but be led to modify their responses to embrace favourable rather than harmful behaviours. Some may also be able to modify their perception of stress and their responses to stress through stress management techniques. Although currently a less fashionable concept than previously, the Type A behaviour pattern 367,368,371,558 may be raised during group discussions, especially by those who do not have any of the standard risk factors. Facilitators should briefly explain that the concept has been largely discredited following further research372,373,506,559–563 and

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discourage patients from labelling themselves as “Type A” individuals. The concept of “hostility” as a marker or cause of risk for cardiovascular disease events564–569 may also be addressed in the context of multiple responses to a perceived stress. Such “hostility” is associated with increased risk of all cause mortality, not cardiovascular mortality alone, and the effects appear to be mediated primarily through adverse behavioural risk factors570 .

Impact upon the spouse and family
Spouses and partners of patients should be invited to participate in the education and counselling sessions, both for their own and the patient’s benefit. Spouses often receive insufficient information and support in hospital 306,571–574 or show a limited understanding of the advice and information given to them306. Attendance of spouses at group discussions during convalescence is highly recommended so that they can obtain valuable information about the illness and gain insights into problems experienced by patients, such as the psychological basis of patients’ irritability and other symptoms. Education and counselling sessions can also provide opportunities for spouses to raise their own concerns. They commonly have many conflicting feelings about the patient’s illness, including anxiety, guilt, resentment and anger356,575,576 . Underlying their distress may be fear of a further event and possible death of the patient. Stress reported by spouses is marked during the acute phase572,577–579 and typically peaks during convalescence580,581 . The practice of discharging patients early from hospital has been shown to contribute significantly to the insecurity of spouses at this time582. Spouses of patients who have undergone coronary artery bypass surgery commonly experience considerable stress during the waiting period which is often prolonged 583. Anxiety in spouses may be greater than that found in patients and may persist for some time534,577,579,580,584–589. However, depression in spouses appears to be less marked 584. Emotional responses of spouses should be discussed during group sessions. Other family members share similar concerns to those of spouses and can also benefit from participating in group discussions. Marital disagreements and tensions are common during convalescence309 and preexisting marital problems may be exacerbated by the illness589. There may be marked differences between patients and spouses in their perceptions of the severity of the event, expectations of outcome, the likelihood of the patient’s compliance with regimens and the level of the patient’s progress 309,534 . There may also be considerable disagreement regarding the prescribed regimens, especially those concerning diet, activity levels and resumption of driving, sexual activity or work309,587 . Awareness that they are expected to be providers of support to the patient 590 often leads spouses to become overprotective591 so that they may attempt to limit the patient’s activities 504,577–579 . Facilitators should raise this common scenario for discussion. Open

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discussion can be useful to clarify regimens and to reassure spouses. It may be necessary to refer some couples with significant marital problems to a social worker or psychologist for further counselling. Separate groups for spouses are also recommended to provide support during convalescence, as discussed in Chapter 15.

Sexual activity and activities of daily living
Resumption of sexual activity may be dealt with during discussion of physical activity, resumption of car driving and other activities of daily living. Occasionally patients or spouses may initiate discussion about their fears of resuming sexual activity but usually the subject needs to be raised by the group facilitator. The main concerns of patients and spouses are time of resumption and the safety of sexual activity 592,593 . A delay in resuming sexual activity after an acute event is not uncommon 594 because of anxiety or depression. The issue of impotence may also be addressed during group discussions, since it is not an uncommon problem for male patients at this stage of their recovery595. It is useful to mention medications or depression as possible causes of impotence and to provide reassurance that the problem is usually temporary. Further discussion between the patient and the treating doctor should be advised. Reduced sexual activity after myocardial infarction has been shown to be significantly associated with psychological distress 596. Patients and spouses require clear guidelines about when they can resume their usual activities safely. Discussion of such matters generally occupy much time during education and counselling groups. It is important to reduce the amount of conflicting information provided by different team members. The occupational therapist or other team member should produce written guidelines regarding resumption of car driving, housework, gardening, hobbies, recreational and other activities, based upon current recommendations. Such a document should be considered to be a general guide only. Specific advice for individual patients may vary, depending on the patient’s age, physical status or other factors. Possible reasons for different guidelines given to patients should be discussed in the group. As a general rule, however, patients can use the level of their perceived exertion during exercise classes as a guide to appropriate levels of activity at home. Patients can usually resume most activities when they feel confident to do so and if they have no symptoms. If they remain in doubt, patients may undergo an exercise test to determine their capacity for resuming various activities.

Return to work
The importance of returning to work for those recently in the workforce should be emphasised regularly during the program. Discussion should cover appropriate times of resuming manual and non-manual work for medical and surgical patients and the possible benefits of returning to work initially on a part-time basis. Common occupational problems after resuming work and how to handle them should also be

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covered. Such problems include fatigue, reduced concentration, irritability, interpersonal tensions and perceptions of a reduced capacity for work96,309. It is usually desirable for patients to resume their former job rather than to seek a new one. Anxious patients and spouses should be reassured about groundless concerns, especially fears that stress at work may cause a further cardiac event. The possibility of retirement is often entertained by patients and spouses. A decision to retire during a period of anxiety or depression after an acute event is often regretted. Patients need to understand the processes of recovery, physically and psychologically, and to be prepared to postpone retirement or other major occupational decisions until they and others feel the patient has recovered and after a trial of return to previous work, possibly modified. Open discussion of these issues is recommended so that patients can address their future with less apprehension and probably with advantageous outcomes. Additional advice from the occupational therapist about resuming work can be most helpful. If there are several patients in the program planning to resume work, a separate session dealing with work-related issues may be appropriate. Further aspects of vocational rehabilitation are discussed in Chapter 15.

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CHAPTER 14
STRUCTURAL ASPECTS OF GROUP EDUCATION AND COUNSELLING PROGRAMS
In this chapter, recommendations are provided regarding structural aspects of education and counselling groups. In Australia, ambulatory programs usually last six weeks and provide weekly group education and counselling sessions. In some programs, groups take place more frequently5,39,41. While similar topics are addressed in most educational and counselling groups, there is considerable variation between programs in the depth and extent of information given. Further, the methods of delivery range from more didactic presentations to informal, interactive discussions. Most studies report an individual, group, or combined approach to educating patients but few describe details of the content of the intervention or the style in which the information is delivered. Support for the recommendations made in this chapter largely come from expert opinion and consensus statements based upon general education and adult learning principles.

Group versus individual counselling
Recommendation
Education and counselling should be conducted in groups. Individual counselling should be available, if required. Strength of evidence = 4 No study of cardiac rehabilitation has been found which compares the effectiveness of group versus individual education and counselling programs upon patient outcomes. However, studies involving other populations confirm the benefits of group approaches 597. While specific queries and concerns of some patients require individual attention, expert opinion supports the view that most education and counselling is best delivered in a group setting. Group sessions allow patients to listen to questions asked by others which they themselves may have been too inhibited to raise. Further, group programs involve less staff time and are therefore more cost effective than individual counselling.

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Principles of adult learning
Recommendation
Education groups should be based on adult learning principles and should encourage interactive discussion. Strength of evidence = 4 The superiority of interactive discussion over didactic lectures has not been confirmed in controlled studies in cardiac rehabilitation. However, studies of other populations indicate that least is learned from didactic lectures, while most is learned from interactive group discussion598. Because education based upon interaction is a relatively slow method of covering a syllabus, didactic lectures followed by limited question time are commonly offered instead in cardiac rehabilitation programs. However, a guided group discussion, led by a facilitator rather than a lecturer, is the preferred method for educating cardiac patients. As such, the term “lecture” is best replaced with “group discussion”. More active involvement of participants achieves better understanding and learning and provides greater opportunity for clarifying misunderstandings 599–602 and increasing self-efficacy603. More direct participation of patients in their own health care has been shown to influence coping and social and psychological recovery after a major cardiac event312 . Other basic educational principles apply in conducting education groups, such as reinforcing and individualising advice, providing feedback and ensuring that the material presented is relevant to participants 321.

Range of topics
Recommendation
Education and counselling groups should aim to cover a defined range of topics during the program. However, discussion should be flexible. Strength of evidence = 4 Each session may focus on one particular topic (see Chapter 13) or combine a number of topics. However, discussion should be sufficiently flexible for participants to raise questions on other issues of concern. The focus of discussion should be on topics of relevance and interest to the participants in the group, with the patients rather than the facilitator at the centre of the learning experience 602. The specified topic for the discussion may occupy only part of the available time to permit open and almost free ranging discussion between patients and the facilitator or between patients. Participants should be encouraged to ask questions. Participants frequently refer to

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topics mentioned in the media and ask for comments and explanation from the facilitators. Topics of particular interest to participants should be identified and addressed. While in some programs patients are advised in advance of the scheduled dates of topics for discussion, this may unfortunately lead some patients to miss certain sessions which they consider are not especially relevant to them. Participants in the group who seek to dominate discussion should be invited to see the facilitator at the conclusion of the session.

Duration and frequency of sessions
Recommendation
It is recommended that education and counselling group sessions lasting approximately 45 minutes should take place twice weekly for four to eight weeks. Strength of evidence = 4 The optimal number, frequency and duration of group education sessions required to produce favourable effects upon knowledge, attitudes, behaviours or risk factors have not been investigated in controlled trials. However, a recent small study comparing programs held once, twice or three times per week suggests greater patient satisfaction with the amount of information provided in programs with two or more education sessions per week7. Based upon expert opinion and common practice, it is recommended that the “syllabus” should be covered in twice weekly sessions over four to eight weeks. Some patients prefer to continue attending group sessions beyond the end of the program to reinforce their understanding.

Time of entry to the education program
Recommendation
Patients should start attending education sessions within a week to 10 days of leaving hospital. Strength of evidence = 4 Patients should enter the cycle of rotating education sessions at any time rather than waiting to attend a particular session first. The concept of conducting “closed” groups, whereby a group commences when sufficient numbers of new patients are recruited, is not recommended. As explained in Chapter 17, early entry to group rehabilitation programs is advised to facilitate physical recovery and to minimise psychological problems during convalescence.

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Size of groups
Recommendation
The size of education groups may vary but ideally should include no more than 20 to 25 people. Strength of evidence = 4 Education groups need to be limited to 20 to 25 people, including spouses or other family members, to maximise participation of individuals and to facilitate interactive discussion. The participants should sit in a semicircle or in groups to encourage discussion rather than in rows in a lecture theatre or room which generally inhibits individual participation. Smaller groups of six to eight are advised for more intensive counselling and exploration of attitudes and emotions.

Style and level of presentation
Recommendation
Information should be delivered using simple language, supported by appropriate audiovisual materials and teaching aids. Strength of evidence = 4 Patients and family members may have limited education304. Those from non-English speaking backgrounds often have limited English. Use of complex terminology and jargon should be avoided during group education and counselling sessions. Unnecessary detail should also be avoided. Medical terms which may have been used about patients in hospital should be explained simply and clearly. Information regarding risk factors should be provided both orally and visually and should be coupled with practical advice regarding behaviour change. The learning process may be facilitated by the use of diagrams and audiovisual aids, including short videos. The use of a blackboard or whiteboard for diagrams or topics is much valued by patients. Studies have compared interventions such as prepared written materials604, slide and sound packages294,300 and self directed learning and management packages605. These studies have all shown benefits in increasing knowledge among cardiac patients. Posters on the walls are often useful. Information booklets and factsheets may be given to patients to take away to reinforce health messages, providing they are simply written and their contents appropriate for the particular group of patients (for example, patients with rheumatic heart disease usually prefer not to have information about coronary heart disease and vice versa). A resource area should be established where session materials and handouts can be stored. Some pamphlets and factsheets for patients and family members should be on display in the room used for group sessions.
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Individual counselling and referrals
Recommendation
Participants requiring additional support should be identified early, referred to appropriate team members and offered individual counselling. Strength of evidence = 4 Comprehensive assessment of the educational, psychosocial and behavioural needs of each individual patient is not feasible in most programs. However, those patients requiring additional advice or support may be identified during entry assessment to the program or later during group sessions. They should be referred for further counselling to appropriate members of the team or to another health professional in the community. In particular, additional dietary counselling is advisable for many patients, preferably together with their spouses. Such advice needs to be individualised 404 . Individual counselling regarding weight loss may also be necessary for patients who are significantly overweight or who need behavioural interventions to assist them in making other lifestyle changes. A social worker or psychologist should provide individual counselling for those with marital, sexual, financial or psychological problems. Work related counselling should ideally be given by the occupational therapist or other vocational counsellor. Patients should be referred to their general practitioner or specialist if they have concerns regarding diagnosis, symptoms, medication or other medical matters relating to their cardiac or other illness.

Protocol for education programs
Recommendation
Production of a written protocol of the education program is recommended. Strength of evidence = 4 A written protocol for the education program is recommended to ensure key issues are addressed and to introduce some uniformity into sessions. It should contain an outline of the core content and main objectives of each session, as well as some factual information and suggestions regarding methods of delivery, appropriate audiovisual aids and suitable resources for patients. Common questions should be listed, together with appropriate answers. The availability of such a protocol would also enable different facilitators to lead sessions more readily.

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Review of education program
Recommendation
The content of education programs should be subjected to periodic expert review. Strength of evidence = 4 A review of the content of education sessions should be undertaken soon after the program begins and thereafter at intervals to ensure the accuracy and scientific validity of information in the light of changing policies and practices and the availability of new evidence. The review should be undertaken by persons with a knowledge of cardiac rehabilitation and secondary prevention and expertise in medical, educational, behavioural and psychosocial aspects of cardiovascular disease. Feedback from participants should also be sought to ensure that the education and counselling sessions are meeting their needs. Additional sessions covering topics recommended by participants should be incorporated, where possible.

Session facilitators
Recommendation
Education and counselling groups should be facilitated by different members of the multidisciplinary team. Strength of evidence = 4 While most group sessions can be facilitated by one trained health care provider in smaller programs in rural and local communities, it is desirable in larger programs for different members of the multidisciplinary team to facilitate education sessions in turn. Specific areas of expertise of each team member are discussed in Chapter 16. Program co-ordinators should ensure that at least one other team member is able to take each education session, as well as the primary facilitator, should the need arise.

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Training of facilitators
Recommendation
Facilitators should receive training covering the content of education and counselling sessions and effective methods of presenting material to groups. Strength of evidence = 4 Professional development is recommended for team members conducting the education and counselling group sessions. Such training should cover key topics addressed in programs, ways of presenting material and suggestions regarding further resources to enhance facilitators’ knowledge of the area. Health care providers working in cardiac rehabilitation should attend a short course51, especially those planning to remain in the field and those working in remote areas. Inhouse training of team members is also advised.

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CHAPTER 15
PROGRAMS FOR SPECIFIC GROUPS

Recommendation
Additional modules or separate programs tailored to the needs of specific groups are recommended. Strength of evidence = 4 Additional modules or separate programs are required for special groups, such as patients resuming work, those who have undergone percutaneous transluminal coronary angioplasty, patients with other forms of heart disease, and those of nonEnglish speaking or aboriginal background. Home-based programs should be provided for patients unable to attend a group program and those living in rural or remote areas with no group programs. Separate groups for spouses of patients are recommended.

Patients resuming work
Recommendation
The goal of return to work is implicit in physical, educational and psychosocial components of cardiac rehabilitation programs. Specific attention to vocational rehabilitation in recommended. Strength of evidence = 3 All team members should reinforce the desirability of resumption of work as an expected outcome of rehabilitation for those patients previously in the workforce. Efforts to facilitate work return should begin as early as possible, since patients who delay are less likely to resume work34,377,606 . Return to work has been shown to improve emotional well-being377 .

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In assessing patients for resumption of work, the Expert Committee on Rehabilitation after Cardiovascular Diseases of the World Health Organisation1 recommends that the following two questions should be asked early in the rehabilitation program: “What is the nature of the job to which you hope to return?” and “what is the most strenuous or demanding aspect of your job?”. The exact nature of the physical demands of the job need to be assessed, preferably by the occupational therapist. General reconditioning during exercise sessions can prepare patients for resuming physically demanding work, coupled with specific muscular strength training, as discussed in Chapter 7. In this regard, repetitive exercises simulating the activities of work are recommended. However, there are commonly just a few aspects of manual occupations which require much physical effort, since most materials nowadays are handled mechanically. Resumption of work is largely dependent upon psychological recovery and acceptance that work itself is not dangerous. Studies have found that patients’ perceptions of their illness and their ability to return to work are the most significant predictors of resumption of work344,385,607,608 . The significant role of doctors in fostering positive expectations of return to work has also been shown609,610 . To foster greater confidence in the patient’s ability to return to work, work evaluations are recommended which closely simulate work demands, such as using a shovel, lifting heavy boxes or crawling under buildings 39,381,611 . This approach is particularly helpful for patients who are anxious about resuming manual jobs. Such simulated work testing is best undertaken by an occupational therapist or another trained staff member. In some cases, it may be appropriate for a doctor to be present and for a defibrillator to be available. Satisfactory performance on such a test can help not only the patient. The doctor and employer can also be reassured that the patient is able to return to work safely. Similarly, a successful exercise test undertaken towards the end of the program can confirm fitness to return to work39. However, there have been few studies investigating the most effective interventions for facilitating return to work and for assisting patients to remain in work. Further research in this area is required 384. If uncertainty about fitness for work persists, then the employer may agree to a trial at work. If the job is found to be too demanding, then modification, if feasible, may be recommended. Further assistance may be required by patients with poor motivation or other difficulties preventing resumption of work, particularly those in manual occupations who have had coronary bypass graft surgery. Work visits undertaken by the occupational therapist can often facilitate return to work. Although job opportunities may be scarce in some occupational groups, efforts should be made to find alternative employment for patients unable to resume their previous work. Referral to a special vocational rehabilitation program, such as the Commonwealth Rehabilitation Service, is recommended for such patients.

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Patients who have had percutaneous transluminal coronary angioplasty (PTCA)
Recommendation
Separate programs of secondary prevention addressing behavioural change should be provided for PTCA patients. Such programs may be abbreviated and conducted outside normal working hours to facilitate attendance. Strength of evidence = 3 In most cardiac rehabilitation programs in Australia, myocardial infarction and coronary bypass surgery patients participate in the same exercise and education sessions 5,40–41 . Patients who have undergone PTCA are also eligible to attend these group programs but frequently fail to do so 5,6,52,53 . Because PTCA patients have not usually experienced the crisis of an acute cardiac event such as myocardial infarction or coronary bypass surgery, they frequently deny any psychological difficulties or the need for a rehabilitation program, initiating fewer lifestyle changes than other cardiac patients 612. Restenosis occurs within the first six months in over 40% of patients receiving PTCA, but is less frequent in patients where stent implantation accompanies the PTCA 613–615 . Results from randomised trials with one to five year follow-up show a significantly higher incidence of repeat revascularisation, greater prevalence of angina and greater use of medication for PTCA patients compared with those who have undergone coronary bypass surgery616–618 . Moreover, many PTCA patients also have poor psychological outcomes, which demonstrates the need for more effective followup612,619 . Importantly, return to work rates have not always met expectations, with delays in resuming work ranging from 25 days to four months489,620,621 . If exercise testing is arranged after PTCA, it should be undertaken as soon as possible, since patients may delay their return to work until the test has been conducted621. A program of secondary prevention is required to encourage PTCA patients to change their behaviours in order to reduce the risk of a major cardiac event in the future612 . In view of the low attendance rates of PTCA patients at standard cardiac rehabilitation programs, an alternative approach is required for this group of patients612,619 . It is therefore recommended that, where possible, separate programs should be provided. They should focus, in particular on education and behavioural interventions to promote behaviour change. Such programs should preferably be made available outside working hours to enable PTCA patients who have resumed work to attend. Suitable models need to be devised and fully evaluated to determine their effectiveness for widespread implementation.

