Cardiac Rehabilitation
Content
Cardiac Rehabilitation
Introduction
Cardiac rehabilitation is the process by which a person who is suffering from ischaemic heart disease, or who has had a myocardial infarction (MI), is encouraged to achieve their full potential in terms of physical and psychological health. In order to be successful, cardiac rehabilitation must draw on the skills of many members of the healthcare team and involve a combination of education, psychological support,exercise training and behavioural change.1,2 Although the mechanism by which it occurs is not yet fully understood, cardiac rehabilitation which includes a programme of structured exercise is now generally believed not only to improve morbidity but also to reduce mortality in patients who have suffered an MI.3,4 It has been thought for many years that all patients, regardless of gender or age, who have ischaemic heart disease and/or cardiac failure, might benefit from cardiac rehabilitation.5 For optimal effect, cardiac rehabilitation programmes should be structured and tailored to the individual patient following an initial assessment. Computer support systems have been shown to assist the decision-making process.6 Cardiac rehabilitation is one of the National Priority Projects on the NHS's improvement agenda. The National Institute for Health and Clinical Excellence (NICE) outlines the clear benefits of these services, including improving survival and quality of life and reducing unplanned hospital admissions.7 The British Association for Cardiac Rehabilitation (BACR) specifically identifies the cardiac specialist nurse as a core member of the cardiac rehabilitation team.8 Intervention by a specialist nurse can substantially reduce the length of hospital stay, hospital costs and the risk of readmission to hospital for heart failure.9,10 General y All patients who have had an MI should be offered a cardiac rehabilitation programme which includes an exercise component. y A range of options should be offered. Patients should be encouraged to attend the options appropriate to their needs but should not be excluded from the entire programme if they do not want to take up one particular component or more. y If the patient has a cardiac or other condition which limits physical exercise this should be treated before this component is offered. A suitably qualified healthcare professional may be able to adapt the physical component to make it more suitable for the patient. y Patients with stable left ventricular dysfunction can be offered the physical component. Engaging patients Although cardiac rehabilitation has been proven to be beneficial, uptake has been suboptimal (40% uptake among heart attack survivors in the UK). Reasons provided by patients are varied and include difficulty in attending the hospital (transport, car parking), a dislike of groups, work or domestic commitments. Home-based programmes have been devised to address these problems and to improve access to, and participation in, cardiac rehabilitation programmes. y When cardiac rehabilitation services are planned, the needs of the particular local community should be taken into account, including health and social factors and deprivation.This will
y y
y y y
ensure that there is maximum engagement with those who have the greatest need, thereby ensuring that services are accessible and relevant to all MI patients. Services should be culturally sensitive. This may mean employing bilingual peer educators or cardiac rehabilitation assistants to reflect the diversity of the local population. The physical component should be adapted to meet the needs of older patients and those with signficant comorbidities. The provision of transport to the service may need to be considered. Patients should be offered mixed-sex or single-sex classes. It is important for patients' health beliefs and basic level of health literacy to be established before lifestyle advice is offered. All healthcare professionals who come into contact with post-MI patients, including senior medical staff, should promote cardiac rehabilitation services. Various methods of contact should be considered, including verbal, postal and telephone communication. One study propounded the benefits of 'telehealth' interventions (internet, telephone and video conferencing).11 Despite its proven benefits, the uptake of cardiac rehabilitation services in the UK is currently poor.12
Health education y Programmes should include general health education and information on how to deal with stress. y An integrated and co-ordinated approach from primary and secondary care teams at this stage, e.g. using a validated structured plan such as 'The Heart Manual', can improve psychological wellbeing and overall outcome. This may be particularly appropriate for patients unwilling or unable to access secondary care-based services, since much can be achieved using a homebased approach. 13 One study in Birmingham found no differences in clinical outcomes in patients participating in hospital-based or home-based programmes.14 y Most patients who have sustained an MI can return to work. Account should be taken of the type of work, the work environment and the physical and psychological state of the patient. y Due regard should be given to the latest guidance from the Driver and Vehicle Licensing Agency(DVLA).15 y Patients can usually fly within 2-3 weeks. If there have been complications, expert advice should be sought. y Patients with a pilot's licence will need to seek the advice of the Civil Aviation Authority before they can pilot a plane. y Depending on psychological and physical status, most patients can resume normal daily activities. y Patients should be taught how to use the Metabolic Equivalent of Task (MET) system.16 This is a useful method for calculating the intensity of a particular activity so that physiological demand can be monitored. Patients who have had a complicated MI may need expert advice. y Patients involved in competitive sports may need expert advice to assess the level of risk. Psychological and social support y Patients should be offered basic stress management advice and may not need more complex treatment such as cognitive behavioural therapy. However, one study found that six components of psychological intervention - usual care, educational, behavioural, cognitive, relaxation and support - offered positive benefits in terms of clinical outcomes.17 y Partners and carers should be involved if this is in accordance with the patient's wishes. y Patients with anxiety or depression should be managed according to the appropriate NICE guidance.18
Phases in cardiac rehabilitation
The Scottish Intercollegiate Guidelines Network (SIGN) describes phases appropriate to the patient's physical and psychological recovery:1 Phase 1: the initial stage following MI or cardiac event
y y y y y y
Assessment of a patient's physical/psychological condition. Assessment of risk factors, e.g. diet, smoking, exercise, lipid profile. Reassurance and correction of any misconceptions. Education. Initial mobilisation. Plan for discharge.