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Patients with other forms of heart disease
Recommendation
Patients with other forms of heart disease may attend specific programs appropriate to their particular educational needs. Small numbers may necessitate individual rather than group education. Strength of evidence = 4 Cardiac rehabilitation programs, designed for patients with coronary heart disease, may satisfy some of the needs of patients with other forms of heart disease such as congestive cardiac failure, rheumatic heart disease, congenital heart disease, hypertensive heart disease, cardiomyopathy and inflammatory heart diseases. However, additional or separate programs are recommended. Rehabilitation for such patients aims to achieve minimal physical, psychological and social impairment, coupled with lifestyle adjustment, to delay disease progress, disability and death. It also aims to provide education about the causes, prognosis and control of the disease1. Education regarding lifestyle change, stressing the importance of adherence to medication, is also essential. Most important is that sufficient support is given to ensure some optimism and hope about the future. This applies to both patient and family. For many, corrective or palliative surgery or transplantation may be offered. Traditional advice for patients with cardiomyopathy or cardiac failure in the past included the imposition of physical restriction. This advice is now reversed. As discussed in Chapter 11, studies have now demonstrated that low intensity exercise training is safe and beneficial for such patients, both physically and psychologically. The benefits of physical activity and exercise training for patients with coronary heart disease also apply to these patients. While major changes in cardiac function are not usually expected, improvement in peripheral muscle function leads to lesser disability through raising the threshold of activity until dyspnoea or fatigue appear. While such improvement may be demonstrated during group exercise classes, it is also necessary to assure that patients and families learn and understand the benefits and safety of exercise. Children with congenital or rheumatic heart disease may require specific educational and vocational training to assure they may achieve occupations which do not impose much physical demand. Although patients with cardiac failure may join standard cardiac rehabilitation programs, the death rate is high in this category of patients which can be distressing to younger cardiac patients recovering from an acute event. If numbers are sufficiently large and resources are available, therefore, a separate group should be

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formed. Patients with cardiomyopathy or cardiac failure are usually aware that they have a poor prognosis. They usually require individual counselling and may also benefit from participating in a special support group. Overnututrition is a common feature among patients with coronary heart disease, manifested by overweight, obesity, insulin resistance and raised LDL cholesterol. However, the opposite may apply to patients with other forms of heart disease. Wasting is common amongst those with heart failure from all causes. Hence, dietary advice is required to assure adequate caloric and other nutritional intake. Patients with rheumatic, congenital and other forms of heart disease, particularly those with heart failure or atrial fibrillation, require an understanding of different medications from those prescribed for patients with coronary heart disease. In particular, anticoagulant treatment, usually with warfarin, must be understood. Digoxin is taken by most patients with atrial fibrillation and by many others. The prevention and management of heart failure is of major importance in these patients. Angiotensin converting enzyme inhibitors and diuretics are usually taken on a long term basis. Thus, the need for balance of medication effects and fluid intake must be understood. Some patients need to learn how to steer a course between fluid retention, on one hand, and hypovolaemia and syncope on the other 622,623 . Patients with rheumatic heart disease must understand the need for longterm penicillin prophylaxis against further episodes of rheumatic fever and the need for antibiotic prophylactic cover to prevent infective endocarditis following dental and other procedures.

Younger patients
Recommendation
While younger patients may benefit from separate exercise classes, they may be enrolled in the same education groups with older patients. Strength of evidence = 4 According to anecdotal evidence, younger patients frequently state that they dislike exercising in groups which include many older patients and may, therefore, drop out from programs prematurely6. If a number of younger patients enrol in the rehabilitation program, a separate exercise session for them is desirable. However, their educational needs may be largely met in a standard education group.

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Patients of non-English speaking background
Recommendation
Patients of non-English speaking background should be encouraged to attend cardiac rehabilitation programs. Separate programs conducted in other languages are recommended, especially for education sessions. These programs may be delivered on a regional basis. Individual counselling, together with an interpreter, should be provided where necessary. Strength of evidence = 3 A significant proportion of patients with limited English fail to attend cardiac rehabilitation programs5,6,52, commonly because of language barriers and cultural attitudes. Such patients may not be invited or they might not fully comprehend the referral arrangements or the nature of the program624. In some cultures, there may also be a reluctance to participate in a health education program of any kind, especially one conducted in a mixed group. Patients who have some command of English can achieve considerable benefits from participating in an exercise program. However, surveys show that in general, the needs of patients of non-English speaking background are not adequately met by standard rehabilitation programs5,7. Thus, consideration should be given to the establishment of separate educational programs for different groups which are culturally relevant and which can be conducted in their own languages. This is especially necessary for the delivery of educational health messages, particularly dietary advice404. The specific requirements and preferences of each ethnic group should be carefully investigated before setting up such programs. Consumer advisory groups may assist in confirming the cultural appropriateness of such ethnospecific cardiac rehabilitation programs. Similarly, the production of literature in other languages should be preceded by examination of the needs of each group. Staff working with patients of non-English speaking backgrounds should seek to understand the cultural beliefs and practices of different ethnic groups. Ideally, ethnic specific groups should be conducted in collaboration with local ethnic communities, possibly in conjunction with a local community health service. Interpreters should be available in hospital to explain follow-up procedures and the need for rehabilitation to patients of non-English speaking backgrounds.

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Aboriginal Australians with heart disease
Recommendation
Separate, culturally appropriate programs delivered by aboriginal health workers should be provided for aboriginal cardiac patients. Strength of evidence = 3 Aboriginal Australians die from cardiovascular disease at approximately twice the rate of the total Australian population458. Several behavioural risk factors for cardiovascular disease are known to be more prevalent among aboriginal Australians than non-aboriginal Australians, especially diabetes and smoking. In a study of a rural community, aboriginal people were more likely to be smokers and not to participate in vigorous exercise than the general population living in capital cities 625. About 60% of aboriginal males and 57% of aboriginal females are classified as overweight or obese 57. Results of a survey in one region suggest that hypertension is two to three times more prevalent among aboriginal people than the general Australian population 626. The National Health Priority Areas Report on Cardiovascular Health (1998)627 recommends that risk factors among aboriginal men and women should be assessed and appropriate preventive health services introduced and integrated into primary health care. The incidence of rheumatic heart disease among aboriginal Australians living in remote areas is currently the highest in the world 628 . Major problems confronting aboriginal Australians include poverty, lower education, poor health status and cultural and racial barriers. These make access to mainstream prevention and treatment services difficult for aboriginal people. In remote areas, these problems are exacerbated by distance. Many of the problems of aboriginal Australians appear similar to those of native North Americans629–635 . Anecdotal evidence indicates that standard cardiac rehabilitation and secondary prevention programs are not suitable for aboriginal patients5,40,41,51 , who rarely attend available programs. Separate, culturally relevant programs should be devised and aboriginal communities should be involved in the development of such programs 636–639 , together with representatives of peak Aboriginal bodies. As a first step, an assessment should be made of the knowledge of aboriginal health workers concerning coronary heart disease and cardiac rehabilitation. Appropriate training should be available for aboriginal health workers to deliver programs for aboriginal cardiac patients. The content and method of delivering health education to aboriginal health workers needs to take into account the learning styles and environmental and cultural differences of aboriginal people. Health workers in mainstream services in rural and remote Australia should acquire the necessary cross cultural skills to work effectively with aboriginal people.
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Patients from rural and remote areas and others unable to attend a group program
Recommendation
Patients in rural areas should attend a group program if one is available in the region. Otherwise, individual follow-up should be provided by general practitioners and nurses, with regular telephone contact and use of appropriate self-help resources. Strength of evidence = 4 The number of cardiac rehabilitation programs is rapidly increasing throughout urban and rural Australia5,40,41,640 . However, patients living in rural and remote areas may nevertheless find it difficult to attend a program because of distance from the program venue. There may be other patients as well who find it impossible to attend a group cardiac rehabilitation program, even if one is available locally, because of illness or other commitments624. For such patients, suitable audiovisual resources should be provided, including a sheet of home exercises, booklets, tapes or videos about heart disease, symptom management, lifestyle change, risk factor modification and advice regarding resumption of activities of daily living. Such self-help programs have been found to be effective352. A manual has recently been produced to guide rural nurses counselling cardiac patients in remote areas in Australia641. If feasible, home visits by a community nurse should be offered5,6,171 . Outreach programs have been developed in the United Kingdom in recent years to provide cardiac rehabilitation to rural patients and spouses. In one such program, patients are given a heart manual in hospital and during the first six weeks after leaving hospital, patients work through the manual under the supervision of a nurse facilitator 642. Patients are telephoned or visited during this period. They are then automatically referred to an assessment clinic run by cardiologists. Patients found to be still anxious or depressed are referred for assistance. The program is considered beneficial for more remote dwellers who receive support and continuity of care from primary care staff who often have detailed knowledge of the family. In some parts of rural Australia, outreach programs have been recently introduced by Divisions of General Practice which involve regular follow-up of individual cardiac patients by general practitioners643 . These outreach rehabilitation programs are based on the concepts of low intensity, home based exercise and general practice supervised rehabilitation. Patients are supported with an education manual addressing recovery issues, exercise and medication. Patients visit their general practitioner within the first week of hospital discharge and then weekly or fortnightly for the next eight weeks.

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While such programs provide patients living in remote areas with much needed advice and guidance, they do not provide peer support which is a major benefit of group programs. If another non-cardiac community program is available which provides group physical activity and/or health education, patients should be encouraged to attend it so that they may achieve some of the psychological and social advantages of interaction with others. Telephone calls from hospital staff soon after hospital discharge and at intervals during the next six or 12 months are also recommended for ongoing support and to provide advice, if required. Studies have demonstrated the effectiveness of providing education and support to cardiac patients by telephone644. Significantly improved outcomes in preventive care were demonstrated in one study involving telephone support to cardiac and other patients645, and in another, improved knowledge about coronary heart disease, self care and regimens was found295. Telephone and mail follow-up by nurses significantly improved smoking habits, cholesterol levels and functional capacities in patients enrolled in a recent randomised controlled study 104. Such telephone follow-up of patients may reduce medical costs as well as achieving improved medical outcomes646. The feasibility of establishing telephone networks with other cardiac patients should also be determined, especially in remote areas, to provide peer support. Similar telephone networks could also be used by health practitioners to provide education and counselling to a small group of individual patients linked by telephone. Further, telephone communication between groups of rural practitioners may be beneficial to provide support and to facilitate exchange of ideas about effective methods of cardiac rehabilitation for rural and remote patients. Other technologies may also be useful, including video conferencing, the internet and CD ROM programs. Isolation and limited access to continuing education have been cited as major problems among practitioners in rural areas 5,6,51 .

Spouses of patients
Recommendation
Spouses should be invited to attend the program and encouraged to participate in exercise and education groups. Individual counselling should be available, as required. In addition, separate spouse groups are recommended. Strength of evidence = 3 As stated in Chapter 13, spouses of cardiac patients often experience much emotional distress during the acute phase of the illness and during convalescence. Longterm studies also report that female spouses continue to have more responsibilities than

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before the event and enjoy less leisure and social activities309,586 . Since the attitudes and behaviours of spouses are important determinants of the rate and extent of patients’ recovery 647, the effects of a cardiac illness upon spouses must be considered. Wives with poor coping capacities 648, dependent personalities 589 and fewer perceived sources of support 649 are particularly vulnerable to distress and may require considerable assistance. Younger spouses who are in the workforce and those from a non-English background may also experience major difficulties309 . The effects of a cardiac illness upon male spouses has been little studied282. Anxiety of spouses in hospital can be reduced by frequent information and reassurance about the patient’s condition650 and written information about the illness 572. Family conferences before the patient’s discharge from hospital may also be helpful 651,652 . For surgical patients, pre-operative counselling for both patients and spouses is highly recommended583 . Individual counselling of couples in hospital has been shown to be effective in reducing anxiety of spouses, with benefits persisting up to six months 584 . In another study, spouses who had access to a counsellor and who received a booklet reported less anxiety than others 653. The support of spouses during convalescence is best achieved through their participation in an outpatient group rehabilitation program. In addition to participating in education and exercise groups with the patients, group sessions for spouses alone may also be effective in meeting spouses’ needs for further information and for reducing their emotional distress356,534,654 . Discrepancies between patient and spouse concerning the patient’s abilities can have a negative impact upon the patient’s recovery309,534,577 . Nevertheless, perceptions of spouses regarding the patient’s capacity can be modified. In one study, spouses were randomly assigned either to participating in an exercise test, observing their husbands’ undergoing the test or to a control group of spouses who waited outside the exercise testing room380. The perceptions of the patients’ exercise capacities of those spouses who underwent an exercise test themselves were similar to those of the patients. Spouses who merely observed the test were less confident than the patients about the patients’ capacities, while those spouses who remained outside the room were the least confident. In another randomised study involving patients and spouses, training in cardiopulmonary resuscitation was provided to spouses 655. However, results showed that patients of spouses in the intervention group were significantly more anxious three months after acute myocardial infarction and had a poorer overall adjustment to their illness at six months. While some studies have produced favourable outcomes, further research is required to develop and evaluate effective interventions to assist spouses of patients who have had an acute cardiac event.

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CHAPTER 16
CARDIAC REHABILITATION TEAMS

The recommended model for ambulatory cardiac rehabilitation and secondary prevention programs is based upon groups, with input from a variety of health professionals. This chapter outlines the main functions of each team member. Program co-ordination, team meetings, staff training and core competencies are also addressed. Recommendations are largely based upon consensus statements of practitioners who participated in a series of focus group discussions6. They are consistent with recommendations of other bodies1,69,70.

Membership
Recommendation
Ambulatory cardiac rehabilitation and secondary prevention programs should be conducted by a multidisciplinary team. Strength of evidence = 4 Minimum standards for ambulatory cardiac rehabilitation and secondary prevention programs in Australia 79 state that programs may be conducted by one single health practitioner with back-up from other local or regional health practitioners, where available, consistent with recommendations for a “basic” facility of the World Health Organisation Expert Committee on Rehabilitation after Cardiovascular Diseases1. This approach has been demonstrated to be feasible in small Australian rural communities where staffing is limited and patient numbers are low5,41. However, the recommendation for best practice cardiac rehabilitation in metropolitan areas and larger rural centres is for programs to be conducted by a multidisciplinary team of health professionals 656,657 , in accordance with recommendations for an “intermediate” facility of the World Health Organisation Expert Committee on Rehabilitation after Cardiovascular Diseases1. The team should include a nurse, physiotherapist, dietitian, occupational therapist, social worker, psychologist, cardiologist, cardiac surgeon and general practitioner. Others who may participate as members of the team include an exercise physiologist, physical educator, diabetes educator, welfare worker,

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pharmacist, psychiatrist, vocational counsellor, ethnic health worker, ambulance officer and pastoral care worker.

Roles of team members
Recommendation
Special areas of expertise amongst team members should be recognised. Strength of evidence = 4 While many tasks can be shared by more than one member of the team, 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. Activities such as processing referrals, co-ordinating programs and following up patients after program discharge may be allocated to any team member who has good organisational and interpersonal skills and sufficient time available to carry out these duties.

Nurse
Recommendation
Nurses fulfil a range of functions in cardiac rehabilitation and secondary prevention programs and should be considered key members of the team. Strength of evidence = 4 Nurses are involved in most ambulatory cardiac rehabilitation and secondary prevention programs throughout Australia. In their view, one of their important roles is to detect medical and other problems which become apparent during the program and to refer patients to other health care providers, when required6,658 . 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 centres, especially in rural areas, nurses are responsible for a greater range of activities, including conducting exercise sessions and recruiting patients to programs5. Whereas some teams members rotate for a short time through a particular service in the hospital or attend outpatient programs only for specified sessions, nurses often attend patients from the time of the patients’ admission to hospital. Nurses therefore provide continuity for patients after

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discharge from hospital and are often perceived by patients to be the program coordinator. Nurses also consider they are best suited to the co-ordinating role because they are multiskilled and have an overall perspective of patients’ problems. Nurses co-ordinate 72% of programs in Victoria5. A similar pattern prevails nationally41.

Physiotherapist
Recommendation
The physiotherapist should assess the physical needs of patients, devise exercise programs tailored to meet the requirements of the individual patient and supervise the exercise sessions. Strength of evidence = 4 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 minimise 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. In 52% of Victorian programs, the physiotherapist supervises the exercise sessions5. While focusing particularly upon the patients’ physical needs, the physiotherapist should 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. According to physiotherapists, patients enjoy exercise sessions and place great importance upon what they can do physically. Exercise is viewed by patients as something which is tangible, measurable and understandable6,7 . Other key roles of the physiotherapist include monitoring patients during exercise sessions. Pains 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

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physiotherapist may overlap to some extent with that of the occupational therapist. To minimise role conflict, each team should determine which health professional has more appropriate skills for the tasks involved in promoting the physical rehabilitation of patients and allocate roles accordingly.

Dietitian
Recommendation
The dietitian is an essential member of the team, undertaking group and individual counselling about nutrition and appropriate dietary habits. Strength of evidence = 4 Although patients receive some dietary information in hospital, dietary advice is best provided by the dietitian during the outpatient program when more time is available to follow-up advice given in hospital. Discussion over a period of weeks is highly desirable to address individual queries, especially from those with limited ability to comprehend dietary information. Moreover, several dietary sessions are recommended, because patients are generally unable to absorb all the necessary information at once. Nearly all ambulatory programs throughout Australia involve a dietitian but the extent of the dietitian’s input varies considerably between programs5,41. In some programs, dietitians facilitate several sessions39, whereas in other programs, only one session is devoted specifically to dietary issues. Research findings suggest that cardiac patients generally want more dietary advice than they currently receive7. Regardless of their cholesterol levels, patients require counselling about healthy dietary habits and explanations about food labels in order to 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. The dietitian needs to provide individualised advice, where possible. Information provided in a group setting can be confusing if there is a significant disparity in the ages and cultural backgrounds of participants. For example, information for an overweight, prediabetic 40 year old patient with lipid abnormality might be quite inappropriate for a 70 year old female with average lipid levels whose major risk factor was hypertension. According to dietitians, general practitioners tend to give the same advice to all patients6. For example, they may prescribe unnecessarily restrictive low fat diets to elderly, female patients whose cholesterol is above some publicised, arbitrary cutpoint (such as 5.5 mMol/L) and give no advice to a young man whose cholesterol level is below the same cutpoint.

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Referral of patients from non-English speaking backgrounds to dietitians of similar ethnic origin is desirable. Apart from language barriers, most dietary information available to cardiac patients remains oriented towards Australian habits and thus may not be relevant to patients from other cultures. Dietitians from other ethnic backgrounds may be employed at community health centres or attached to general medical practice in the region. An important function of the dietitian is to clarify misconceptions about diet and nutrition. Team members agree that 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 providers6 and are understandably confused about which advice they should follow. According to dietitians, dietary advice provided by general practitioners and nurses, in particular, is often at variance with advice given by dietitians 6. To avoid conflicting and inaccurate dietary information being imparted by different members of the team, dietitians need to ensure that all team members follow the same general guidelines concerning diet and reinforce the dietitian’s advice. To encourage more consistent and relevant dietary advice to patients, it is desirable for team members to receive regular inhouse training and updating regarding appropriate dietary advice for cardiac patients. The problem could be minimised further by having regular team meetings and producing or having available written guidelines and formal protocols for nutritional education sessions. Specific dietary advice should be delegated to the dietitian, with other team members providing general information only. Counselling regarding weight loss may also need to be individualised and appropriate. Dietitians expressed concern that other team members commonly provide incorrect information about weight loss and recommend fad diets to patients, putting pressure on them to lose weight quickly when slow loss is considered more appropriate 6.

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Occupational therapist
Recommendation
The occupational therapist has important roles in the team, especially in facilitating return to work and assisting the patient to function effectively and independently. Strength of evidence = 4 The occupational therapist’s role in cardiac rehabilitation programs is oriented towards assisting the patient to function effectively and independently in 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 disablement. The occupational therapist has specific training to undertake 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 undertakes work conditioning and, if required, may also conduct simulated work tests, liaise with the employer and visit the worksite611. Occupational therapists state that doctors are often unaware of the nature of the patients’ jobs and may give the patient inappropriate advice about resuming work. Thus, communication is recommended between the treating physician and the occupational therapist regarding plans for return to work. 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. The roles of the occupational therapist are poorly defined659 and are commonly misunderstood by other team members 6,40,41. 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 other staff 660. For example, stress management sessions are sometimes conducted by the occupational therapist5,6,41. Occupational therapists are involved in patient education and counselling and are trained in group dynamics and facilitating groups. In some programs, the occupational therapist participates in the group exercise sessions 5,41. Occasionally the occupational therapist co-ordinates the overall program5,41 . It is important for other team members to refer patients to the occupational therapist, if there are perceived occupational problems. Although the roles of the occupational therapist and physiotherapist may overlap, their primary functions differ, with the physiotherapist using exercise and physical
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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, many tasks may be undertaken by either team member5,40,41. Typically, however, the occupational therapist is more involved in the later stages of the patient’s recovery rather than in hospital.

Social worker
Recommendation
The social worker plays an important role in the team by promoting the psychosocial recovery of the patient and supporting the patient’s family. Strength of evidence = 4 The social worker can make an important contribution to the psychosocial adaptation of the patient and family through education and intervention661,662 . The social worker’s primary role is to detect any psychological or social problems and to undertake counselling, if required. Issues commonly addressed during counselling include grief and stages of loss; the development of coping strategies to handle emotional responses such as anxiety and depression; the impact of the illness on the family; and sexual activity, a concern commonly raised with the social worker during individual counselling rather than with other team members, and return to work and the future. Ideally, the social worker should have access to patients in hospital to assess the need for counselling, rather than awaiting referral from other staff. Detection of psychosocial problems may be difficult because of their subtle presentation. In many programs, the social worker is responsible for attending to the practical needs of patients including discussion of the patient’s financial status, and where necessary, facilitating the patient’s access to social security benefits, liaising with employers and arranging for interpreters 5,40,41,663 . The social worker may also facilitate access to community services such as meals on wheels and home care nursing agencies. In some hospitals, these functions may be carried out by a welfare worker. The social worker also has an important linking function661,663 , communicating with patient’s spouse and family, especially during the acute phase of the illness, and offering assistance. A family meeting may be organised by the social worker to assess and assist with the patient’s and family’s adaptation to the illness651. Another useful role played by the social worker is to organise and conduct separate spouse groups during convalescence to address any psychological problems and concerns they may

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have. The social worker may also follow up the patient during convalescence and, if the patient dies, offer support to the spouse. Greater involvement of the social worker in addressing the needs of special groups is recommended. Such groups include those patients from other cultures and those who are insecure about resuming work. The social worker can make a positive contribution to teamwork by providing feedback about how the patient is coping with the illness. Instructing patients in stress management and relaxation techniques may also be undertaken by the social worker. While the social worker’s role is especially important during the acute phase, some emotional, family and other problems may only become apparent during convalescence. Thus, it is essential for a social worker to be involved in the ambulatory program. Social workers perceive that, unfortunately, there is a far greater emphasis upon the physical aspects of rehabilitation during outpatient programs, with insufficient time allocated to psychosocial aspects6. This deficiency is becoming more pronounced with shortened hospital stays. At present, social workers participate in 56% of the education groups provided in Victorian ambulatory programs. Social workers report that doctors and other members of the team do not always understand the roles of the social worker, often encroaching upon their territory without the necessary skills to do so 6. They state that while nurses may undertake counselling of patients, they are more limited in their approach. Welfare workers also counsel patients but have relatively little training to do so. According to social workers, welfare workers are less aware of the dynamics of psychosocial aspects of rehabilitation 6. Apart from the psychiatrist and psychologist, the social worker is the only member of the team with training in psychosocial counselling in individual, group and family settings.

Psychologist
Recommendation
The psychologist should be involved in cardiac rehabilitation and secondary prevention programs to assist with psychosocial aspects of the patient’s rehabilitation and to facilitate behavioural changes. Strength of evidence = 4 Psychologists have a role in conducting relaxation or stress management sessions664,665 . The psychologist may also be trained in individual and group counselling and can therefore facilitate sessions with patients and spouses 666. In undertaking counselling 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
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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. Relatively few cardiac rehabilitation and secondary prevention programs in Australia include a psychologist at present5,41 and their involvement in programs in European countries varies considerably 667. However, clinical psychologists can also make a significant contribution by using behavioural strategies to help patients acquire skills to change and maintain healthier behaviours. This aspect of secondary prevention needs further development in cardiac rehabilitation programs. Psychologists should be more extensively involved in programs to address this need.

Cardiologist
Recommendation
The cardiologist should define the medical parameters of the program, review the medical content, encourage patients to attend the program, facilitate the roles of other team members and support the program. Strength of evidence = 4 Cardiac rehabilitation and secondary prevention programs include a significant component of education concerning medical topics, as discussed in Chapter 13. 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 programs6. Further, they maintain that restrictive dietary advice is often given to patients by nurses 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 minimise the amount of conflicting and inappropriate advice, as recommended in Chapter 17. While cardiologists do not generally play an active role in group cardiac rehabilitation programs 276, 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 members668. Where possible, it is highly desirable for the cardiologist to facilitate an occasional group discussion during the outpatient program. Occasional brief visits by the

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cardiologist to a group discussion or an exercise session are also much appreciated by patients 6. 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 5. In a few programs, a cardiologist with a special interest in cardiac rehabilitation may be appointed as Director of Cardiac Rehabilitation. However, such programs are usually managed by an appointed co-ordinator. Although most hospitals have a policy of automatic referral of eligible patients to ambulatory programs 5,41, some cardiologists claim that certain patients (such as those with atypical chest pain with no confirmed diagnosis of coronary heart disease) who are unsuitable for the program are sometimes enrolled by nurses or other team members6. If cardiologists consider certain individual patients unsuitable for rehabilitation, they should advise the program co-ordinator and include a written note to this effect in the patient’s medical records.

Cardiac surgeon
Recommendation
The cardiac surgeon should support cardiac rehabilitation and secondary prevention programs by referring patients and encouraging them to attend. Strength of evidence = 4 While cardiac surgeons do not actively participate in cardiac rehabilitation and secondary prevention programs in Australia5,40, they should endorse the program, referring patients and encouraging them to attend. Most cardiac surgeons endorse automatic referral of almost all patients who have undergone coronary artery bypass surgery 6.

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General practitioner
Recommendation
The general practitioner should refer patients to group rehabilitation programs and manage the long-term medical follow-up of patients. Strength of evidence = 4 Referral to an ambulatory rehabilitation program should be organised 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 attend276. 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 6,40,288 . According to one study, the strength of the primary physician’s recommendation to attend a cardiac rehabilitation program was the most powerful predictor of attendance288. 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 fulfil these roles adequately, the general practitioner needs sufficient information about the aims and content of cardiac rehabilitation and secondary prevention programs. As recommended in the following chapter, 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 underutilised as a resource6. In their opinion, cardiac rehabilitation offers opportunities for a shared care approach in which their input could be very valuable. While recognising 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 maximise 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 6. 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 changes669–671 . Thus, the general practitioner has an important educational role, especially after the patient completes the ambulatory group program. The program co-ordinator 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

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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 minimise the likelihood of patients receiving conflicting information. The general practitioner has continuing responsibility for ensuring that there is longterm satisfactory control of patients’ symptoms, lipids, smoking habit, blood pressure, diabetes, weight and well-being. This may necessitate intermittent or regular testing, as indicated by national or other current guidelines. Team members should emphasise the importance of the general practitioner’s role and encourage patients to see their general practitioner at regular intervals. While the general practitioner is often close to the patient and family, other health care providers may have more time to devote to handling the patient’s nutritional, psychosocial and other concerns. The general practitioner should refer the patient to other health care providers, such as dietitians and social workers, as required6. In a few programs in Australia, especially in community settings, a general practitioner facilitates occasional education group discussions at cardiac rehabilitation and secondary prevention programs5,40. However, as a general rule, it may not be feasible for the general practitioner to be an active participant in the group program because of time constraints 6.

Exercise physiologist
Recommendation
The exercise physiologist has advanced training in exercise prescription and should design and conduct exercise sessions which involve high intensity exercise training. Strength of evidence = 4 In a few parts of Australia, an exercise physiologist conducts exercise sessions instead of a physiotherapist 40–41 . Exercise physiologists are more likely to be employed in exercise programs providing high intensity exercise training.

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Exercise therapist
Recommendation
An appropriately trained exercise therapist may conduct exercise sessions as part of ambulatory cardiac rehabilitation and secondary prevention programs. Strength of evidence = 4 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.

Diabetes educator
Recommendation
A diabetes educator is a valuable member of the team and may provide individual or group counselling. Strength of evidence = 4 Many cardiac patients suffer from diabetes mellitus or are at high risk of developing diabetes because they are overweight or obese. Diabetes educators occasionally facilitate education groups in ambulatory programs but are more commonly involved in the counselling of individual patients who are referred to them by other team members5,41.

Welfare worker
Recommendation
A welfare worker, with additional training or experience, may fulfil some of the roles of the social worker. Strength of evidence = 4 Some hospitals employ a welfare worker as well as, or instead of, a social worker. The welfare worker’s training lies more in attending to practical issues, such as arranging payment to the patient of any social security benefits and liaising with employers about matters concerning return to work5,40. These issues are of great importance to some patients. The welfare worker may also assist the patient with financial problems arising during periods of unemployment and provide family support.

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Rehabilitation physician
Recommendation
A rehabilitation physician who has experience managing patients with cardiac illness may participate in the team conducting the cardiac rehabilitation and secondary prevention program. Strength of evidence = 4 In some countries, the rehabilitation physician is actively involved in inpatient and ambulatory cardiac rehabilitation programs. In Australia, however, the rehabilitation physician is rarely involved in programs conducted during convalescence, apart from a few which are provided for patients admitted to rehabilitation hospitals5,40,41 .

Pharmacist
Recommendation
The pharmacist can play an important role by providing information and advice to the patient regarding medications and encouraging compliance with regimens. Strength of evidence = 4 Patients attending cardiac rehabilitation programs typically have many questions concerning the purpose of their medications and common side effects. These issues can be effectively addressed either by a pharmacist, doctor or nurse, providing that simple terms are used and complex pharmacological jargon avoided. Pharmacists are currently involved in 65% of ambulatory programs in Victoria. In country programs, pharmacists facilitate education groups more frequently than in metropolitan centres5.

Psychiatrist
Recommendation
A psychiatrist should be available to the team for referral of cardiac patients with psychiatric problems. Strength of evidence = 4 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

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psychiatric illness which is exacerbated by the cardiac event or illness672. The social worker, psychologist and other staff trained or experienced in counselling are able to help most patients who are experiencing psychological problems, referring them to a psychiatrist if it is indicated.

Vocational counsellor
Recommendation
A vocational counsellor should be available to team members for referral of patients requiring vocational advice, support and possible retraining. Strength of evidence = 4 As discussed in Chapter 15, patients who need specialised vocational counselling may be referred to special vocational rehabilitation centres in the region, such as Commonwealth rehabilitation centres. Here they are prescribed an exercise program specifically tailored to their job requirements. They also receive help in resuming work or finding new employment. For most cardiac patients, however, assistance from an occupational therapist is usually adequate.

Community health worker
Recommendation
The community health worker can provide ongoing support to patients and families, especially during later stages of the patient’s recovery. Strength of evidence = 4 The community health worker commonly has a nursing background and is generally multiskilled. He or she can provide ongoing support and assistance to patients and families, referring to other health care providers, as required. Teams delivering hospital-based cardiac rehabilitation and secondary prevention programs should strengthen links with community health services and encourage patients to use these services for further support and advice.

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Other health practitioners
Recommendation
Other personnel may occasionally participate in cardiac rehabilitation programs, including such health professionals as medical interpreters, ethnic health workers, ambulance officers and pastoral care workers. Strength of evidence = 4 Medical interpreters should be available to assist patients with little or no English. Occasionally, an ethnic health worker may also attend programs to support such patients. In some ambulatory programs, an ambulance officer may be included among facilitators of group discussions. The pastoral care worker may offer support to patients during the acute phase of their illness or subsequently.

Program co-ordinator
Recommendation
One member of the team should be designated the co-ordinator to ensure proper organisation of the program. Any member of the team with appropriate skills may be the program coordinator. Strength of evidence = 4 A designated program co-ordinator is essential to ensure efficient running of the program. The co-ordinator requires good organisational, management and interpersonal skills, the time to devote to the tasks involved and a commitment to the program. Team members should approve the choice of co-ordinator. It has been traditional for nurses to co-ordinate programs in Australia 5,40,41, in part because there are more nurses available to fulfil this role. Nurses have usually had previous contact with patients and have established empathy with them 6. While some cardiologists and general practitioners consider that the cardiologist should coordinate the program, they also recognise that the cardiologist does not have the time to carry out the many duties of program co-ordinator6. Other team members, such as occupational therapists, consider that in some respects, nurses are less suitable to be the program co-ordinator because their backgrounds are generally in acute health, whereas others, including occupational therapists, are trained in rehabilitation6. An important function of the co-ordinator is to organise referrals, liaise with general practitioners and forward discharge summaries to them when patients complete the program. The co-ordinator should also be responsible for referring patients to

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appropriate community services during or following the program and maintain contact with patients, if possible, to follow-up their long term progress. The coordinator requires good record-keeping skills for these tasks. Another responsibility of the co-ordinator is organising team meetings and ensuring all team members are familiar with the program. The co-ordinator should identify specific roles within the team, minimising any conflict between team members and avoiding duplication of effort. However, some overlapping of roles may be beneficial if it reinforces advice from other team members. In-house training of team members should be organised by the co-ordinator, as required. The co-ordinator requires enthusiasm, confidence and a commitment to cardiac rehabilitation. Another important attribute is the ability to motivate others in the team. Further, the co-ordinator needs to have a sound knowledge of coronary heart disease and other cardiac conditions, as well as the relevant terminology. A good knowledge of each stage of recovery from an acute cardiac event and of the rehabilitation process is also required.

Regional co-ordinator
Recommendation
In regions where several programs are offered, it may be appropriate to appoint a regional co-ordinator of programs. Strength of evidence = 4 A regional co-ordinator may be necessary in certain regions to facilitate referrals between programs in the same area or within the same health care network and to encourage uniformity in the structure and content of programs.

Team meetings
Recommendation
Meetings of the rehabilitation team should be held at regular defined times Strength of evidence = 4 Team meetings are recommended to facilitate communication between team members and to provide regular opportunities to discuss patients who have recently enrolled and those who are experiencing problems. The specific input of each team member in relation to individual patients can also be clarified during meetings to avoid overlapping of roles. Team meetings should be held at least monthly, and preferably

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weekly. They should be attended by all team members. As well as addressing the needs of individual patients, these meetings should also review the program, refining it as required.

Core competencies and staff training
Recommendation
Team members should have appropriate qualifications and core competencies. Strength of evidence = 4 Core competencies of health professionals involved in best practice cardiac rehabilitation and secondary prevention programs in Australia have not yet been defined and require further study. However, it is generally accepted that team members should hold a recognised qualification, such as a degree or diploma. Nurses should ideally have coronary care training in addition to general nursing qualifications. Additional qualifications for program co-ordinators or other team members who plan a longer career in the field may also be appropriate, such as a tertiary qualification in health education or cardiac rehabilitation, if available. A minimum requirement should be attendance at a short course in cardiac rehabilitation 51, together with observation of some established programs. Continuing education by attending national and state conferences and workshops is highly desirable. As previously stated, all team members should participate in some form of periodic inhouse training to acquire an understanding of the aims and content of each component of the program and to appreciate the roles of other team members. While certain team members may be primarily responsible for specific tasks, it is useful for all team members to have some knowledge and skills in areas such as the following: • counselling patients • facilitating behaviour change • supervising exercise sessions • conducting interactive discussion groups • discharge planning • program management • patient follow-up • nutrition education • emergency procedures (all staff should have current CPR training) It is also advantageous for program co-ordinators and other team members to acquire basic skills in data collection and documentation, and the use of a personal computer. Such skills should facilitate systematic record keeping of patients’ progress, contacts with attending doctors and other health care providers, and periodic auditing of the program.

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CHAPTER 17
ORGANISATIONAL ISSUES

Best practice requires monitoring and continuous improvement of the processes of program delivery, as well as measurement of program outcomes. Earlier chapters examined the scientific evidence for the benefits of cardiac rehabilitation and secondary prevention programs. This chapter deals with the processes for effective organisation and implementation of programs. A number of authoritative bodies recommend that referral procedures and other organisational aspects of cardiac rehabilitation and secondary prevention programs should be formalised70,388. Material in this chapter draws extensively upon health care providers’ perceptions of best practice and consumer feedback.

Establishing programs
Recommendation
Organisational aspects of the program should be clearly defined and documented and periodically reviewed. Strength of evidence = 4 When establishing a cardiac rehabilitation and secondary prevention program, a document should be produced giving details of the following: • overall business plan • aims and objectives • content and program modules • equipment, equipment maintenance and resources • venue and space • patient target groups • entry and discharge assessments • program duration and session times • frequency and length of sessions • referral procedures • strategies for handling nonattenders and dropouts • staffing, team roles

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• • • • • • • • • •

liaison with doctors and other health care providers reporting lines and responsibilities staff training and performance reviews funding, budgets and budget management health and safety responsibilities professional and public liability promotion of the program procedures for recording patient information methods of benchmarking and evaluation review of program objectives, content and structure

Some of the above matters are covered in more detail elsewhere in these Best Practice Guidelines. Those specifically relating to organisational aspects of programs are dealt with in this chapter. The process of establishing a program should include consultation with practitioners already working in the field. In Australia, the recently revised manual produced by the National Heart Foundation of Australia entitled “How to plan a cardiac rehabilitation program” should be purchased and used as a guide674. Attendance at a short training course 51 is also recommended. Professional and public liability issues need to be considered and expert advice should be sought regarding these matters.

Eligibility for referral to the program
Recommendation
All eligible patients should be automatically referred to an ambulatory cardiac rehabilitation and secondary prevention program, unless the patient’s doctor advises otherwise. Agreement for automatic referral to programs should be sought at each hospital, with provision for veto in individual cases where medical contraindications are considered to exist. Strength of evidence = 4 Automatic referral to ambulatory programs is practised in over 70% of hospitals and community health centres in Victoria5. Elsewhere in Australia, formal referrals are more often required, although automatic referral is becoming increasingly common41. There may be contraindications on medical grounds to the enrolment of some individual patients. In such cases, the treating doctor should advise the program coordinator of the patient’s unsuitability for attendance at the outpatient program, together with the reason. This decision should be recorded in the patient’s history.

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The treating doctor must be consulted about referral of patients whose diagnosis is equivocal, in order to avoid the harmful effects of inaccurate “cardiac” labelling”675.

Hospital discharge plan
Recommendation
Hospital discharge plans should include clear written procedures for referring patients to an ambulatory group program and for arranging follow-up doctors’ appointments. Strength of evidence = 4 As discussed in Chapter 3, participation rates in cardiac rehabilitation programs is less than half the eligible patients who have suffered an acute cardiac event attend an ambulatory cardiac rehabilitation program in Victoria 53, despite the widespread network of programs5. In the United States of America, probably less than one fifth of eligible patients attend2,54. A major factor in such nonattendance is the absence of effective referral procedures2,5,6. Referrals should be arranged before patients are discharged from hospital. Follow-up appointments with the patient’s general practitioner and specialists should also be routinely arranged. After leaving hospital, patients should be contacted by the program co-ordinator who should reinforce the desirability of the patient’s attending the program and provide assistance, if required, to facilitate attendance

Method of invitation to the program
Recommendation
Invitations to attend an ambulatory program should be given to patients in writing, preferably signed by the patient’s treating doctor, together with a simple brochure about the program, and an appointment for first attendance arranged and documented in the patient’s hospital records. Strength of evidence = 4 Because of patients’ heightened anxiety in hospital and their concern with other issues, invitations to attend a rehabilitation program which are conveyed verbally are commonly forgotten or misunderstood6,52. Therefore, a letter of invitation handed to the patient by the program co-ordinator or other designated person is required. It may be given to the patient together with written details of follow-up medical appointments. The letter should be accompanied by a simple brochure about the program. Information about the program should include a brief description of the

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contents of the program and details of the venue, date of first attendance, frequency and duration of the program, clothing requirements and cost, if any. An appointment for first attendance at the program should be negotiated and the benefits of attending should be highlighted. The letter should be signed by the program co-ordinator and, ideally, by the patient’s doctor as well. Studies in other settings suggest that invitations to attend a program by letter attracts a higher rate of attendance than verbal invitations, especially if the letters are signed by the patient’s doctor or other authoritative person 676. Participation in a ambulatory program may also be increased if doctors, during their ward rounds, refer to the program and encourage patients to attend.

Invitations in other languages
Recommendation
Patients of non-English speaking backgrounds should be given a letter of invitation and brochure about the program in their own language. An appointment should be arranged for first attendance at the program. Strength of evidence = 4 Patients of non-English speaking background may not fully understand what the program entails if the invitation is given verbally or if the invitation is written in English. Invitations written in the patient’s own language have been shown to increase participation rates at health education programs. The assistance of interpreters should be sought in hospital and when patients of non-English speaking backgrounds first attend the program. Since family members are expected to play an important role in the patient’s recovery, it is also desirable for such patients to bring a relative fluent in English to the first, and where possible, subsequent sessions, so that family members can hear and understand the discussion..