Phase 2: the post-discharge stage The early discharge period is the time at which the patient is the most vulnerable and psychological distress at this stage is a predictor of poor outcome and increased use of hospital services independent of the physical damage to the heart.19 Patients should be screened for anxiety and depression at this stage and should be treated with suitable non-cardiotoxic antidepressants if appropriate. Phase 3: structured exercise and rehabilitation Graded exercise is a vital component of cardiac rehabilitation, although it does not alter morbidity and mortality rates if offered in isolation. Aerobic low-to-moderate intensity exercise will be suitable for most patients who have been assessed as low-to-moderate risk. This form of exercise programme may generally be undertaken either at home or under supervision in the community, e.g. graded exercise programmes in leisure centres where staff have received basic life support training. One meta-analysis confirmed that light-to-moderate exercise in a group setting offered the greatest benefit in terms of improved quality of life.20 Exercise training for high-risk patients would normally be carried out in a hospital or other suitable venue able to provide facilities and staff trained in resuscitation should this prove necessary. Graded exercise should be accompanied at this stage by other interventions tailored to meet the individual patient's requirements. Lifestyle changes should be encouraged and supported where appropriate, e.g. weight reduction, smoking cessation, retraining with a view to returning to work. This is likely to be accompanied by education concerning the cardiac condition and the reasons why changes in lifestyle might be desirable. Phase 4: long-term maintenance In order to be effective, physical activity and changes in lifestyle need to be maintained for the longterm. A protocol which allows for the regular review of all patients with ischaemic heart disease and/or heart failure by the primary care team is desirable.1 Long-term review will permit continued support of lifestyle changes in addition to assessment of drug therapy, and physical and psychological wellbeing, and will allow early intervention, where required, in all areas.
Document references
1. Cardiac rehabilitation, Scottish Intercollegiate Guidelines Network (SIGN) Guideline (2002) 2. Williams B, Poulter NR, Brown MJ, et al; Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV.; J Hum Hypertens. 2004 Mar;18(3):139-85.