Initiating referrals and motivating patients
Recommendation
The program co-ordinator or nominee should personally hand the patient the letter of invitation, explaining its contents, encouraging the patient to attend and arranging the first attendance. Strength of evidence = 4 Some patients are not sufficiently motivated to attend a cardiac rehabilitation program. Others anticipate problems in attending because of transport, language,

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work commitments or other difficulties. It is important for the co-ordinator to determine the level of patients’ motivation to attend and to explore possible barriers to attendance before the patient is discharged from hospital. Further explanation and an offer of assistance may encourage such patients to attend. This should be done when handing the patient the letter of invitation to the program. It may be helpful to ask a former patient who has participated in an ambulatory program to talk to patients who appear reluctant to attend. Contacting patients by telephone after discharge from hospital may also increase attendance rates. If the patient does not have a telephone at home, the telephone number of a neighbour or relative should be requested and noted in the program co-ordinator’s records in case follow-up is required.

Invitations to spouses
Recommendation
Spouses should receive an individual letter or brochure, inviting them to attend the program and pointing out the potential benefits of their attendance. Strength of evidence = 4 In most cases, spouses are encouraged to attend the program with the patient. However, the proportion of spouses who actually do attend varies between programs 5,6. Spouses who are in the workforce cannot usually attend day-time sessions. Nevertheless, they may appreciate the invitation to attend and to learn about the program and the importance of the patient attending. Some studies have found that spouses who may have been keen to participate in the program were not informed by the patient that they were invited to do so309. Thus, direct contact with the spouse by a team member is desirable. If spouses are unable to attend the entire program, they should be encouraged to attend the initial session when the patient is assessed and rehabilitation plans are made. Spouses who cannot attend personally may be offered the opportunity to discuss any concerns with a team member by telephone.

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Selection of program
Recommendation
The program co-ordinator should refer patients to the program at the parent hospital or to another suitable program near the patient’s home, whichever is most acceptable to the patient. Strength of evidence = 4 Patients may attend the program offered at the hospital to which they were admitted or, if discharged from a metropolitan hospital to the country, to the nearest program in the district. Patients in metropolitan areas who live some distance from the parent hospital may also be referred to another program near their home. Program coordinators should consult the Directory of Cardiac Rehabilitation Programs produced by the National Heart Foundation of Australia to identify the most appropriate program640 . Possible options should be discussed with the patient before discharge from hospital. Contact should then be made by telephone with the co-ordinator of the program to which the patient is being referred to make the necessary arrangements. A written referral should then follow, which should be transmitted by facsimile prior to discharge to minimise any delay in enrolling the patient. The co-ordinator of the designated program should be responsible for contacting the patient about a commencement date. Anecdotal evidence suggests that these procedures are not always followed 5,6 .

Time of commencing the program
Recommendation
Patients should begin attending the program within a few days or a week of leaving hospital, unless there are medical reasons for delaying enrolment. Strength of evidence = 4 Early enrolment in a program is strongly recommended. Convalescence is a time when patients commonly experience significant psychological problems, especially a depressed mood 360,499,503,513 . Patients gain significant psychological benefits from attending a group rehabilitation program, through recognising that their problems are not unique and by observing rapid progress in others and themselves7,309. Since the recommended rehabilitation programs are based on light to moderate exercise, there is no need to defer attendance at the program until a greater level of fitness has been attained or an exercise test conducted (see Chapter 10). Patients unable to exercise during early convalescence can benefit psychologically and socially from meeting other patients and from participating in the education sessions. Reports indicate that
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some patients are not invited to begin a program for four weeks or more after hospital discharge because of long waiting lists5,6. In such cases, it is preferable to refer patients, if possible, to another program with no waiting list rather than allow an excessive delay before starting the program. If there is a frequent overload of patients, a second parallel program should be introduced.

Entry assessment
Recommendation
Patients should be formally assessed at entry to the program and a mutually acceptable treatment plan devised. Strength of evidence = 4 Before patients commence the program, they should attend for a pre-program assessment. At this interview, the purpose of the program and its contents should be explained to the patient and, if present, family members. Consent should be obtained from the patient to enter the program. Patients must also be informed that they may withdraw from the program at any time or seek to have the program modified to suit their specific needs. Patients’ perceptions of their illness and their expectations of recovery should be explored. Specific concerns should be discussed and the regimens clearly explained. A plan should be devised and agreed upon, focusing on specific goals of rehabilitation for that patient and addressing potential barriers to lifestyle change 290. For patients who need to make several behavioural changes, it is preferable to prioritise the desired changes. Where possible, the patient’s spouse or partner should attend and participate in the decision-making process, together with the patient and staff member conducting the assessment. The importance of attending and completing the program should be emphasised to the patient at this stage, and if possible, a commitment to attend should be obtained from the patient. Studies have shown that obtaining a written commitment to attend reduces dropout. The entry assessment may be quite brief, but approximately 30 minutes on average should be set aside for each patient. The entry assessment interview facilitates the establishment of rapport. Fortunately, most patients have relatively few problems and these are commonly readily recognised. Further targeted planning may take place during the first few sessions. The plan may be reviewed and revised, as appropriate, during the course of the program. A provisional time for review and discharge of the patient should be set. Input into the plan from other members of the multidisciplinary team is important, either at the entry assessment or later during team meetings.

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At the entry assessment, the patient’s medical record should be consulted. The following should be documented on an appropriate form: • diagnosis • past medical history • current medications • physical and functional status • risk factor profile • health behaviours • occupation, employment status, plans for resuming work, type of work • most demanding aspect of work or lifestyle • financial status • psychosocial issues, including the availability of social support. • appointments to attend general practitioner, cardiologist or surgeon

Selection of program modules
Recommendation
In addition to group exercise and education sessions, other program modules may be recommended for some patients, if required. Strength of evidence = 4 Patients should be referred, if required, to specialised programs addressing specific needs or to other health care providers for individual counselling about specific problems. For example, some patients may benefit from vocational retraining or attendance at smoking cessation classes. Others may require individual counselling to help them deal with psychological, social or financial problems. Many patients require separate, additional dietary counselling. The need for such referrals may be identified at the entry assessment, during the rehabilitation program, at weekly team meetings or informally by any team member conducting sessions. Some larger programs provide a range of exercise, education and counselling sessions. Patients should be enrolled in those modules which best suit their individual rehabilitation needs.

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Encouraging participation in programs and monitoring attendances
Recommendation
Program staff should document attendances at each session and monitor attendance patterns carefully. Nonattenders and dropouts should be contacted and encouraged to attend the program. Strength of evidence = 4 Several studies report high rates of nonattendance and dropout at cardiac rehabilitation and secondary prevention programs52,53,276,285,288 . Factors commonly associated with nonattendance include distance from the program venue or lack of transport 276,288 , inconvenient timing of the program624, female gender 54,55,276,285 , older age54,55,277,624 , especially among women55,276, unemployed status and lower socioeconomic status 52,55,276,285,677 , functional impairment 285 , presence of complex problems56, a perception that the illness is not serious288, lower socioeconomic status and less education 55,285 , lack of referral 52,276,286 , especially among patients discharged from a general medical ward678 , or those who are depressed288; and weak or no recommendation by the doctor288,671 . Studies show dropout from programs is more common among smokers 679, and those of lower socioeconomic status 677,679 . A program register should be available to record details of patients who have been referred to the program and of those who have been enrolled. Attendances at sessions should be monitored. Patients who have been referred to the program but who fail to attend, or who drop out after a few sessions, should be contacted to find out their reasons for doing so and to provide assistance to facilitate their attendance. Referral sources could also be examined to identify whether patients from particular hospital units are not attending. Characteristics of nonattenders and dropouts should be documented. A contact name and telephone number should be included in the letter of invitation and in the brochure about the program so that patients can advise staff if they cannot commence on the specified date or if they need to be absent from the program after commencing. As noted previously, local patient “consumer” groups can be helpful in contacting patients to encourage them to attend the program, especially in country areas. Other ways of minimising nonattendance and dropout should be explored. Different approaches may be required to encourage the attendance of specific groups of patients (for example, those who have had coronary angioplasty, older women, patients with limited English or patients who do not drive a car).

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Discharge review
Recommendation
Patients should be formally assessed upon discharge from the program. Strength of evidence = 4 As previously stated, an exercise test towards the end of the program can be an effective way of demonstrating the patient’s progress and assessing readiness to resume work and other activities39,379 . The exercise test should be coupled with a medical review of the patient’s risk factors and medications and discussion of any concerns. Plans for returning to work, if applicable, should be addressed. For some patients, simulated work assessments should also be undertaken before discharge, as noted earlier. Arrangements for medical follow-up should be confirmed and patients should be encouraged to attend their doctors. Patients and spouses should be invited to contact the program co-ordinator in the future, if they have any concerns.

Referral to maintenance programs
Recommendation
All patients should be encouraged to enrol in a maintenance program or another suitable local community program upon completion of the ambulatory program. Strength of evidence = 4 Because of their short duration, ambulatory programs conducted during convalescence may not produce major changes in lifestyle or achieve significant reduction of risk factors. However, early programs can be effective in motivating patients to adopt healthier lifestyles96,171. To facilitate maintenance of behaviour change and adherence with advice, patients need continuing support 495,680 . They should be referred to a longterm maintenance program, if one is available, and strongly encouraged to attend. Considerable benefits have been demonstrated from ongoing participation in longterm programs through continued access to expert advice, as well as support from other group members. These benefits include a reduction in hospital admissions, further cardiac events and deaths14,17,80,81,185 . If applicable, individual patients should also be referred to a special clinic for ongoing management of specific problems, such as hyperlipidaemia, diabetes, obesity, hypertension or smoking.

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Referral to community health services and support groups
Recommendation
Referral to a community health service in the area may also be appropriate. Strength of evidence = 4 Patients should be advised of other local community services, which commonly provide physical activity programs, behavioural and psychosocial counselling and other relevant services. Patient “consumer” groups also offer ongoing social support for cardiac patients and their family members.

Communication with doctors
Recommendation
The program co-ordinator should communicate in writing with the patient’s general practitioner and specialist, advising them of the patient’s enrolment in the program. The program co-ordinator should also inform the patient’s doctors about any problems which have occurred during the program and forward a brief discharge summary. Strength of evidence = 4 So that doctors are adequately informed about the rehabilitation program, a brochure should be produced and circulated to them. It should include a brief description of the content of the program and provide details of the co-ordinator’s name and contact details. Doctors must be advised about enrolment of their patients in the rehabilitation program and asked to encourage the patient to attend. Any problems which arise during the program should be communicated to the general practitioner and specialist. A brief summary of the patient’s progress should also be sent to the general practitioner and specialist at the time of the patient’s discharge from the program, including any exercise test results, risk factor measurements, assessments of physical and psychosocial functioning and other outcome data. Patients should also be given a patient held record containing this information which they should take to their doctors and other health care providers to facilitate communication and shared care.

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Longterm follow-up of patients
Recommendation
Patients should be invited to initiate contact with team members after their discharge from the ambulatory program. The program co-ordinator or other team member should also contact patients by telephone after three, six and 12 months. Strength of evidence = 4 In addition to longterm management from the general practitioner and specialist, patients should ideally be contacted by telephone by a member of the rehabilitation team so that patients who are experiencing psychological or work problems or difficulties maintaining recommended lifestyle changes can be identified. Significant problems some months after an acute cardiac event are not uncommon309,531 . Such contact with high risk patients is particularly important to identify lapses with regimens, particularly those concerning smoking, diet, medication and medical attendances. Advice and support can be offered and assistance in making medical or other appointments, if necessary. If telephone contacts are not feasible, a postal questionnaire may be sent to assess progress and to offer further support, if required. Appropriate referrals, including medical appointments, should be arranged for those requiring assistance.

Comment
The low attendance rate of patients who are invited to ambulatory programs2,5,52–56 raises serious issues of access and equity. Patients who have failed to attend a ambulatory program, for whatever reason, may well be able to attend at a later date. Motivation may change, awareness of need may increase, transportation may become possible later in convalescence, the patient may learn late of the benefits of rehabilitation programs from another patient; a doctor may learn late of the benefits of rehabilitation programs from another patient; a doctor or other health professional may discover that the patient has failed to attend the hospital-based program. The convalescent period may well be over. Such patients should be offered a second chance. This may well be at a program other than at the parent hospital. Communitybased maintenance programs recruit many such patients, who need similar education and support as do those in ambulatory programs. Thus, programs designed to be maintenance (phase 3) programs find that they largely also have to function as if they were ambulatory (phase 2) programs. The division of cardiac rehabilitation into “phases” becomes blurred in the face of this reality. Development of community programs designed to cope with both convalescent and maintenance needs of patients seems to be required to offer proper facilities with good access and equity. This is an issue for further research and development.

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CHAPTER 18
PROGRAM EVALUATION

As discussed in previous chapters, the benefits of many aspects of cardiac rehabilitation programs have not been adequately substantiated in rigorous scientific studies 680. More research is required to determine the effectiveness of the various components of cardiac rehabilitation in facilitating recovery of the patient and promoting secondary prevention of the disease. Further, there is a need for greater uniformity in the outcomes measured and in the tools and methods used to evaluate outcomes of cardiac rehabilitation programs. Discrepancies in the findings of past investigations in this area may be attributable in part to differences in the selection of outcomes, measurement tools and overall research design, rather than to actual differences in the effectiveness of the interventions under examination. Reliable, valid and responsive measures of outcome are essential.

Program evaluation
Recommendation
Evaluation is recommended to monitor and, if necessary, to improve the processes of program delivery and to document outcomes. Strength of evidence = 4 Careful outcome evaluation is required to determine and compare the costs of interventions in cardiac rehabilitation. Demonstration of the benefits of interventions used in cardiac rehabilitation programs is important for decision-making regarding the allocation of health care resources. There is therefore increasing pressure upon those delivering cardiac rehabilitation services to be accountable in terms of quality and costs 681. As well as documenting outcomes, comprehensive process evaluation is essential to ensure efficient programs and to identify weaknesses requiring attention in the delivery of programs.

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This chapter briefly reviews approaches to evaluation and provides guidelines for both outcome and process evaluation for best practice cardiac rehabilitation and secondary prevention programs.

Outcome evaluation
Traditional goals of cardiac rehabilitation have been to promote recovery following the acute illness by improving physical outcomes and functional status of the patient and encouraging early return to work. Reduction of mortality and morbidity have been recognised longterm aims for secondary prevention of the disease. A number of studies referred to in earlier chapters have investigated the effects of cardiac rehabilitation programs upon “hard” endpoints, such as mortality, morbidity (including recurrent events and rehospitalisation) and resumption of work. However, outcome studies of this kind require longterm follow-up of large numbers of patients in controlled studies which are beyond the scope of most programs. Outcome evaluation of cardiac rehabilitation programs usually involves investigation of short term outcomes including functional capacity, quality of life, risk factor profiles, health behaviours and knowledge.

Instruments assessing functional capacity
While commonly a part of quality of life assessments, functional capacity may be measured independently.

Graded exercise test
Objective evaluation of exercise capacity is commonly measured by performance of a continuous graded exercise test, either on a treadmill or a cycle ergometer. In outcome studies, exercise tests are undertaken before entry to an exercise training program and upon completion of the program. Exercise testing may be undertaken some months later to measure the longterm effects of the program.

6 minute walk test
A less costly and simpler test, the 6 minute walking test, is also used for objective assessment of exercise capacity of cardiac patients682–684 . In this test, patients are asked to walk as hard as they can. The 6 minute walk test is of particular use with older cardiac patients. It has good reliability, especially in patients with heart failure.

Shuttle walk
The shuttle walk is another measure of exercise capacity for use with cardiac patients 685, which closely mimics a graded exercise test.

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Duke Activity Survey Index
A further self-report questionnaire measuring functional status is the 12 item Duke Activity Survey Index 686.

Specific Activity Questionnaire
A recently developed Australian tool is the Specific Activity Questionnaire (SAQ)687. Unlike the New York Heart Association and Canadian Cardiovascular Society classifications, the SAQ provides a measure of functional capacity which is reported to correlate moderately well with peak VO2 determined by exercise testing and is therefore recommended as a useful tool in cardiac population studies when formal exercise testing is impractical and uneconomical687.

Instruments assessing symptoms
New York Heart Association (NYHA)
Despite some flaws, the functional classification of the New York Heart Association (NYHA)688 is a commonly used observer rated classification for quantifying the degree to which symptoms limit the performance of everyday physical activities.

Canadian Cardiovascular Society (CCS)
The Canadian Cardiovascular Society (CCS)689 has produced an improved modified version of the NYHA criteria for anginal symptoms.

Seattle Angina Questionnaire
Another tool for assessing symptoms is the Seattle Angina Questionnaire, a 19-item self-administered questionnaire designed for cardiac patients who have chest pain, chest tightness or angina690.

Minnesota Living with Heart Failure Questionnaire (LIhFE)
The LihFE is a valid, reliable and responsive instrument containing 21 items691.

Quality of life
While there is no universal agreement regarding the definition of quality of life, it is accepted that it is a multidimensional phenomenon, embracing psychological wellbeing and social functioning as well as physical functioning. Improvement in quality of life has been widely recognised as an important goal of cardiac rehabilitation. However, quality of life has only recently been used as an outcome measure in major studies. Generic measures and disease specific measures represent the two basic approaches to assessing health related quality of life (HRQL). Generic instruments include health profiles and utility measures. Health profiles are single instruments which measure different aspects of HRQL, while utility measures basically require patients to

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estimate their HRQL along a single continuum from death to full health692. Generic HRQL instruments are designed as outcome measures to allow comparisons across populations and interventions, while disease specific HRQL instruments focus on symptoms and problems relating to a particular disease and are thus used as outcome measures in specific populations.

Generic measures of health related quality of life (HRQL)
The following generic HRQL tools have been used in previous studies of cardiac patients.

Medical Outcomes Study Short Form 36 (SF-36)
The Medical Outcomes Study Short Form 36(MOS SF-36)693 is a shortened version of the Medical Outcome Survey (MOS)694. It has 36 items measuring eight health concepts, namely: physical functioning, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health. The different scales in the SF-36 show adequate internal consistency. Construct validity has been demonstrated through factor analysis in a study with patients experiencing a variety of conditions 693. The SF-36 has been used with a range of different illnesses, including coronary heart disease. Some studies of patients undergoing cardiac rehabilitation 275,695 have used the SF-36. Evaluation of a cardiac rehabilitation sample before and after a 12 week program showed significant improvement on all scales 695. However, as pointed out by Oldridge, these observational studies were limited by the absence of a control group or longterm follow-up696. The SF-36 is being increasingly used in Australian studies. In Victoria, it is being administered to patients attending cardiac rehabilitation programs to establish its suitability and sensitivity in this population 697 . The Australia Bureau of Statistics has released normative data for the Australian population.

Nottingham Health Profile (NHP)
The NHP 698 is a widely used tool, particularly in the United Kingdom, for measuring perceived health problems and their effects upon activities of daily living. The NHP has been used with cardiac populations699,700 . Studies have shown that patients with a poor perceived health status measured by the NHP also have a poorer result using other traditional clinical measures of outcome, such as exercise capacity determined by treadmill test 700. However, some limitations in scoring the NHP have been identified 701. A study comparing the SF-36 and the NHP in cardiac patients found that the SF-36 was a better measure of quality of life than the NHP, its scales showing more sensitivity, with higher internal consistency coefficients and clearer evidence of discriminant validity701.

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Profile of Moods States (POMS)
The POMS provides 65 adjectives which are self rated to indicate various mood states (eg anger, tension; depression) considered transient and responsive702. The POMS has been used in past studies of cardiac patients516,703,704 and is simple to administer.

Sickness Impact Profile (SIP)
A longer questionnaire, the SIP, contains 136 items which measure physical functioning, psychosocial domains and five independent factors705. It has been used with cardiac patients 706. The SIP provides more detailed information than the SF36 but it takes 45 minutes to complete.

Psychosocial Adjustment to Illness Scale (PAIS)
The PAIS is an interviewer administered questionnaire, although a self-report version has been developed 707,708 . It provides an assessment of functioning in a variety of psychological and social domains, including health care orientation, vocational environment, domestic relationships, sexual relations, extended family relations, social and leisure activities and psychological distress.

Specific measures of health related quality of life
Several health related quality of life (HRQL) instruments have been specifically developed for use with cardiac patients. They include the following.

Quality of Life after Myocardial Infarction Questionnaire (QLMI)
The QLMI contains subscales measuring physical symptoms and restrictions (the Limitations domain) and emotional function, confidence and self-esteem (the Emotions domain) 696 . It is reported to be a valid, reliable and responsive specific HRQL instrument. Developed in Canada, it has recently been modified and validated for use in Australia as the MacNew Quality of Life after MI Questionnaire709.

Minnesota Living with Heart Failure Questionnaire(LIhFE)
The LihFE 691 has 21 items and assesses physical, socioeconomic and psychological impairment in patients with heart failure. It has been widely used, particularly in pharmacological trials.

Heart Patients’ Psychological Questionnaire (HPPQ)
The HPPQ 710 has a 12 item Disability Scale and a 12 item Well-Being Scale. It was designed and validated in Belgium to assess changes in feelings of disability and wellbeing in men with coronary heart disease attending an outpatient cardiac rehabilitation program. Reports indicate that the HPPQ is a reliable and sensitive measure of psychological functioning in cardiac patients710.

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Instruments measuring single psychological states
Several instruments are available to measure specific psychological states, such as anxiety and depression. The following commonly used questionnaires were not specifically developed for cardiac patients, with the exception of the Cardiac Depression Scale 711.

State Trait Anxiety Inventory (STAI)
The STAI is a 40 item questionnaire consisting of a 20 item scale assessing state (current) anxiety and a 20 item scale measuring trait (general) anxiety712. It can be completed quite quickly and has been used in previous studies of cardiac patients 713,714 .

Hospital Anxiety and Depression Scale (HADS)
The HADS is a 14 item scale with separate subscales for anxiety and depression715. Developed for use with medically ill patients in hospital, it is commonly used as a screening tool to detect psychological disturbance. While it is brief and has been widely used in past studies of cardiac patients 716,717 , it has some limitations. For example, the depression subscale omits many items relating to somatic symptoms and thus measures only some aspects of depression711 .

Beck Depression Inventory (BDI)
The BDI is a 21 item scale for measuring depression718. A short version has also been produced. Although commonly used to assess depression in cardiac patients 719,720 , it is less suitable for this population than other scales because, unlike the HADS, it was originally designed for use with psychiatric patients. Thus, many items cover more severe symptoms of a depressive illness (such as suicidal thoughts), rather than milder symptoms of a depressed mood experienced by most cardiac patients. Consequently, many cardiac patients achieve very low scores on the BDI and subtle changes in mood are not detected512.

Cardiac Depression Scale (CDS)
Developed in Melbourne, the CDS was produced to provide a more sensitive depression scale for cardiac patients. Its 26 items reflect the range of depressive symptoms seen in cardiac patients. The CDS correlates well with the BDI but without the marked skewness of the latter711 .

Other questionnaires
There are a number of other scales which have been used to measure psychological functioning in cardiac patients, including the Zung Self-Rating Depression Scale721 , the Center for Epidemiological Studies-Depression Inventory (CES-D)722, the IPAT Anxiety Questionnaire 723 and the IPAT Depression Questionnaire724.

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Visual Analogue Scales (VAS)
Visual Analogue Scales 725 are a simple method of measuring psychological states, such as anxiety, depression and denial. Visual Analogue Scales typically consist of 10 centimetre lines, anchored at both ends with words descriptive of the maximal and minimal extremes of the dimension being measured. The subject is required to indicate his or her feelings by marking the line at the appropriate point between the two extreme statements (for example, “I have never felt happier” to “I have never felt more miserable”). Visual Analogue Scales are also used to assess self efficacy and perceived level of fitness or physical symptoms such as pain level. They are particularly useful in monitoring changes in individuals over time. Like other measures, they have some weaknesses (such as the tendency for scores to cluster) but they are simple and speedy to complete and have been established as valid and reliable in a range of clinical and research applications. They are usually used for self assessment but they can also be useful for observer ratings.

Measures of other psychosocial outcomes
Other outcomes relevant to cardiac rehabilitation include social, occupational, marital and sexual adjustments. Few measures in these areas have been specifically developed for studies of cardiac patients. However, interview-based instruments, such as the Structured and Scaled Interview to Assess Maladjustment (SSIAM)726 and the Social Adjustment Scale (SAS)727 have been modified and administered to cardiac patients to enable a more detailed investigation of these dimensions of recovery96. Another instrument used in past research with cardiac patients includes the Life Experience Survey 728 , which measures perceived stress. Patients’ perceptions of outcomes can also be quantified without using numerical scales. For example, patients can assess their usual sexual activity as “better than”, “worse than” or “the same as” before their cardiac event. Similarly, patients’ perceptions of their physical, psychological or overall recovery can be classified as “total”, “almost”, “partial” or “not at all”96.

Selecting methods of assessing quality of life
Selecting instruments to measure quality of life and other psychological and social outcomes can be difficult. While brevity and ease of administration and scoring are important considerations, other important criteria include the need for instruments to be easy to understand; responsive (sensitive to changes); valid (measuring the characteristics desired); clinically relevant (providing meaningful data) and reproducible (producing the same results when repeated or when administered by different team members). Further, instruments selected must be able to detect any changes in affect or quality of life. Some questionnaires may be unsuitable because they were intended only for screening purposes.

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Generic HRQL tools (eg NHP, SIP) are useful in that they enable comparisons to be made between different populations and between interventions so that cost effectiveness of an intervention can be demonstrated. A potential disadvantage of generic tools is that they may be unresponsive to small disease-specific changes in quality of life which might have clinical significance. In this respect, instruments specifically designed for cardiac patients may be more appropriate. However, according to Oldridge696, good outcomes measurement requires the use of both generic and disease specific measures, since a range of information is required. Generic and specific HRQL measures provide complementary types of information. Thus, no single outcome measure will suffice. The significant limitation of administering psychological questionnaires to cardiac patients which were originally developed for other populations has already been noted. Because instruments such as these were originally standardised on psychiatric patients, many items are unsuitable and address a wide range of psychopathology which is irrelevant to medically ill patients. Cardiac patients do not typically experience problems of psychopathology but feelings of disability and diminished well-being. Nevertheless, instruments such as the BDI718 and the 567-item Minnesota Multiphasic Personality Inventory (MMPI)729 have been frequently used in the past to investigate outcomes of cardiac patients, possibly because they were well-known questionnaires. The BDI continues to be used to assess depression in cardiac patients. The failure of many studies to demonstrate improvements in quality of life from cardiac rehabilitation may possibly be attributable to the use of inappropriate instruments such as these. Psychological scales administered to cardiac patients need to measure affective responses commonly experienced after an acute cardiac illness, such as a sense of loss (for example, loss of energy, interest or optimism), and must be able to detect any subtle changes in affect. As discussed in Chapter 13, depression in cardiac patients is more akin to a bereavement reaction than to a depressive illness and is usually subtle and transient. Measures focusing on common problems such as feelings of disability, loss and impaired well-being may be more appropriate than traditional measures to provide evidence for the psychological benefits of cardiac rehabilitation. An important practical consideration in deciding how best to assess quality of life in cardiac patients is the applicability of the method to various subgroups of patients. Patients with little English find it difficult or impossible to complete many of the above self-report inventories. Few are currently available in other languages. Moreover, many commonly used inventories contain jargon, complex wording and colloquial expressions which can confuse patients with lower levels of education. Even relatively brief questionnaires can be an ordeal for some older patients. Other patients simply do not enjoy completing questionnaires of any kind and consequently

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may not answer questions properly. Thus, outcome assessment based on self-report questionnaires may exclude many patients. Although more time-consuming, a brief interview may be a more suitable method of assessing quality of life in such patients. Responses to open-ended questions asked during interviews can provide important insights into patient attitudes and add meaning to the quantifiable responses collected via structured self-report questionnaires. While quality of life instruments are becoming increasingly accepted as useful assessment tools and suitable outcome measures in cardiac rehabilitation, further research is needed to provide guidance regarding the suitability of particular questionnaires. Further, data are required to determine whether the instruments outlined above are valid and reliable measures in specific groups of patients, such as older patients, those who have undergone coronary angioplasty and those with multiple diseases. It is most important to explain the purpose of the questionnaires to patients and to establish rapport with them beforehand to increase their motivation to complete the questionnaires satisfactorily. Staff training in administering questionnaires and checking responses is essential.

Knowledge
While increased knowledge may not lead to favourable behaviour change, it can decrease anxiety and give patients a greater sense of control over their progress. Knowledge has been used as an outcome measure of cardiac rehabilitation in several studies, as discussed in Chapter 12. However, few studies have used validated instruments to assess knowledge. Two such knowledge questionnaires are the Cardiac Health Knowledge Questionnaire389 and the Coronary Angioplasty Risk Factor Inventory (CARFI)730. Both questionnaires have been used in recent studies of cardiac patients 731,732 . The Victorian Cardiac Rehabilitation Questionnaire (VCRQ)733 includes items which assess knowledge, as well as behaviour change and attitudes towards behaviour change.

Cardiac Health Knowledge Questionnaire
The Cardiac Health Knowledge Questionnaire389 comprises three subscales: the Basic Cardiac Health Knowledge scale (30 items) investigating knowledge of the functions of the cardiovascular system and the pathogenesis and manifestations of coronary heart disease; the Cardiac Lifestyle Knowledge scale (15 items) covering behavioural aspects in the aetiology of coronary heart disease and in rehabilitation; and the Cardiac Misconceptions scale (10 items), which assesses awareness of common misconceptions about the consequences of a heart attack.

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Coronary Angioplasty Risk Factor Inventory (CARFI)
The CARFI 730 consists of 25 true-false, multiple choice or fill-in items and has three different forms for use before coronary angioplasty and at two follow-up assessments. The questionnaire provides two scores assessing knowledge of PTCA procedures and cardiac risk factors, together with an overall score totalling the two scores. The third form measures risk factor knowledge only.

Victorian Cardiac Rehabilitation Questionnaire
The Victorian Cardiac Rehabilitation Questionnaire733 provides multiple choice items to assess knowledge, health behaviours and symptom management. It is currently undergoing further development.

Open-ended questions
It is asserted by some that questionnaires containing multiple choice items provide a measure of recognition rather than recall. They may therefore be a less reliable method of measuring actual knowledge than open-ended questions which may be asked via self-report questionnaire or interview.

Risk factors and health behaviours
Achieving a reduction in modifiable risk factors (smoking, high cholesterol, high blood pressure, obesity and physical inactivity) is a primary goal of cardiac rehabilitation and secondary prevention programs.

Smoking
Current smoking status should be recorded for all patients who have been smokers in the past. Measurement for the purposes of program evaluation is usually by patient self-report. Years of cigarette smoking, frequency of smoking and number of cigarettes smoked should be recorded. Because deception among smokers is not uncommon, confirmation may be sought from a family member. In rigorous studies, objective assessments of smoking status are usually obtained to corroborate self report, using physiological or biochemical measures of serum thiocyanate, expired carbon monoxide or salivary, urine or plasma cotinine levels.

Cholesterol
A fasting blood sample should be taken after the patient has rested for five minutes to provide a lipid profile (including total cholesterol, HDL cholesterol, LDL cholesterol and triglyceride levels). The cholesterol level recorded immediately upon admission to hospital is regarded as the most accurate baseline measure. Measurements made soon after the acute event may not accurately reflect the patient’s lipid profile because of the effect of the event upon lipid levels. A further measurement should be made after three months. Total cholesterol levels of patients may be grouped as follows: <4.5 mmol/L (desirable); 4.5 to 5.4 mmol/L(acceptable); 5.5 to 6.4 mmol/L (raised);

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>6.5 mmol/L (high). The aim for all patients should be to achieve a lower level of cholesterol.

Blood pressure
Systolic and diastolic blood pressures should be measured while the patient is seated after resting for five minutes. This should suffice for routine measurements. Ambulatory monitoring of blood pressure may be utilised for special purposes. Systolic blood pressure may be categorised as follows: <130 MmHg (normal); 130–139 MmHg (acceptable); 140–149 MmHg (borderline); and >150 MmHg (raised).

Body weight
Body mass index (BMI) is calculated by dividing the patient’s weight (kgs) by height (metres) squared. Abdominal girth and hip waist ratio should also be measured. A BMI < 20 is classified as underweight; 20–25 as normal; >25–30 as overweight; and > 30 as obese 734.

Physical activity
Physical activity is typically assessed by self-report because of the impracticality of monitoring patients’ leisure time activities. Physical activity may be investigated by assessing the frequency of walking, including the duration and time taken for each walk) 735 and other activities such as gardening, housework and dancing. Categories such as “very active”, “moderately active”, and “inactive” may then be assigned. Scales designed to measure physical activity in the general community are usually unsuitable for older cardiac patients. An appropriate instrument to assess and quantify physical activity in such cardiac patients needs to be produced. The Specific Activity Questionnaire 687 is a useful measure of perceived ability to undertake specific physical activities.

Dietary habit
Commonly used tools for measuring dietary intake are diet histories, weighed food intake records and 24 hour dietary recall. However, these methods can be time consuming. Questionnaires recording the frequency with which the listed foods are eaten are preferable. The Short Fat Questionnaire736 is a brief 17 item self-report questionnaire developed in Australia which measures dietary saturated and unsaturated fat intake and provides a total score. However, no questions are included to assess consumption of low fat alternatives. Additional questions may be asked to assess the consumption of other foods.

Adherence to medication and advice
As previously noted in Chapter 13, nonadherence to medication is associated with higher death rates 497,498 and is thus an important marker of adverse outcomes. Methods used in clinical trials to monitor adherence to medication regimens, such as pill counts, are usually not feasible in a rehabilitation setting. Thus, it is necessary to

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rely on patient self-report. However, satisfactory correlation has been shown between self-reports of adherence and pill counts737. Patients may be asked, either during interviews or via self report questionnaires, whether they always take their medication exactly as prescribed, or whether they occasionally or regularly fail to follow the prescribed advice. However, the manner in which patients are asked about adherence to advice will largely determine the validity of their responses. More valid responses are likely to be obtained during semistructured interviews with a trained interviewer. Patients may be broadly classified as “totally compliant”, “partially compliant” or “not at all compliant” with advice regarding their medication. Adherence to other regimens (such as advice to lose weight, stop smoking or increase physical activity) can be similarly classified. Nevertheless, it should be emphasised that it is difficult, if not impossible, to give global measures of adherence or nonadherence. Most cardiac patients are placed on a number of regimens, adhering to some but not to others. Further, they may adhere for some, but not all, of the time to particular regimens 309. Patients should always be asked to explain their reasons for not adhering to advice.

Attitudes towards behaviour change
Behaviour change is a process, as emphasised in earlier chapters. A four to six week program of cardiac rehabilitation may not be sufficient to achieve actual changes in health behaviours. A longer follow-up (for example, after three, six and 12 months) is usually required to assess behavioural outcomes. Nevertheless, it is important to assess the effectiveness of cardiac rehabilitation upon intention to change, attitudes towards change and self-efficacy (or confidence) in making changes. A number of studies of cardiac patients have measured these outcomes in relation to behaviours such as smoking, making dietary changes, losing weight and becoming more physically active, although the relationship between patient attitudes and such behaviours is not yet well defined.

Intention to change
The strength of intention to adopt a new health behaviour, such as starting a regular walking program, may be simply measured using a self rating scale containing several points ranging from “extremely likely” to “extremely unlikely” 738.

Attitude towards change
A similar approach may be used in assessing which stage of change the patient has reached in changing a particular behaviour, such as stopping smoking. Using statements based upon the Prochaska and diClemente model of behaviour change485 , patients may be offered a choice of five statements ranging from “I have no thought of stopping” to “I’m definitely taking action to stop” smoking.

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Self efficacy regarding change
A similar approach may be used to measuring how confident or certain the patient is about stopping smoking by asking whether the patient is “very confident”, “quite confident”, “not very confident” or “not at all confident”739.

Work
It is important to record occupational outcomes of patients who were in the workforce before their cardiac event. Patients should be contacted after six and 12 months to determine whether or not they have resumed work, changed or modified their jobs and remained in the workforce. Time of return to work (number of weeks since the acute illness or entry to the program) should also be recorded. A more comprehensive evaluation of occupational outcomes should include investigation of how well the patient has adapted to work after resuming. Occupational adjustment is best assessed by interview, using semistructured questions such as those contained in a modified version of the SSIAM 726 which was recently used in an Australian trial involving cardiac patients 96.

Outcome indicators
The following are suggested outcomes and outcome indicators to use in evaluation of cardiac rehabilitation and secondary prevention programs. However, it must be emphasised that it would be difficult, and indeed unnecessary, to attempt to assess all these outcomes and outcome indicators for all patients attending programs. The extent of assessment will depend upon the particular population of patients, the purpose of the evaluation and the resources available to conduct the evaluation. It may be considered appropriate to assess outcomes of a consecutive series of patients attending over a specified period. Given the complex issues involved in comprehensive program evaluation, advice from experienced researchers should be sought regarding sample size, methods of data collection and data analysis. The following outcome indicators apply to patient evaluation at the end of the program. However, they may also be used for longterm evaluation after six or 12 months. These indicators need to be tested and modified in the light of their usefulness. It should be noted that the recommended cutpoints for cholesterol and blood pressure change with time, with lower levels now being recommended than in the past. They are currently under review by many bodies. Appropriate levels depend to some extent on the age and gender of the patient.

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Functional capacity
• Number (%) of patients whose functional capacity is assessed • Number (%) of patients with increased functional capacity

Activities of daily living
• Number (%) of former drivers who resume car driving • Number (%) of patients who resume their usual sexual activity • Number (%) of patients who resume appropriate daily activities as specified at entry assessment

Physical status
• Number (%) reporting reduced angina/dyspnoea or other physical symptoms • Number (%) reporting improved physical health

Quality of life
• • • • • • Number (%) of patients whose quality of life is assessed Number (%) of patients reporting satisfactory physical functioning Number (%) of patients reporting satisfactory psychological functioning Number (%) of patients reporting satisfactory social functioning Number (%) of patients reporting satisfactory marital functioning Number (%) of patients requiring additional support referred for counselling

Knowledge
• Number (%) of patients whose knowledge level is assessed • Number (%) of patients with improved knowledge

Risk factors, health behaviours and attitudes
Smoking
• • • • • Number (%) of smokers who stop smoking Number (%) of smokers who maintain nonsmoking status Number (%) of smokers who strengthen their intention to stop smoking Number (%) of smokers who are more confident about stopping smoking Number (%) of smokers who are more confident about maintaining nonsmoking status • Number (%) of smokers taking active steps to stop smoking

Cholesterol
• • • • Number (%) of patients who know their total cholesterol level Number (%) of patients whose cholesterol is measured by the GP or program staff Number (%) of patients with high cholesterol on cholesterol lowering diet Number (%) of patients with high cholesterol on medication

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Blood pressure
• • • • Number (%) of patients who know their blood pressure Number (%) of patients whose blood pressure is measured Number (%) of patients with high blood pressure on medication Number (%) of patients with high blood pressure whose blood pressure is reduced

Body weight
• • • • • • • Number (%) of patients who know their weight Number (%) of patients whose weight is measured Number (%) of obese or overweight patients who reduce their weight by >2 kgs Number (%) of patients who strengthen their intention to lose weight Number (%) of patients who are more confident about losing weight Number (%) of patients who are more confident about maintaining weight loss Number (%) of obese or overweight patients taking active steps to reduce weight

Physical activity
• Number (%) of patients whose level of physical activity is assessed • Number (%) of patients who walk or who are physically active 30 minutes daily or on most days • Number (%) of patients who strengthen their intention to increase physical activity • Number (%) of patients who are more confident about increasing their level of physical activity • Number (%) of patients who are more confident about maintaining their level of physical activity • Number (%) taking active steps to increase their physical activity

Dietary habits
• Number (%) of patients whose dietary habits are assessed • Number (%) of patients consuming less saturated fat • Number (%) of overweight or obese patients who reduce their total daily caloric intake • Number (%) of patients who strengthen their intention to change their dietary habits • Number (%) of patients who are more confident about changing/maintaining improved dietary habits • Number (%) of patients taking active steps to change their dietary habits

Adherence to medication and advice
• Number (%) of patients whose adherence to each defined regimen is assessed • Number (%) of patients defined as totally, partially or not at all compliant with each regimen

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Work (paid employment)
• Number (%) of patients formerly in the workforce who resume work • Number (%) of patients formerly in the workforce who resume within 3 months of the event or program entry • Number (%) of patients with work difficulties who receive additional assistance from occupational therapist and/or receive a work visit after resuming work • Number (%) of patients working at one year • Number (%) reporting satisfactory occupational adaptation at work

Hospital readmissions
• Number of hospital readmissions during the 12 months since entry to the program • Number of days spent in hospital during the 12 months since entry to the program

Process evaluation
It is essential to assess patient satisfaction with the program and to monitor the efficiency with which the cardiac rehabilitation program is delivered to patients.