3. Secondary prevention in primary and secondary care for patients following a myocardial infarction, NICE Clinical Guideline (2007) 4. Jolliffe JA, Rees K, Taylor RS, et al; Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001;(1):CD001800. [abstract] 5. Gordon NF, Gulanick M, Costa F, et al; Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004 Apr 27;109(16):2031-41. 6. Goud R, de Keizer NF, ter Riet G, et al; Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation. BMJ. 2009 Apr 27;338:b1440. doi: 10.1136/bmj.b1440. [abstract] 7. Commissioning a cardiac rehabilitation service, NICE, (2007) 8. Standards and Core Components for Cardiac Rehabilitation, British Association for Cardiac Rehabilitation, (2007) 9. Grange J; The role of nurses in the management of heart failure. Heart. 2005 May;91 Suppl 2:ii39-42; discussion ii43-8. [abstract] 10. Blue L, Lang E, McMurray JJ, et al; Randomised controlled trial of specialist nurse intervention in heart failure. BMJ. 2001 Sep 29;323(7315):715-8. [abstract] 11. Neubeck L, Redfern J, Fernandez R, et al; Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Cardiovasc Prev Rehabil. 2009 Apr 29. [abstract] 12. Bethell H, Lewin R, Dalal H; Cardiac rehabilitation in the United Kingdom. Heart. 2009 Feb;95(4):271-5. Epub 2008 Jan 20. [abstract] 13. The Heart Manual, British Heart Foundation Cardiac Care Research Group, 2008 14. Jolly K, Lip GY, Taylor RS, et al; The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart. 2009 Jan;95(1):36-42. Epub 2008 Mar 10. [abstract] 15. At a Glance Guide to the Current Medical Standards of Fitness to Drive, Driver and Vehicle Licensing Agency, Swansea 16. Metabolic Equivalent (MET) Level; Centres for Disease Control and Prevention, 2007 17. Welton NJ, Caldwell DM, Adamopoulos E, et al; Mixed treatment comparison meta-analysis of complex interventions: psychological interventions in coronary heart disease. Am J Epidemiol. 2009 May 1;169(9):1158-65. Epub 2009 Mar 3. [abstract] 18. Depression in adults, NICE Clinical Guideline (October 2009); Depression: the treatment and management of depression in adults 19. Thompson DR, Lewin RJ; Coronary disease. Management of the post-myocardial infarction patient: rehabilitation and cardiac neurosis. Heart. 2000 Jul;84(1):101-5. 20. Gillison FB, Skevington SM, Sato A, et al; The effects of exercise interventions on quality of life in clinical and healthy populations; a meta-analysis. Soc Sci Med. 2009 May;68(9):1700-10. Epub 2009 Mar 18. [abstract]
Internet and further reading
y y y Cardiac Rehabilitation Resources, British Heart Foundation, March 2009 BACR - British Association for Cardiac Rehabilitation; Links to training and resources Gayda M, Brun C, Juneau M, et al; Long-term cardiac rehabilitation and exercise training programs improve metabolic parameters in metabolic syndrome patients with and without coronary heart disease. Nutr Metab Cardiovasc Dis. 2006 Dec 1;. [abstract] Jackson L, Leclerc J, Erskine Y, et al; Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart. 2005 Jan;91(1):10-4. [abstract] Anxiety (partial update), NICE Clinical Guideline (January 2011); Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults
y y
Introduction
Cardiac rehabilitation is the process by which a person who is suffering from ischaemic heart disease, or who has had a myocardial infarction (MI), is encouraged to achieve their full potential in terms of physical and psychological health. In order to be successful, cardiac rehabilitation must draw on the skills of many members of the healthcare team and involve a combination of education, psychological support,exercise training and behavioural change.1,2 Although the mechanism by which it occurs is not yet fully understood, cardiac rehabilitation which includes a programme of structured exercise is now generally believed not only to improve morbidity but also to reduce mortality in patients who have suffered an MI.3,4 It has been thought for many years that all patients, regardless of gender or age, who have ischaemic heart disease and/or cardiac failure, might benefit from cardiac rehabilitation.5 For optimal effect, cardiac rehabilitation programmes should be structured and tailored to the individual patient following an initial assessment. Computer support systems have been shown to assist the decision-making process.6 Cardiac rehabilitation is one of the National Priority Projects on the NHS's improvement agenda. The National Institute for Health and Clinical Excellence (NICE) outlines the clear benefits of these services, including improving survival and quality of life and reducing unplanned hospital admissions.7 The British Association for Cardiac Rehabilitation (BACR) specifically identifies the cardiac specialist nurse as a core member of the cardiac rehabilitation team.8 Intervention by a specialist nurse can substantially reduce the length of hospital stay, hospital costs and the risk of readmission to hospital for heart failure.9,10 General y All patients who have had an MI should be offered a cardiac rehabilitation programme which includes an exercise component. y A range of options should be offered. Patients should be encouraged to attend the options appropriate to their needs but should not be excluded from the entire programme if they do not want to take up one particular component or more. y If the patient has a cardiac or other condition which limits physical exercise this should be treated before this component is offered. A suitably qualified healthcare professional may be able to adapt the physical component to make it more suitable for the patient. y Patients with stable left ventricular dysfunction can be offered the physical component. Engaging patients Although cardiac rehabilitation has been proven to be beneficial, uptake has been suboptimal (40% uptake among heart attack survivors in the UK). Reasons provided by patients are varied and include difficulty in attending the hospital (transport, car parking), a dislike of groups, work or domestic commitments. Home-based programmes have been devised to address these problems and to improve access to, and participation in, cardiac rehabilitation programmes. y When cardiac rehabilitation services are planned, the needs of the particular local community should be taken into account, including health and social factors and deprivation.This will