Patient satisfaction
Patients should be asked whether they found the program beneficial and in which ways. Criticism of the program should also be sought, although it is most important that patients should be invited to make suggestions for improving the program, rather than soliciting criticisms per se. Most patients feel a sense of gratitude towards members of the rehabilitation team and will be reluctant to make open criticisms, even via a self-report questionnaire. Comments about specific components of the program should be sought, including the adequacy of information given and the areas where more information is desired. Feedback about the program duration, time of the program and other structural issues should also be requested. Patients should be asked for their feedback at the time of their discharge from the program. In addition, patients may be invited to comment about individual education sessions upon completion of the session. Patient evaluation of programs is usually sought via an anonymous self-report questionnaire, because this method is considered to be both time efficient and conducive to more honest appraisals. Such questionnaires are generally produced inhouse and tailored to suit the particular program. The usual format is for boxes to be provided which patients are requested to mark to indicate their response. It is important to provide extra space so that patients can add any additional comments if they wish. However, as already emphasised, many patients dislike filling in questionnaires or find them difficult to complete. An effective alternative approach is to conduct exit satisfaction surveys by telephone. Ideally, these should be carried out by a health

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professional not closely involved in delivering the program. A questionnaire can be completed by the interviewer, which should include open-ended questions and probing questions to elicit as much information as possible about the patient’s attitude towards the program. It is useful to seek feedback from patients after about three months following their discharge from the program when they are commonly more responsive and forthcoming about which of their needs were not adequately met by the program. It is essential to obtain feedback from patients and to implement suggested improvements, where feasible. Feedback from patients who have dropped out of programs may be especially valuable. Patient evaluation of programs constitutes possibly the most important aspect of program evaluation.

Delivery of the program
Several recommendations regarding processes for program delivery were made in Chapter 17. In this chapter, process indicators are suggested which should demonstrate how well an individual cardiac rehabilitation program has achieved its goals in relation to program delivery.

Process indicators
Efficient delivery of cardiac rehabilitation services is reflected by careful attention to discharge plans and the timely completion of tasks concerning referral of patients to the program, entry and discharge assessments, attendance patterns, consumer input into evaluation, communication with doctors and documentation of the program content and staffing requirements. Other recommended practices, including making a range of modules available to suit the needs of particular patients, should also be assessed as part of program evaluation. The following are suggested as potentially useful quantifiable indicators. They are grouped according to whether they concern communication, patient management or program evaluation.

Communication
Program referrals
Timely forwarding of referral to program co-ordinator Time between patient’s discharge from hospital and receipt by program co-ordinator of referral by telephone and confirmed by facsimile or mail (timely = within three working days). Indicator: Number (%) of patients whose referrals are received within three working days of patients’ discharge from hospital

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Timely response by co-ordinator to referrals: Time between receipt of referral and initial contact with patient (by telephone/ facsimile/mail or personal contact) to inform the patient that the referral has been received and to arrange initial assessment (timely = within three working days). Indicator: Number (%) of patients for whom attempts to contact have been made within three working days of receipt of referral. Timely documentation of entry assessment and agreed rehabilitation plan Time from entry assessment to placing documented assessment and plan in the patient’s rehabilitation file and forwarding hospital medical record (timely = within two working days). Indicator: Number (%) of patients with a documented entry assessment and plan in the patient’s rehabilitation file within two working days from the entry assessment, with a copy forwarded to the hospital medical record. Timely documentation of discharge summary Time between discharge review and placing of written discharge summary in the patient’s rehabilitation file and forwarding the summary to the hospital medical record, documenting outcomes of the cardiac rehabilitation program and follow-up arrangements (timely = five working days). Indicator: Number (%) of patients with documented discharge summary in the patient’s rehabilitation file within five working days from discharge review, with a copy forwarded to the hospital medical record.

Liaison with general practitioners
Good communication between the cardiac rehabilitation program co-ordinator and the patient’s general practitioners (GP) is essential. The following indicators of effective communication with GPs are recommended: Timely forwarding of entry assessment and plan to GP Time from entry assessment to forwarding of entry assessment and plan to the GP (timely = within two working days). Indicator: Number (%) of patients whose entry assessment and plan are forwarded to the GP within two working days from the entry assessment. Timely forwarding of discharge summary to GP Time from discharge review to forwarding of discharge summary to the GP (timely = five working days). Indicator: Number (%) of patients whose discharge summary is forwarded to the GP within five working days from the discharge review.

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Patient management
Assessment of patients
Timely entry assessment of referred patients Time from receipt of written referral by program co-ordinator to the first meeting with the patient (and family member) for entry assessment (timely = within seven working days). Indicator: Number (%) of patients assessed within seven working days of receipt of referral Completion of discharge review Completion of a discharge review including review of risk factors, medication, work plans, psychosocial functioning and, where possible, a graded exercise test. Follow-up arrangements should include details of medical appointments, advice regarding a maintenance program, community supports, plans for a review phone call and a telephone number the patient can call for further assistance. Indicator: Number (%) of patients formally reviewed at discharge from the program

General practitioner follow-up
Patients should be encouraged to see their GP at appropriate intervals for follow-up after discharge from the rehabilitation program. Timely follow-up by GP Time between discharge review and appointment with GP (timely = within four weeks of the discharge review). Indicator: Number (%) of patients who consult their GP within four weeks of completing the rehabilitation program.

Program evaluation
Program attendance
Every program should endeavour to improve its attendance and completion rates and to reach all its target groups. Patients should receive a written referral to the program and should attend soon after hospital discharge. The following indicators may be used to evaluate the effectiveness of the program in these respects. • Number (%) of patients for whom a written referral to the program has been received before hospital discharge • Number (%) of patients who first attend the program within 10 days of hospital discharge • Number (%) of patients referred to the program who attend the program

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• Number (%) of patients who complete the program (attending > two-thirds of available sessions) • Number (%) of female patients referred to the program who attend the program • Number (%) of female patients who complete the program (attending > two-thirds of available sessions) • Number (%) of patients with limited English who attend the program or an ethnospecific program • Number (%) of patients with limited English who complete the program (attending > two-thirds of available sessions)

Program modules
The characteristics of patients attending a program will depend on the location and size of the program and the availability of other services in the area. It has been recommended that programs contain separate modules to cater for the needs of different subgroups, particularly those who often fail to attend available programs, such as those who have undergone coronary angioplasty, younger patients and those with a limited command of English. It is also desirable to provide separate spouse groups. Recommended indicators in relation to program modules are as follows: • Availability of appropriate sessions for patients who have undergone coronary angioplasty • Availability of appropriate sessions for younger patients • Availability of appropriate sessions for patients with limited English • Availability of appropriate sessions for spouses or other family members

Consumer input
As discussed above, it is important to obtain feedback from patients about the program so that any weakness can be overcome. Indicators of consumer input may include the following: • Number (%) given a patient satisfaction survey or participating in a telephone interview • Number (%) completing a patient satisfaction survey or participating in a telephone interview • Number (%) of dropouts who are contacted and asked for feedback

Participation of general practitioners
GP referrals to programs should also be encouraged and, where possible, participation of the GP in the rehabilitation program itself (for example, by facilitating one of the education sessions). The following indicators are recommended: • Number (%) of patients referred to the program by GPs • Number (%) of sessions in which GPs have participated

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Documentation
Recommendations for best practice have been made regarding the availability of documented emergency procedures, program protocols and GP referral procedures. The following indicators should be used for benchmarking purposes: • Availability of written emergency procedures • Availability of written program protocol • Availability of written referral procedures • Systematic documentation of attenders, nonattenders and dropouts • Written protocols for follow-up of attenders, nonattenders and dropouts

Staff issues
The following indicators pertain to recommendations made regarding the desirability of holding regular team meetings, employing appropriately qualified staff and encouraging further training: • Occurrence of regular team meetings • Employment of staff who have recognised professional qualifications • Availability of opportunities for further training

Minimum data sets
Whereas evaluation may involve assessment of only some of the indicators listed above, all cardiac rehabilitation program co-ordinators should record a certain amount of basic information about all patients attending the programs. The development of a common minimum data set is important for the process of comparing programs, both for reporting requirements for funding and the future use of clinical indicators. The minimum data sets developed by the National Heart Foundation 388 should be routinely collected. Additionally, the following should be recorded for each patient: employment status (ie whether the patient is in the workforce or not); current or most recent occupation (last paid occupation of those who have retired should be recorded so that occupation (either current or past) can be used as an indicator of socioeconomic status); and living arrangements (whether the patient lives alone - an indicator of possible social isolation). • • • • • • • • • • program ID date of birth home address postcode preferred language aboriginality country of birth date of entry to program principal diagnosis (ICD-9-CM) reason for dropout living arrangements • patient ID (eg Medicare number or other unique identifier) • gender • marital status • occupation (current or last) • employment status • date of hospital discharge • additional diagnosis (ICD-9-CM) • date completed program

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The name of a relative or close friend not living with the patient may also be noted to facilitate later follow-up of patients who change their place of residence. The following data concerning program delivery should also be collected: • number of referrals • number of patients who attend • number of family members who attend • number of major cardiac complications during the program • number of minor cardiac complications during the program.

External audit or peer review
External audit or peer review of cardiac rehabilitation and secondary prevention programs is not yet practised in Australia but it is undertaken in some countries such as Germany 721. Such assessments involve benchmarking a selected program against other programs which represent best practice in the field. Process and outcome indicators such as those listed above are used to evaluate the adequacy of the program. The audit also involves investigating records of individual patients, whose identities remain anonymous to the review team, to confirm that the nominated patients have attended the stated number of sessions and undergone the rehabilitation program and assessments claimed. Results of such audits conducted in Germany are required by the health insurance commission.

Conclusion
This chapter has discussed several of the major issues involved in undertaking process and outcome evaluation. While program evaluation is critically important to achieve best practice, it should not consume a disproportionate amount of staff time. Expert advice should be obtained regarding appropriate methods of evaluation which best suit the needs of particular programs or the specific purpose of the proposed evaluation.

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CHAPTER 19
COST, COST SAVING AND COST EFFECTIVENESS
Cardiac rehabilitation program costs vary throughout the world. Costs in Australia, New Zealand and the United Kingdom are similar, as the programs are similar. Canadian programs are somewhat more costly because of the greater exercise component. Programs in the USA are markedly more expensive because frequent sessions of high intensity exercise are the basis for the program, with consequent monitoring costs and prior exercise stress testing.

Victorian public hospitals
A costing has been undertaken at a major metropolitan teaching hospital in Melbourne, with a large medical and surgical throughput. At this hospital, the patient attendance rate after myocardial infarction and coronary bypass surgery is less than 50% of those eligible. This is a common feature worldwide. The exercise component of the program is of low to moderate intensity. Monitoring is by perceived exertion or heart rate without ECG or telemetry. Exercise stress tests and other tests undertaken upon patients enrolled in the program are not costed to the program, as they are not primarily undertaken to guide the rehabilitation program. The cost of this cardiac rehabilitation program was calculated to be $A44,784 overall in 1997 (personal communication). This cost covered the costs of 216 attending patients during the year. The program was based upon six weeks of group exercise and education, conducted once per week, with each session lasting for two hours (45 to 60 minutes of exercise, 45 to 60 minutes of discussion). There were 20 to 30 patients attending each group session, with an average of 24 patients, together with some family members. The cost was $A207.33 per patient who attends the program, a cost of $34.56 per session. However, the costing is for program delivery. It does not fully cover the costs of co-ordination, patient assessment and communication. The weekly mean program costs were calculated to be $5,598. It is not possible for this program to handle more patients without setting up a second parallel program. A second parallel program could be achieved at a lesser cost per patient, but at a significantly greater cost overall. It would, however, permit greater individual attention to patients. If the same number of patients were to attend twice

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weekly for six weeks, again the cost per patient would be significantly increased, but it would be less than double the current cost. The survey of model programs undertaken for these Best Practice Guidelines included the program at the above hospital7. The survey showed a similar degree of patient satisfaction with programs which were attended once, twice or three or more sessions per week. However, more patients who attended this once per week program considered that they would benefit from more contact with staff, more discussion time, more education, more social support and more exercise during the six week program. The implication is that the number of patients in each group was too great or, possibly, that a twice weekly program may achieve better satisfaction and, one assumes, greater benefits. In consequence, it may be reasonable to divide the single program into two parallel programs to reduce the number of patients attending each group session or to change to a twice weekly program. Either change would increase the overall cost towards $400 per patient. Further research into costing, cost benefit and cost effectiveness is required in these details of program planning, content and implementation. The possibility of extending the overall duration of the program to eight weeks or more remains open. However, the great majority of patients claim satisfaction with six weeks. Extending the program duration to eight weeks could lead to possible adverse effects for some patients (for example, reduced perception of recovery, financial stress, job loss). Longer duration of the program does not appear to be a preferred option. Costs per patient in other programs vary from those discussed above. The major difference in cost per patient depends upon the number of patients attending each class, while salary costs per hour remain similar for the conduct of each class. Thus, an education class of 10 patients may lead to costs per patient approaching twice that in a program where there are 20 patients per class. Another factor influencing cost is the time spent by the program co-ordinator assuring patient referral and attendance and the entry and discharge assessments of each patient. In one hospital-based program, patients attend for six weeks twice weekly for both exercise and education groups (personal communication). Between 300 to 360 patients attend this program each year. There are usually up to 20 patients in each of two exercise classes, who come together as a group of up to 40 patients for the education group session. While patients are thereby offered twice as much education time, the number of patients in the education group may reduce the desired interactive nature of the presentation. The overall cost of the program has been calculated at approximately $90,000 per year, a cost of approximately $300 per patient or $25 per session per patient. This is likely to be as low a cost per patient as could be achieved, but this is because exercise groups are large and education groups are excessively large.

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It appears reasonable to suggest a cost of $250 to $300 per patient for a six week program once per week, with two hour sessions (one hour of exercise, one hour of education), allowing for adequate time to be devoted to each patient at entry assessment and during the program. Similarly, it would seem reasonable to suggest a cost of $450 to $500 per patient for a six week program, conducted twice per week for two hours, without sessions being overloaded by numbers. As indicated above and in Chapter 8, there is good evidence that rehabilitation exercise programs conducted twice per week are as effective as those conducted thrice per week. Once per week rehabilitation exercise classes may be as effective as twice or thrice per week, provided a suitable home walking program is advised205. There is no evidence to form an opinion regarding education classes being better conducted once per week or twice per week. There is a need for both sufficient exposure to information and sufficient opportunity for patient participation and understanding. As pointed out in Chapter 13, the benefits of interactive learning are greatest through small education groups. The size of the group and the skills of the facilitator may be more important for learning than the number and duration of classes made available to patients. Thus, while smaller classes indicate greater cost per patient, it seems smaller classes may lead to better outcomes and consequent cost effectiveness than attempting to minimise costs per patient by having large numbers of patients per class.

Victorian private hospitals
Some private hospitals in Victoria conduct cardiac rehabilitation programs, each somewhat different from the others, but all meeting National Heart Foundation Minimal Standards (six sessions of exercise, six sessions of group education and discussion) 79. Patients who belong to appropriate health funds have cardiac rehabilitation included in the contract agreement between the fund and the hospital reimbursement for management of their acute myocardial infarction, coronary bypass surgery or percutaneous transluminal coronary angioplasty. If not covered in this way, patients may pay on a sessional (up to 2 hours per session) basis without reimbursement. Incorporating all possible expenditure at one such hospital for eight two hour sessions gave a calculated cost (excluding return on investment) of $347.06 per patient or $43.38 per patient per session.

Canada
The 1997 Victorian public hospital cost ($A34.56 per patient per attendance) and private hospital cost ($A43.38 per patient per attendance) parallels the cost of a Canadian program in 1991 terms of $Can 30.00 per patient per attendance740. In this

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Canadian program, patients attend twice weekly for eight weeks, with a somewhat higher level of exercise and consequent additional monitoring but with significantly less educational component. The overall cost for that program was calculated to be $Can 480.00 per patient.

United States of America
Programs in the USA are usually conducted at a higher intensity of exercise and are considered to necessitate electrocardiographic or telemetered monitoring, together with closer supervision of the exercise. Hence costs are greater. Cardiac rehabilitation programs classically involve three exercise sessions per week and extend over 12 weeks (a total of 36 sessions per patient). Additionally, exercise tests are usually undertaken to determine training heart rate. The cost of the 36 session cardiac rehabilitation program in USA has been well reported741,742 . The cost per patient has risen, together with other medical costs, from $US 1,280.00 in 1985 to $US 2,810.00 in 1995. (This cost includes the pre-requisite cost for an exercise stress test of $180.00 in 1985 with equivalent rise in costs to 1995). The addition of cardiac rehabilitation to standard hospital and post hospital care of patients with myocardial infarction or coronary bypass surgery increases the overall episode cost by only 2 to 3% 741,743 .

United Kingdom
A survey of a sample of cardiac rehabilitation programs in the United Kingdom undertaken in 1997 reported an overall mean program cost of £33,000, a mean cost per patient of £360 and a mean cost per patient per session of £47 (but with a median cost of £26) 744. The wide range of costing was largely related to patient throughput and hours of patient contact time. Most programs provided were, in general, similar to those in Australia 49 with services provided primarily by physiotherapists and nurses, with relatively little input from physicians and psychologists. It has been noted that, while guidelines and audit standards have been recommended73, there remain significant deficiencies in attendance patterns, procedures, process and program audit745. In particular, there appeared to be insufficient attention to patient education and knowledge, psychological, social, occupational issues and outcomes. Further attention to these issues would somewhat increase program costs. It is accepted that hospital-based outpatient ambulatory cardiac rehabilitation programs are desirable to achieve seamless rehabilitation, extending from acute hospital care into long term community follow-up 746 . It is also recognised that the community aspect of cardiac rehabilitation and follow-up requires development and testing to determine which types of programs are most likely to prove effective in maintaining longterm care, patient quality of life and secondary prevention746.

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Comment
Costs of ambulatory cardiac rehabilitation programs conducted during convalescence vary between countries and between individual programs. The cost per patient clearly depends upon several factors. The most important of these are as follows: • the number of sessions, each of approximately one hour of exercise and one hour of education (optimal 12 sessions in six weeks); • the number of patients in each exercise group (optimal number 10–20 patients); • the intensity of exercise and degree of monitoring (optimal monitoring by heart rate and rate of perceived exertion, not by technology); • the number of patients in each education group (optimal number 10–20 patients plus family members); • the cost of entry assessment (optimal duration half hour per patient); • the cost of discharge assessment and program discharge review (optimal half hour duration excluding discharge exercise stress test which is optional); • costs of co-ordination, referral, organisation and documentation. Assessment of costs of programs similar to the above “optimal” program indicates approximately $40 per patient per session. That would mean a cost per patient of $480 for the 12 sessions extending over six weeks, each session lasting two hours in total. These costs do not include the costs of the venue, equipment and overheads which are insignificant when compared with the above salary-based components. They also do not include costs for review of outcomes for patients, either by recall and face to face interview and checking or by telephone. Further, the costing does not take into account the need for maintenance (phase 3) programs which should follow the ambulatory convalescent (phase 2) program. It should be noted that those programs showing the greatest cost savings have included both early ambulatory and maintenance programs. The cost of such maintenance programs is not adequately documented anywhere. Some model programs need to be established and evaluated. The evaluation should include a careful cost analysis.