y y
y y y
ensure that there is maximum engagement with those who have the greatest need, thereby ensuring that services are accessible and relevant to all MI patients. Services should be culturally sensitive. This may mean employing bilingual peer educators or cardiac rehabilitation assistants to reflect the diversity of the local population. The physical component should be adapted to meet the needs of older patients and those with signficant comorbidities. The provision of transport to the service may need to be considered. Patients should be offered mixed-sex or single-sex classes. It is important for patients' health beliefs and basic level of health literacy to be established before lifestyle advice is offered. All healthcare professionals who come into contact with post-MI patients, including senior medical staff, should promote cardiac rehabilitation services. Various methods of contact should be considered, including verbal, postal and telephone communication. One study propounded the benefits of 'telehealth' interventions (internet, telephone and video conferencing).11 Despite its proven benefits, the uptake of cardiac rehabilitation services in the UK is currently poor.12
Health education y Programmes should include general health education and information on how to deal with stress. y An integrated and co-ordinated approach from primary and secondary care teams at this stage, e.g. using a validated structured plan such as 'The Heart Manual', can improve psychological wellbeing and overall outcome. This may be particularly appropriate for patients unwilling or unable to access secondary care-based services, since much can be achieved using a homebased approach. 13 One study in Birmingham found no differences in clinical outcomes in patients participating in hospital-based or home-based programmes.14 y Most patients who have sustained an MI can return to work. Account should be taken of the type of work, the work environment and the physical and psychological state of the patient. y Due regard should be given to the latest guidance from the Driver and Vehicle Licensing Agency(DVLA).15 y Patients can usually fly within 2-3 weeks. If there have been complications, expert advice should be sought. y Patients with a pilot's licence will need to seek the advice of the Civil Aviation Authority before they can pilot a plane. y Depending on psychological and physical status, most patients can resume normal daily activities. y Patients should be taught how to use the Metabolic Equivalent of Task (MET) system.16 This is a useful method for calculating the intensity of a particular activity so that physiological demand can be monitored. Patients who have had a complicated MI may need expert advice. y Patients involved in competitive sports may need expert advice to assess the level of risk. Psychological and social support y Patients should be offered basic stress management advice and may not need more complex treatment such as cognitive behavioural therapy. However, one study found that six components of psychological intervention - usual care, educational, behavioural, cognitive, relaxation and support - offered positive benefits in terms of clinical outcomes.17 y Partners and carers should be involved if this is in accordance with the patient's wishes. y Patients with anxiety or depression should be managed according to the appropriate NICE guidance.18
Phases in cardiac rehabilitation
The Scottish Intercollegiate Guidelines Network (SIGN) describes phases appropriate to the patient's physical and psychological recovery:1 Phase 1: the initial stage following MI or cardiac event
y y y y y y
Assessment of a patient's physical/psychological condition. Assessment of risk factors, e.g. diet, smoking, exercise, lipid profile. Reassurance and correction of any misconceptions. Education. Initial mobilisation. Plan for discharge.
Phase 2: the post-discharge stage The early discharge period is the time at which the patient is the most vulnerable and psychological distress at this stage is a predictor of poor outcome and increased use of hospital services independent of the physical damage to the heart.19 Patients should be screened for anxiety and depression at this stage and should be treated with suitable non-cardiotoxic antidepressants if appropriate. Phase 3: structured exercise and rehabilitation Graded exercise is a vital component of cardiac rehabilitation, although it does not alter morbidity and mortality rates if offered in isolation. Aerobic low-to-moderate intensity exercise will be suitable for most patients who have been assessed as low-to-moderate risk. This form of exercise programme may generally be undertaken either at home or under supervision in the community, e.g. graded exercise programmes in leisure centres where staff have received basic life support training. One meta-analysis confirmed that light-to-moderate exercise in a group setting offered the greatest benefit in terms of improved quality of life.20 Exercise training for high-risk patients would normally be carried out in a hospital or other suitable venue able to provide facilities and staff trained in resuscitation should this prove necessary. Graded exercise should be accompanied at this stage by other interventions tailored to meet the individual patient's requirements. Lifestyle changes should be encouraged and supported where appropriate, e.g. weight reduction, smoking cessation, retraining with a view to returning to work. This is likely to be accompanied by education concerning the cardiac condition and the reasons why changes in lifestyle might be desirable. Phase 4: long-term maintenance In order to be effective, physical activity and changes in lifestyle need to be maintained for the longterm. A protocol which allows for the regular review of all patients with ischaemic heart disease and/or heart failure by the primary care team is desirable.1 Long-term review will permit continued support of lifestyle changes in addition to assessment of drug therapy, and physical and psychological wellbeing, and will allow early intervention, where required, in all areas.
Document references
1. Cardiac rehabilitation, Scottish Intercollegiate Guidelines Network (SIGN) Guideline (2002) 2. Williams B, Poulter NR, Brown MJ, et al; Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV.; J Hum Hypertens. 2004 Mar;18(3):139-85.
3. Secondary prevention in primary and secondary care for patients following a myocardial infarction, NICE Clinical Guideline (2007) 4. Jolliffe JA, Rees K, Taylor RS, et al; Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001;(1):CD001800. [abstract] 5. Gordon NF, Gulanick M, Costa F, et al; Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004 Apr 27;109(16):2031-41. 6. Goud R, de Keizer NF, ter Riet G, et al; Effect of guideline based computerised decision support on decision making of multidisciplinary teams: cluster randomised trial in cardiac rehabilitation. BMJ. 2009 Apr 27;338:b1440. doi: 10.1136/bmj.b1440. [abstract] 7. Commissioning a cardiac rehabilitation service, NICE, (2007) 8. Standards and Core Components for Cardiac Rehabilitation, British Association for Cardiac Rehabilitation, (2007) 9. Grange J; The role of nurses in the management of heart failure. Heart. 2005 May;91 Suppl 2:ii39-42; discussion ii43-8. [abstract] 10. Blue L, Lang E, McMurray JJ, et al; Randomised controlled trial of specialist nurse intervention in heart failure. BMJ. 2001 Sep 29;323(7315):715-8. [abstract] 11. Neubeck L, Redfern J, Fernandez R, et al; Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Cardiovasc Prev Rehabil. 2009 Apr 29. [abstract] 12. Bethell H, Lewin R, Dalal H; Cardiac rehabilitation in the United Kingdom. Heart. 2009 Feb;95(4):271-5. Epub 2008 Jan 20. [abstract] 13. The Heart Manual, British Heart Foundation Cardiac Care Research Group, 2008 14. Jolly K, Lip GY, Taylor RS, et al; The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart. 2009 Jan;95(1):36-42. Epub 2008 Mar 10. [abstract] 15. At a Glance Guide to the Current Medical Standards of Fitness to Drive, Driver and Vehicle Licensing Agency, Swansea 16. Metabolic Equivalent (MET) Level; Centres for Disease Control and Prevention, 2007 17. Welton NJ, Caldwell DM, Adamopoulos E, et al; Mixed treatment comparison meta-analysis of complex interventions: psychological interventions in coronary heart disease. Am J Epidemiol. 2009 May 1;169(9):1158-65. Epub 2009 Mar 3. [abstract] 18. Depression in adults, NICE Clinical Guideline (October 2009); Depression: the treatment and management of depression in adults 19. Thompson DR, Lewin RJ; Coronary disease. Management of the post-myocardial infarction patient: rehabilitation and cardiac neurosis. Heart. 2000 Jul;84(1):101-5. 20. Gillison FB, Skevington SM, Sato A, et al; The effects of exercise interventions on quality of life in clinical and healthy populations; a meta-analysis. Soc Sci Med. 2009 May;68(9):1700-10. Epub 2009 Mar 18. [abstract]
Internet and further reading
y y y Cardiac Rehabilitation Resources, British Heart Foundation, March 2009 BACR - British Association for Cardiac Rehabilitation; Links to training and resources Gayda M, Brun C, Juneau M, et al; Long-term cardiac rehabilitation and exercise training programs improve metabolic parameters in metabolic syndrome patients with and without coronary heart disease. Nutr Metab Cardiovasc Dis. 2006 Dec 1;. [abstract] Jackson L, Leclerc J, Erskine Y, et al; Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart. 2005 Jan;91(1):10-4. [abstract] Anxiety (partial update), NICE Clinical Guideline (January 2011); Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults
y y