Cost saving
Recommendation
Cardiac rehabilitation is recommended to produce significant direct cost saving through reduced hospital readmissions, hospital costs, disability pensions and support services, while improving quality and duration of life. Strength of evidence = 2 The established benefits impinging on cost include reduced hospital readmissions 160,740,743,747 and reduced death rates in the ensuing one to 10 years14,81,91

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greater work resumption with persistence in work for those in the workforce121,174,182,748 improved independent functioning and overall quality of life121. Reduced hospital readmissions for heart failure and avoidance of transplantation amongst patients with congestive heart failure through participation in a cardiac rehabilitation program is definite218. Removal of patients with stable angina pectoris from waiting lists for coronary artery bypass surgery is possible147. Amongst patients after acute myocardial infarction, it is reasonable to accept the findings of multiple trials and of meta analyses 80,81 that a mortality reduction of approximately 20% occurs over the next three years following participation in a cardiac rehabilitation program. The most favourable assessment of cost saving through cardiac rehabilitation has been the careful economic analysis of the controlled study from Sweden160. The saving in direct costs over the period of five years amongst men enrolled in the cardiac rehabilitation program was equivalent to $US 12,000.00 per patient (in 1988 terms). There were significant savings in hospital costs through reduced recurrent events, hospital attendances and hospital readmissions. A greater number of men in the rehabilitation group remained in employment, reducing the payment of disability and unemployment benefits, with great savings to the national insurance fund. Additionally, there was a significant reduction in mortality, statistically significant after 10 years 91. Indirect cost benefits, social benefits and quality of life were not analysed.

Cost effectiveness
Recommendation
Multifactorial cardiac rehabilitation is recommended as a cost effective use of medical care resources. Strength of evidence = 2 The dollar cost per year of life saved ($/LYS) has been calculated to be $US 2,130/YLS in 1985, rising to $US 4,950/YLS in 1995, the difference being driven by rising hospital and rehabilitation costs741. Such a low level of $/YLS places cardiac rehabilitation in the range of benefits similar to the $/YLS achieved through coronary angioplasty for severe angina in patients with single vessel disease749 and conferring possibly greater benefits than coronary bypass surgery749, or treatment with simvastatin for secondary prevention for patients with coronary artery disease 750,751 , while being inferior in cost effectiveness to counselling in smoking cessation749,752 . An economic evaluation based upon cost utility in terms of dollars/quality adjusted life years saved ($/QALYS) has been reported 740. This study showed gains in $/QALYS similar to other major accepted interventions in patients with cardiovascular disease.
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CHAPTER 20
RECOMMENDATIONS FOR FUTURE RESEARCH
As indicated throughout these Guidelines, further research is needed in many areas, including the following:

Exercise training
• Comparison of outcomes of outpatient exercise rehabilitation programs with frequency once, twice or three times per week. • Investigation of outcomes of outpatient exercise rehabilitation programs of different durations (eg 4,6,8,12 weeks) • Further investigation of the safety and efficacy of resistance training in higher risk and other cardiac groups

Education, counselling and behavioural interventions
• Comparison of different educational and counselling interventions to increase knowledge in cardiac patients • Investigation of the efficacy of education groups in cardiac rehabilitation of different sizes, frequency, duration and structure • Development and evaluation of interventions to reduce weight in overweight and obese cardiac patients • Evaluation of interventions to promote maintenance of physical activity and fitness in cardiac patients • Evaluation of the effectiveness of behavioural interventions in improving health behaviours of patients who have undergone coronary angioplasty (including reducing smoking and weight and increasing physical activity) • Investigation of relapse prevention methods for smoking cessation and weight reduction in cardiac patients • Investigation of the determinants and patterns of non-adherence in different cardiac patient groups and the evaluation of interventions to increase adherence

Psychosocial interventions
• Development of interventions to support spouses of cardiac patients in hospital and during convalescence • Investigation of the effects upon cardiac patients and their families of very early discharge of patients from hospital

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• Evaluation of stress management programs in cardiac rehabilitation • The development of effective interventions to improve psychosocial functioning of patients and spouses

Vocational rehabilitation
• Development and evaluation of interventions to increase return to work and improve occupational adjustment following acute cardiac events

Programs for specific groups
• Development and evaluation of cardiac rehabilitation programs for patients of non-English speaking backgrounds • Development and evaluation of cardiac rehabilitation programs for Aboriginal patients • Further development and evaluation of cardiac rehabilitation programs for rural and remote patients • Development and evaluation of cardiac rehabilitation programs for patients who have undergone coronary angioplasty and stent implantation • Development and evaluation of cardiac rehabilitation programs for patients with stable angina • Development and evaluation of cardiac rehabilitation programs for patients with unstable angina • Development and evaluation of cardiac rehabilitation programs for patients with significant co-morbidity • Investigation of the processes of recovery and outcomes of female cardiac patients • Investigation of the needs of children with congenital heart disease and their carers • Investigation of outcomes of group exercise, education and counselling programs in heart failure patients • Investigation of outcomes of group exercise, education and counselling programs for elderly patients • Investigation of outcomes of group exercise, education and counselling programs in patients with implantable defibrillators • Investigation of the effectiveness of cardiac rehabilitation programs in patients with congenital heart disease, rheumatic heart disease and other forms of heart disease

Organisational issues
• Development and assessment of the effectiveness of cardiac rehabilitation programs based upon modules • Development and evaluation of strategies to increase participation of patients and spouses in cardiac rehabilitation programs

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• Investigation of patterns of attendance at programs and identification of predictors of nonattenders and dropouts • Development of community-based programs to meet the needs of patients at different stages of recovery • Comparison of costs and cost effectiveness of different models for cardiac rehabilitation programs • Investigation of shared care approaches to secondary prevention in cardiac patients • Development and evaluation of strategies to improve communication with general practitioners following the discharge of cardiac patients from hospital and from cardiac rehabilitation programs • Comparison of the effectiveness of cardiac rehabilitation group programs conducted through general medical practice with those conducted by multidisciplinary teams • Investigation and definition of core competencies of members of cardiac rehabilitation teams

Evaluation
• Development of sensitive instruments to assess psychological, social, occupational and interpersonal functioning in cardiac patients • Development of more sensitive physical activity scales for cardiac patients • Development of more sensitive dietary scales for cardiac patients • Development of instruments to assess compliance in cardiac patients • Development of predictors of outcomes of cardiac patients, using inhospital and convalescent data • Development of multidimensional measures of quality of life in cardiac patients • Investigation of the applicability of generic tools in cardiac populations • Development and testing of key process and outcome indicators

Cost, cost saving and cost effectiveness
• • • • Investigation of detailed current program costs Investigation of costs of suggested optimal program components Investigation of costs of suggested additional program modules Further study of cost savings and cost saving estimates, based upon computer modelled outcomes, determined by changed risk factor profiles, upon discharge from programs • Cost effectiveness measures ($/YLS and $/QALYS) related to the effects of low cost, low technology programs of cardiac rehabilitation.

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Others studies
• Investigation of the role of telephone follow-up and the use of telephonic networks to support cardiac patients, spouses and health professionals, especially in rural and remote areas • Identification of effective components of multifactorial programs • Further evaluation of simple low cost models of cardiac rehabilitation and secondary prevention applicable to Australia and other countries.

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REFERENCES

1

World Health Organisation Expert Committee. Rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Technical report series number 831. Geneva: World Health Organisation; 1993. Wenger NK, Froelicher ES, Smith LK et al. Cardiac Rehabilitation. Clinical Practice Guideline No 17. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research USA and the National Heart, Lung, and Blood Institute. AHCPR Pub No. 96-0672; 1995. The World Health Report: conquering suffering, enriching humanity. Report of the Director-General. Geneva: World Health Organisation; 1997 The global burden of disease: A comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. CJL Murray CJL and Lopez AD, editors. World Health Organisation, World Bank and Harvard School of Public Health. Cambridge, Mass: Harvard University Press; 1996. Report on 1996 survey of Victorian cardiac rehabilitation programs. Melbourne: Heart Research Centre; 1999. Report on attitudes of health care providers towards cardiac rehabilitation and secondary prevention services. Melbourne: Heart Research Centre; 1999. A comparative study of four model cardiac rehabilitation and secondary prevention programs: a report on a pilot study. Melbourne: Heart Research Centre; 1999.

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658 Furnham A, Pendleton D, Manicon C. The perception of different occupations within the medical profession. Soc Sci Med 1981;15E:289–300. 659 Westbrook M. Professional stereotypes: how occupational therapists and nurses perceive themselves and each other. Aust Occup Ther J 1978;25:12. 660 Helm M, Ellson J. Cardiac rehabilitation: occupational therapy enhancement of an existing cardiac outpatient rehabilitation programme. Br J Occup Ther 1988;51:385–9. 661 Sokol B. Intervention with heart attack patients and families. Social Casework 1983;64:162–8. 662 Sulman J, Verhaeghe G. Myocardial infarction patients in the acute care hospital: a conceptual framework for social work intervention. Social Work in Health Care 1985;11:11–20. 663 McKendry N, Logan R. Cardiac rehabilitation: the role of the social worker. NZ Med J 1979;90:111–2. 664 Blumenthal JA, Califf R. Williams S, Hindman M. Continuing medical education cardiac rehabilitation: A new frontier for behavioral medicine. J Cardiac Rehabil 1983;3:637–56. 665 Chesney MA. Biobehavioural treatment approaches for cardiovascular disorders. J Cardiopulm Rehabil 1985;5:226–32. 666 Nichols KE. Psychological care by nurses, paramedical and medical staff: essential developments for the general hospitals. Br J Med Psychol 1985;58:231–240. 667 Maes S. Psychosocial aspects of cardiac rehabilitation in Europe. Br J Clin Psychol 1992;31:473–83. 668 Mulcahy R. Do different kinds of social and cultural settings require different kinds of rehabilitation programmes? In; Mathes P, Halhuber MJ, editors. Controversies in cardiac rehabilitation. Berlin : Springer-Verlag; 1982. 669 Thompson SC, Schwankovsky L, Pitts J. Counselling patients to make lifestyle changes: the role of physician self-efficacy, training and beliefs about causes. Fam Pract 1993;10:70–5. 670 Wiggers JH, Sanson-Fisher R. General practitioners as agents of health risk behaviour change: Opportunities for behavioural science in patient smoking cessation. Behav Change 1994;11:167–76. 671 Holka BS. Patient-clinician interactions and compliance. In; Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins University Press; 1979. 672 Tesar GE, Hackett TP. Psychiatric management of the hospitalized cardiac patient. J Cardiopulm Rehabil 1985;5:219–25. 673 Lloyd GC, Cowley RH. Distress or illness? A study of psychological symptoms after myocardial infarction. Br J Psychiatry 1983;142:120–5. 673 Orchard WH. Anxiety in patients with coronary disease. National Heart Foundation of Australia Notes of Cardiovascular Diseases. Melbourne: National Heart Foundation of Australia; 1964. 674 How to plan a cardiac rehabilitation program. National Heart Foundation of Australia. Second edition. Canberra. 1997. 675 Beitman BD, Mukerji V, Flaker G, Basha IM. Panic disorder, cardiology patients and atypical chest pain. Psychiatric Clinics of North America 1988;11:387–97. 676 Richardson A, Williams S, Elwood M, Bahr M, Medlicott T. Participation in breast cancer screening: randomised controlled trials of doctors’ letters and of telephone reminders. Aust J Public Health 1994;18:290–2. 677 Pell J, Pell A, Morrison C, Blatchford O, Dargie H. Retrospective study of influence of deprivation on uptake of cardiac rehabilitation. BMJ 1996;313:267–8. 678 Lawson-Matthew PJ, Wilson AT, Woodmansey PA, Channer KS. Unsatisfactory management of patients with myocardial infarction admitted to general medical wards. J R Coll Physicians Lond 1994;28:49–51. 679 Oldridge N, Streiner D. The health belief model: Predicting compliance and dropout in cardiac rehabilitation. Med Sci Sports Exerc 1990;22:678–83. 680 Brubaker PH, Warner JG, Rejeski WJ, Edwards DG, Matrazzo BA, Ribisl PM, et al. Comparison of standard and extended length participation in cardiac rehabilitation on body composition, functional capacity and blood lipids. Am J Cardiol 1996;78:769–73.

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681 Pashkow P, Ades PA, Emery CF, Frid DJ, Houston-Miller N, Peske G, et al. Outcome measurement in cardiac and pulmonary rehabilitation. AACVPR Outcomes Committee. American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil 1995;15:394–405. 682 Guyatt G, Sullivan M, Thompson P et al. The 6-minute walk: A new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985;132:919–23. 683 Guyatt GH. Measurement of health related quality of life in heart failure. Irish J Psychol 1994;15:148–63 684 Cipkin D, Scriven J, Crake T, Poole-Wilson P: Six-minute walking test for assessing exercise capacity in chronic heart failure. BMJ 1986;292:653–5. 685 Singh SJ,Morgan MDL, Scott S, Walters D, Hardman AE. Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax 1992;47:1019–24. 686 Hlatky M, Boineau R, Higgenbotham M, et al: A brief self-administered questionnaire to determine functional capacity (The Duke Activity Status Index). Am J Cardiol 1989;64:651–4. 687 Rankin SL, Briffa TG, Morton AR, Hung J. A Specific Activity Questionnaire to measure the functional capacity of cardiac patients. Am J Cardiol 1996;77:1220–3. 688 Harvey R, Doyle E, Ellis K. Major changes made by the Criteria Committee of the New York Heart Association. Circulation 1974;49:390. 689 Campeau L. Grading of angina pectoris. Circulation 1976;54:522. 690 Spertus JA, Winder JA, Dewhurst TA et al. Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease. J Am Coll Cardiol 1995;25:333–41. 691 Rector TS, Kubo SH, Cohn JN. Patients’ selfassessment of their congestive heart failure: content, reliability and validity of a new measure, the Minnesota Living with Heart Failure Questionnaire. Heart Failure 1987;3:198–209. 692 Oldridge NB. Outcome assessment in cardiac rehabilitation: health-related quality of life and economic evaluation. J Cardiopulm Rehabil 1997;17:179–94. 693 Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36). I.Conceptual framework and item selection. Med Care 1992;30:473–83. 694 Tarlov AR, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The Medical Outcomes Study: an application of methods for monitoring the results of medical care. JAMA 1989;262:925–30. 695 Jette DU, Downing J. Health status of individuals entering a cardiac rehabilitation program as measured by the Medical Outcomes Study 36-item Short Form Survey (SF-36). Phys Ther 1994;74:521–7. 696 Oldridge NB, Gottlieb M, Guyatt GH, Jones NL, Feeny D, Streiner D. Predictors of healthrelated quality of life with cardiac rehabilitation after acute myocardial infarction. J Cardiopulm Rehabil 1998;18:95–103. 697 Bunker S, Cotz J, McBurney H, McCrae S. Health outcomes in cardiac rehabilitation using the Medical Outcomes Study Short Form 36 to measure the health status of patients at entry to and exit from outpatient cardiac rehabilitation [abstract]. Proceedings of the Managing and Measuring Health Outcomes Conference: Canberra, Australia; 1997. 698 Hunt S, McEwen J, McKenna S. A quantitative approach to perceived health. J Epidemiol Community Health 1980;34:281–95. 699 Caine N, Harrison SCW, Sharples LD, Wallwork J. Prospective study of life before and after coronary artery bypass grafting. BMJ 1991;302:511–6. 700 Skinner JS, Albers CJ, Hall RJC, Adams PC. Comparison of Nottingham Health Profile (NHP) scores with exercise duration and measures of ischaemia during treadmill exercise testing in patients with coronary artery disease. Eur Heart J 1995;16:1561–5. 701 Dempster M, Bradley J, Wallace E, McCoy P. Measuring quality of life in cardiac rehabilitation: comparing the Short Form 36 and the Nottingham Health Profile. Coronary Health Care 1997;1:211–7.

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702 McNair D, Lorr M, Droppleman L. Profile of Mood States. San Diego, CA: Education and Industrial Testing Service; 1971. 703 Dimsdale JE, Hackett TP. Effect on denial on cardiac health and psychological assessment. Am J Psychiatry 1982;139:1477–80. 704 Shephard RJ, Kavanagh T, Klavora P. Mood state during postcoronary cardiac rehabilitation. J Cardiopulm Rehabil 1985;5:480–4. 705 Gibson B, Gibson J, Bergner M et al. The Sickness Impact Profile: development of an outcome measure of health care. Ann Intern Med 1975;65:1304–10. 706 Ott CR, Sivarajan ES, Newton KM et al. A controlled randomized study of early cardiac rehabilitation: The Sickness Impact Profile as an assessment. Heart Lung 1983;12:162–70. 707 Derogatis LR. The Psychosocial Adjustment to Illness Scale (PAIS). J Psychosom Res 1986;30:77–91. 708 Raft D, McKee DC, Popio KA, Haggerty JJ. Life adaptation after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting. Am J Cardiol 1985;56:395–8. 709 Heller RF, Lim L, Valenti L, Knapp J. A randomised controlled trial of community based counselling among those discharged from hospital with ischaemic heart disease. Aust NZ J Med 1995;25:362–4. 710 Denollet J. Health complaints and outcome assessment in coronary heart disease. Psychosom Med 1994;56:463–74. 711 Hare DL, Davis CR. Cardiac Depression Scale: validation of a new depression scale for cardiac patients. J Psychosom Res 1996;40:379– 86. 712 Spielberger C, Gonsuch R, Luschene R. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologist Press; 1970. 713 Egan V, Miller E, McLennan I. Does the personal questionnaire provide a more sensitive measure of cardiac surgery relatedanxiety than a standard pencil and paper checklist? Personality and Individual Differences 1998; 24:465–73. 714 Burker EJ, Blumenthal JA, Feldman M, Burnett R, White W, Smith LR, et al. Depression in male and female patients undergoing cardiac surgery. Br J Clin Psychol 1995; 34:119–28. 715 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psych Scand 1983;67:361–70. 716 Duits AA, Duivenvoorden HJ, Boeke M, Taams MA, Mochtar B, Krauss XH, et al. The course of anxiety and depression in patients undergoing coronary artery bypass graft surgery. J Psychosom Res 1998;45:127–38. 717 O’Rourke A, Lewin B, Whitecross S, Pacey W. The effects of physical exercise training and cardiac education on levels of anxiety and depresion in the rehabilitation of coronary artery bypass patients. Int Disabil Stud 1990;12:104–6. 718 Beck AT, Ward CH, Mendelson M, Mock JE, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561– 71. 719 Crowe JM, Runions J, Ebbesen L, Oldridge N, Streiner DL. Anxiety and depression after acute myocardial infarction. Heart Lung 1996;25:98–107. 720 Timberlake N, Klinger P, Smith P, Venn G, Treasure T, Harrison M, Newman SP. Incidence and patterns of depression following coronary artery bypass graft surgery. J Psychosom Res 1997;43:197–207. 721 Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63–70. 722 Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Measurement 1977;1:385–401. 723 Krug SE, Scheier IH, Cattell RB. Handbook for the IPAT Anxiety Scale. Institute for Personality and Ability Testing. Champaign (IL): The Institute; 1976. 724 Krug SE, Laughlin JE. Handbook for the IPAT Depression Scale information. Champaign (IL): Institute for Personality and Ability Testing; 1976. 725 McCormack HM, De L Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007–19.

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726 Gurland BJ, Yorkston NJ, Stone AR, Frank JD, Fleiss JL. The structured and scaled interview to assess maladjustment. I. Description, rationale and development. II. Factor analysis, reliability and validity. Arch Gen Psychiatry 1972;27:259–67. 727 Weissman MM. The assessment of social adjustment a review of techniques. Arch Gen Psychiatry 1975;32:357–65. 728 Sarason IG, Johnson JH, Siegel JM. Assessing the impact of life changes: development of the Life Experiences Survey. J Consult Clin Psychol 1975;46:932. 729 Hathaway SR, McKinley JC. The Minnesota Multiphasic Personality Inventory manual. Minneapolis: University of Minnesota Press; 1943. 730 Murphy MC, Fishman J, Shaw RE. Education of patients undergoing coronary angioplasty: factors affecting learning during a structured education program. Heart Lung 1989;18:36–45. 731 Havik OE, Maeland JG. Patterns of emotional reactions after a myocardial infarction. J Psychosom Res 1990;34:271–85. 732 Tooth L, McKenna K, Maas F, McEniery P. The effects of pre-coronary angioplasty education and counselling on patients and their spouses: a preliminary report. Patient Education and Counseling 1997;32:185–96. 733 Robinson P, McBurney H, Bunker S. The development of the Victorian Cardiac Rehabilitation Questionnaire [abstract]. Proceedings of the 4th Annual Scientific Meeting of the Australian Cardiac Rehabilitation Association: Adelaide, Australia; 1994. 734 Rabkin SW, Chen Y, Leiter L, Liu L, Reeder BA. Risk factor correlates of body mass index. Canadian Heart Health Surveys Research Group. CMAJ 1997;157 Suppl 1:S26–31. 735 Wetzler HP, Cruess DF. Self-reported physical health practices and health care untilization : findings from the National Health Interview Survey. Am J Public Health 1985;75:1329–30. 736 Dobson, A, Blijlevens, R, Alexander, HM, Croce, N, Heller, R, Higginbotham N, et al. Short Fat Questionnaire: a self-administered measure of fat-intake behaviour. Aust J Public Health 1993 17 144–9 737 Haynes RB, Taylor DW, Sackett DL, editors. Compliance in health care. Baltimore: Johns Hopkins Press; 1979. 738 Trotter L, Mullins R, editors. Quit evaluation studies. Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria for the Victorian Smoking and Health Program. Melbourne: Anti-Cancer Council of Victoria; 1998. 739 StrecherVJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self efficacy in achieving health behaviour change. Health Education Quarterly 1986;13:73–92. 740 Oldridge N, Furlong W, Feeny D et al. Economic evaluation of cardiac rehabilitation soon after myocardial infarction. Am J Cardiol 1993;72:154–61. 741 Ades PA, Pashkow FJ, Nestor JR. Costeffectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997;17:222–31. 742 Byl N, Reed P, Franklin B, Gordon S. Cost of phase II cardiac rehabilitation: implications regarding ECG monitoring practices [abstract]. Circulation 1988;78 Suppl 11:136. 743 Ades PA. Decreased medical costs after cardiac rehabilitation. A case for universal reimbursement. J Cardiopulm Rehabil 1993;13:75–7. 744 Gray A, Bowman GS, Thompson DR. The role of cardiac rehabilitation services in England and Wales. J R Coll Physicians Lond 1997;31:57–61. 745 Lewin RJ, Ingleton R, Newens AJ, Thompson DR. Adherence to cardiac rehabilitation guidelines: a survery of rehabilitation programmes in the United Knigdom. BMJ 1998; 316:1354–5. 746 de Bono DP. Models of cardiac rehabilitation. Multidisciplinary rehabilitation is worthwhile, but how is it best delivered? [editorial]. BMJ 1998;316:1329–30. 747 Bondestam E, Breikss A, Hartford M. Effects of early rehabilitation on consumption of medical care during the first year after acute myocardial in patients > 65 years of age. Am J Cardiol 1995;75:767–71.

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748 Picard MH, Dennis C, Schwartz RG, Ahn DK, Kraemer HC, Berger WE, et al. Cost-benefit analysis of early return to work after uncomplicated acute myocardial infarction. Am J Cardiol 1989;63:1308–14. 749 Kupersmith J, Holmes-Rovner M, Hogan A, Rovner D, Gardiner J. Cost effectiveness analysis in heart disease. Part I: General principles. Prog Cardiovasc Dis 1994;37:161–84. 750 Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of heart disease. JAMA 1991;265:1145–51. 751 Kinosian B, Glick H, Schwartz JS. Scandinavian Simvastatin Survival Study (4S): cost effectiveness (CE) of cholesterol lowering treatment [abstract]. J Am Coll Cardiol 1996;27:165A. 752 Krumholz HM, Cohen BJ, Tsevat J, Pasternak RC, Weinstein MC. Cost effectiveness of a smoking cessation program after myocardial infarction. J Am Coll Cardiol 1993;22:1667–72.

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GLOSSARY

ACE inhibitor (angiotensin-converting enzyme inhibitor) A drug used in treatment of hypertension and heart failure. Acute myocardial infarction (AMI) A heart attack in which there occurs death of heart muscle due to blockage of a coronary artery. Adherence The continued maintenance of a prescribed or recommended behaviour, regimen or medication. Aerobic exercise Exercise in which there is repetitive movement of large muscle groups. This exercise leads to increase in the uptake of oxygen. Hence the term “aerobic”. The term has in the past been applied to high intensity exercise, but it has now been broadened to include any exercise that leads to increased oxygen uptake. Ambulatory ECG (Holter recording) A continuous record of the electrocardiograph during normal daily living, usually through a day or more. Ambulatory cardiac rehabilitation program An outpatient program conducted during early convalescence up to about three months after discharge from hospital. “Ambulatory” is preferable to the term “phase 2” to describe programs conducted during convalescence. Aneurysm A sac formed due to weakness in the wall of an artery, a vein or a heart chamber in which bulging or dilatation occurs. Angina pectoris Pain or discomfort in the chest due to inadequacy of blood supply to meet the demands of the heart muscle commonly during effort or emotion and which is eased by rest.

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Angiography The process whereby blood vessels are outlined using X-ray examination after injection of fluid which is opaque to X-rays. Arrhythmia Abnormal heart rhythm which may be permanent, intermittent or transient. Atherosclerosis The condition in which there occur plaques containing cholesterol and other materials which form in the inner linings of large and medium sized arteries, leading to localised thickening. Behavioural intervention Systematic instruction and learning of techniques and methods to modify healthrelated behaviours. Best practice Best practice refers to optimal standards of care, reflected in the achievement of the best possible outcomes, processes and structures. Best practice guidelines identify benchmarks for providing optimal health services, thus contributing to quality assurance. Implicit in the concept of best practice is the requirement that the recommended practices should be cost effective. Beta blocker (b-adrenergic receptor blocking agent) A drug which antagonises the effects of sympathetic stimulation, thereby producing a slower heart rate, lower blood pressure and reduced heart muscle contraction, leading to lessened oxygen demands of the heart muscle and, hence, decreasing angina pectoris. Blood pressure Pressure generated in the arterial system when the blood is driven by force from the main pumping chamber of the heart (the left ventricle). The systolic blood pressure is the highest pressure at the peak of ventricular contraction. The diastolic blood pressure is the lowest pressure when the ventricular muscle is most relaxed prior to the next contraction. Cardiac arrest Cessation of heart action due to ventricular fibrillation or ventricular standstill (cessation of all heart pumping activity and failed ventricular activity). Cardiac catheterisation Passage of a catheter into the heart through an artery or vein under X-ray control, used for cardiac diagnosis.

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Cardiac mortality Death due to heart disease, often expressed as percentage of death rates or rate of deaths per 100,000 of population. Cardiomyopathy Disease of the heart muscle commonly of unknown or obscure origin, not due to coronary heart disease, high blood pressure or valvular disease. The term, however, is sometimes used to explain heart muscle disease secondary to these known causes. Cardiovascular disease (CVD) All diseases of the heart and blood vessels. These include coronary heart disease, rheumatic heart disease, cardiomyopathy, hypertensive and other forms of heart disease and of blood vessel disease, including stroke. Cardiovascular mortality Death due to any disease of the heart and blood vessels. Cholesterol A fatty substance found in all animal tissue. It is a normal ingredient of all cells. It is transported in the blood, linked to a protein which makes it soluble in the blood (lipoprotein). High levels of cholesterol lead to deposition within the linings of the arteries, thereby producing atherosclerosis. Chronotropic dysfunction Reduced response of the heart rate to exercise or other stress. This impaired increment in heart rate response is most commonly found in patients after acute myocardial infarction and in elderly patients. Client A person receiving attention or advice from a professional practitioner. Thus, a physician’s patient may also be a social worker’s client. A term preferred by many when referring to a patient who has been discharged from hospital and is receiving attention or advice in a community setting. Cognitive behaviour therapy A psychotherapeutic approach used to change maladaptive behaviour through replacing dysfunctional and negative thoughts and beliefs with adaptive ones. Comorbidity A disease, disorder or disability which co-exists with other diseases or disabilities. Compliance Acceptance of, and adherence to, a prescribed or advised behaviour, regimen or medication. The terms “compliance” and “adherence” are sometimes used interchangeably.

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Convalescence The period of recovery from an illness, usually considered to be from hospital discharge to resumption of normal or acceptable functioning. In cardiac rehabilitation programs this has traditionally between six to 12 weeks. Coronary angiography Technique whereby the coronary arteries are outlined by fluid which is opaque to Xrays. Coronary artery bypass graft surgery (CABGS) The bypassing of a narrowing or obstruction in a coronary artery. This may be by using portion of a vein removed from the leg or elsewhere, by using an artery from within the chest wall (an internal mammary artery) or by using an artery from the forearm or elsewhere (a free arterial graft). Coronary artery disease (CAD) The condition in which there is atherosclerotic irregularity and narrowing within the coronary arteries due to atherosclerosis. Coronary heart disease (CHD) Heart disease resulting from the atherosclerotic narrowings of coronary artery disease. Coronary occlusion The process of obstruction or blocking of a coronary artery, usually by a blood clot (coronary thrombosis). Cost benefit The gain (by some measure of outcome) arising from a defined expenditure. Cost effectiveness The relative gain (by some measure of outcome) whereby the cost benefit of one form of intervention may be compared with another. Counselling Providing advice, support and consultation. Didactic An adjective describing the delivery of information in a formal lecture format. Diuretic A drug which leads to the passing of additional urine via the kidneys, used in the treatment of hypertension and heart failure. Dyspnoea Awareness of difficulty in breathing or the noticing of laboured breathing.

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Echocardiography The use of ultrasound to detect and record the structures and the motion of those structures and to measure cardiac chamber size, shape and wall thickness while also being used to assess movement of blood in the heart. Education Systematic instruction. This may be by free discussion, by structured interactive group work, by lecture or by visualisation or reading of information. Ejection fraction Measure of the pumping capacity of the left ventricle of the heart. It is the difference between the end-diastolic volume and the end-systolic volume of the left ventricle divided by the left ventricular end-diastolic volume. Electrocardiogram (ECG or EKG) A graphic record of the electrical activity of the heart obtained with an electrocardiograph. Ergometer Equipment such as a stationary cycle, treadmill or steps used to measure the amount and physiological effects of exercise. Ergometry The process of measuring the physiological effect of exercise. Exercise test (stress test) A test in which the patient exercises on a treadmill, cycle or other equipment for monitoring of heart rate, blood pressure, electrocardiogram or consumption of oxygen. Exercise training A program of repeated exercise undertaken at a guided or prescribed intensity and frequency over a period of time, usually several weeks. The exercise training is based upon so-called aerobic or dynamic exercise, designed to improve physical performance at both maximal and submaximal levels. Such exercise may be of low, moderate or high intensity. Exercise training may also include resistance training involving the use of muscular effort against resistance, with the aim of increasing muscular strength Fibrillation Extremely rapid irregular twitching of muscle resulting in atrial fibrillation or ventricular fibrillation. Heart failure (congestive heart failure) Failure of the heart to maintain adequate blood flow to the tissues, with retention of fluid and congestion of the lungs, legs or other parts of the body.

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Heart rate Number of heart beats per minute. High density lipoprotein (HDL cholesterol) A lipid and protein complex for transport of cholesterol, triglycerides and other fats from the tissues to the liver. (High levels are protective against atherosclerosis.) Hypercholesterolaemia Excessive elevation of the cholesterol level in the blood. Hyperlipidaemia Excessive level of cholesterol, triglycerides or other lipid fractions in the blood. Hypertension Abnormally raised blood pressure within the arteries (high blood pressure) . Hypotension Abnormally low blood pressure. Implantable cardiac defibrillator An electronic device which senses rapid ventricular tachycardia or ventricular fibrillation and then delivers an electric countershock to the heart to break the potentially lethal arrhythmia. Interactive education A process of teaching and learning through discussion and bidirectional questions and answers. Ischaemic heart disease (IHD) Commonly used as an alternative term to coronary heart disease implying that the coronary heart disease is symptomatic or overt, through angina pectoris, unstable angina pectoris, myocardial infarction or other measures of myocardial ischaemia. Kilocalorie A unit of energy. The energy required to raise the temperature of one litre of water by one degree Centigrade (also referred to as one Calorie which equals 1000 lesser calories). Kilojoule Unit of energy used as a measure alternative to Kilocalorie. One Kilojoule = 1000 Joules. One Joule is derived from an electrical unit- the amount of heat generated by a current of one ampère acting for one second against a resistance of one ohm. Used as a unit of available food energy or expended energy one Kilocalorie is approximately 4.2 Kilojoules.

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Left ventricular function The pumping function of the left ventricle, that being the high pressure chamber which pumps blood into the arterial circulation. Lipid Fatty substances, normally water insoluble, but made soluble through combination with protein molecules. Lipoprotein Complex of lipid and protein molecules which transport lipids (cholesterol and triglycerides) being soluble within the blood. Low density lipoprotein (LDL) Complex of lipid and protein molecules transporting cholesterol from the liver to the tissues. (High levels contribute to and worsen atherosclerosis.) Maintenance program A program which provides longterm support from the time of discharge from an ambulatory program. “Maintenance” program is preferable to the term “phase 3” program. MET Metabolic equivalent. A measure of oxygen uptake through the lungs. Levels of activity may be categorised in METs. One MET is the amount of oxygen taken up by a normal adult sitting at rest. It is equivalent to approximately 3.5mL of oxygen/kg/ min. Meta-analysis The process whereby results of randomised clinical trials using similar design, with similar outcome measures from a similar intervention (or the same intervention) are aggregated to permit statistical analysis of large number of subjects. Multidisciplinary The application of, or pertaining to, or arising through, many professional disciplines. Multifactorial The application of, or pertaining to, or arising through more than one intervention conducted during the same period. Myocardial infarction The process of death or of damage to heart muscle, arising through coronary artery occlusion. Myocardium Heart muscle.

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Myocardial ischaemia Inadequate blood supply to the heart muscle. Pacemaker An electronic device which senses cessation of cardiac electrical impulse and introduces an alternative electrical impulse to induce cardiac muscle contraction. Percutaneous transluminal coronary angioplasty (PTCA) A procedure whereby a coronary artery stenosis is opened to enlarge the lumen in the artery through pressure applied from a balloon attached to an angioplasty catheter inserted into the coronary artery. Radionuclide ventriculography (RNVG) The assessment of chamber size (usually left ventricle) and performance by intravenous radioisotope injection. Rate pressure product (double product) The product of systolic blood pressure multiplied by heart rate. An index of cardiac work which is an indirect index of myocardial oxygen requirement. Resuscitation The process of restoration of consciousness or life in an unconscious or dying person. This is usually in the form of cardiopulmonary resuscitation (CPR). Restenosis The recurrence of narrowing of an artery occurring after the correction of the narrowing. Revascularisation The restoration of adequate blood flow usually to heart muscle. The commonest techniques for revascularisation are CABGS and PTCA. Rheumatic heart disease Diseases of the heart valves and heart muscle caused by rheumatic fever. Rheumatic fever occurs, in susceptible persons, through an abnormal response to infection, usually of the throat, with a particular bacterium (Group A, beta haemolytic streptococcus). Risk factors These are variables or states which are characteristically associated with an increased rate of subsequent disease. Self-efficacy Self-confidence or a belief that one is competent and able to achieve a desired goal.

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Shared care The delivery of co-ordinated health care by more than one health professional or group of professionals (eg physician, nurse practitioner and dietitian). Stenosis A narrowing within a blood vessel or other tube. Stent The open mesh tube inserted into an artery to hold the artery open following, or as part of, PTCA or other angioplasty. ST segment displacement A shift from the normal baseline of the ST segment in the electrocardiogram. This occurs during the period of repolarisation and is often an indication of ischaemia. Tachycardia Rapid heart action. This may be regular and normal (sinus tachycardia), arise from the atrium (atrial tachycardia, flutter or fibrillation), from the conducting system (supraventricular tachycardia) or from the ventricles (ventricular tachycardia). Target heart rate The heart rate to which one may aim during exercise training. It is usually derived from the peak rate achieved during a symptom limited maximal exercise test. Thrombolytic therapy Pharmacological intervention to dissolve blood clots within the vascular system. Streptokinase (SK) and tissue type plasminogen activator (TPA) are commonly used. Triglyceride Fat consisting of glycerol and three fatty acids. Unstable angina Chest pain which occurs at rest, is prolonged or appears abruptly for the first time, but which does not denote the occurrence of acute myocardial infarction. Ventricular dysfunction Abnormality of the pumping function of (usually) the left ventricle of the heart. Ventricular fibrillation Rapid irregular, totally inefficient chaotic contractions resulting in cardiac arrest (apparent cessation of heart action). Ventricular tachycardia Rapid heart action due to an abnormal rapid contraction pattern arising within the ventricles.

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ACKNOWLEDGEMENTS

Production of these Best Practice Guidelines for Cardiac Rehabilitation and Secondary Prevention was funded by the Victorian Department of Human Services as part of the Cancer and Heart Offensive. The authors gratefully acknowledge the assistance and support of Mr Martin Turnbull, Mrs Margaret Smyth and Mrs Susan Tabak of the Public Health and Development Division of the Victorian Department of Human Services during the production of these Guidelines. They also wish to record their grateful thanks to project co-investigators, Dr Michael Jelinek and Dr Ian McDonald, for their significant contributions toward this project. Valuable comments on the final draft were made by Dr Helen McBurney, Mr Tom Briffa and Mr Steve Bunker, as well as other members of the Consultative Committee. The contribution of Ms Janet Compton, who facilitated the focus groups, is also appreciated. Several others assisted with the background research for this document or provided clerical assistance. They include Mrs Elaine Race, who co-ordinated the surveys undertaken as part of the development of the Guidelines, Ms Emma Gilbert, Ms Julie Humphreys, Mrs Christine Eichler, Ms Sharon Johnson, Ms Biljana Krsmanovic and Ms Julie Webb-Pullman. Mrs Carol McManus was responsible for typing many drafts and editing the final manuscript. Her contribution is gratefully acknowledged. The members of the Consultative committee, who are listed below, made constructive comments and provided ongoing support during the development of the Guidelines.

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CONSULTATIVE COMMITTEE

Mr Garth Birdsey Pharmacy Department, Geelong Hospital, Geelong Ms Therese Bowden Castlemaine Community Health Centre, Castlemaine Mr Tom Briffa Exercise physiologist, NHMRC Clinical Trials Centre, Sydney, New South Wales Mr Steve Bunker Rehabilitation Manager, National Heart Foundation (Vic Div), Melbourne Ms Peta Cadd Co-ordinator, Community Care, Epworth Hospital, Melbourne Ms Janet Compton Manager, Physiotherapy Department, Alfred Health Care Group, Melbourne Mr Raoul Copolov Heartbeat Victoria Inc, Melbourne Mrs Anne Cross Cardiac Rehabilitation Co-ordinator, Bairnsdale Regional Health Service, Bairnsdale Professor Peter Disler Medical Director of Rehabilitation, Essendon & District Memorial Hospital, Melbourne Mr Don Ewart Heartbeat Victoria Inc, Melbourne Dr Elton Fagan Cardiologist, Alfred Health Care Group, Melbourne Dr Alan Goble Cardiologist, Heart Research Centre, Melbourne
The positions listed are those held during the early stages of the project when meetings took place.
BEST PRACTICE GUIDELINES FOR CARDIAC REHABILITATION AND SECONDARY PREVENTION

238

Mrs Suzanne Hooper Cardiac Rehabilitation Co-ordinator, Knox Private Hospital, Melbourne Dr Michael Jelinek Cardiologist, St Vincent’s Hospital, Melbourne Dr Dianne Keenan General practitioner, Northland Shopping Centre Medical Clinic, Melbourne Ms Kathryn Kelly Cardiac Rehabilitation Co-ordinator, The Royal Melbourne Hospital, Melbourne Mr Leigh Kinsman Clinical nurse educator, Bendigo Health Care Group, Bendigo Dr Helen McBurney Manager, Physiotherapy Department, La Trobe University, Melbourne Dr Ian McDonald Director, Centre for the Study of Clinical Practice, St Vincent’s Hospital, Melbourne Mrs Elaine Race Research Co-ordinator, Heart Research Centre, Melbourne Mr Robert Roe Department of Learning Assessment and Special Education, Faculty of Education, The University of Melbourne, Melbourne Ms Sally Stewart Social Worker, Royal Melbourne Hospital, Melbourne Ms Margarite Vale Dietitian, St Vincent’s Hospital, Melbourne Ms Lynda Vamvoukis Public Health Unit, Victorian Department of Human Services, Melbourne Mr Bill Whitehead National Director, Heart Support Australia, Echuca Ms Paula Williams Cardiac Rehabilitation Co-ordinator, Donvale Rehabilitation Hospital, Melbourne Dr Marian Worcester Director, Heart Research Centre, Melbourne

The positions listed are those held during the early stages of the project when meetings took place.

BEST PRACTICE GUIDELINES FOR CARDIAC REHABILITATION AND SECONDARY PREVENTION

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