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Cardiac Rehabilitation

Heart disease causes distress and impairs quality of life. Cardiac rehabilitation is a multidisciplinary approach to improve short-term recovery and promote long-term changes in lifestyle which help to correct adverse risk factors. It is a process by which patients are restored to and maintained in optimal physical, emotional, social, vocational and economic state.

Cardiac rehabilitation services usually include exercise training, risk factor modification, education and counselling. The principal justification for rehabilitation is the encouragement of return to full activities and a reduction in well-documented convalescence problems of lack of confidence and sleep, anxiety, depression fatigue and worry about non-specific physical symptoms together with excessive caution about everyday activities [1].

Where are we now?

The prevalence of ischaemic heart disease varies considerably, but for a district with a population of 250,000 between 25 and 750 patients a year will be suitable for cardiac rehabilitation.

Although efficacy and importance of cardiac rehabilitation is well recognised, the nature of existing hospital or community-based services in the UK varies considerably. Fewer than half of health districts have established programmes. Few of the programmes which do exist have been subjects of careful audit, and there is little information on issues such as the type of service offered, characteristics of patients who use the service, the training and training needs of healthcare professionals involved, resources and outcome measures used.

Benefits of exercise?

Pooled data from several studies has indicated that exercise-based cardiac rehabilitation results in a reduction in overall and cardiovascular mortality of around 25% [2,3]; the first of these references analysed combined results of 10 RCTs involving 4347 patients, and the second overviewed 22 RCTs.

Benefits of risk factor intervention?

Studies of risk factor intervention and psychological support have produced less dramatic but still impressive effects, not only for patients themselves, but also for their partners [4-6].

Benefits of psychosocial interventions?

There are no published reports of RCTs with convincing evidence for the benefits of psychosocial interventions.

Problems faced now?

There is a need for objective assessments of the physical, psycho-social and economic benefits of cardiac rehabilitation programmes. Programmes need to be developed which are evidence-based and which have on-going evaluation of a number of components of a comprehensive system, including graded exercise, education and support, and secondary prevention measures. The way in which service can be delivered effectively to special groups, like the elderly, women and ethnic minorities warrants special attention.

There are no accepted procedures for the assessment of quality of life during cardiac rehabilitation. What is required are standardised acceptable measures for use in individual patient care, audit of programmes, evaluation of interventions and examination of cost effectiveness.

Conclusion

The availability of cardiac rehabilitation programmes seems justified because it is cost effective [7], the financial benefits gained in terms of productivity and maintaining an occupational income by return to work are clear, and rehabilitation may results in lower costs of further hospital admissions [8]. Mechanisms for delivering a cost-effective service need greater definition.

Checklist for Cardiac Rehabilitation

A cardiac rehabilitation programme should have most or all of the following, though the structure will depend upon available resources including people, equipment, patients and organisation and co-ordination of sessions.

People

An experienced coronary care nurse is ideal for taking responsibility for co-ordinating the programme. Services of a physiotherapist, dietician, clinical psychologist, pharmacist, vocational counsellor and social worker may be included to varying extents where appropriate.

Equipment

Resuscitation equipment including a defibrillator must be at hand and exercise equipment should be checked regularly and correctly maintained.

Patients

Inexpensive early routine care (exercise, advice, self-help materials) should be available for all patients. Monitoring during convalescence is necessary to identify those requiring extra continuing help for cardiac, social or psychological problems, whether or not they have attended a routine programme.

Organisation & Co-ordination

Close co-ordination between cardiac aftercare and rehabilitation services is important. A local full-time co-ordinator is essential to ensure that patients are identified, to liaise with other professionals and to monitor and audit activity in relation to agreed guidelines.

Content

The cardiac rehabilitation programme should offer a range of components, including a flexible menu of methods, and emphasise individual prescription of care. A programme usually includes exercise training, relaxation, risk factor modification, education and counselling. Programmes should begin from the cardiac event itself and should place emphasis on the patients resuming control of their recovery and future lifestyle.

Evaluation and audit

Each programme should keep a record of the numbers attending (including partners) and the drop out rate and reasons for non-attendance.

Outcome measures should include risk factor reduction outcomes (smoking, physical activity, blood pressure, weight, cholesterol), physical outcomes (mortality, reinfarction, cardiac arrest, ventricular function, myocardial ischaemia, physical working capacity, symptom limitations, task and activity performance), psychosocial outcomes (return to work, quality of life) as well as other outcomes (adverse events, non compliance, readmission).



Dr David R Thompson
National Institute of Nursing, Oxford

References:

  1. J Jorgan, H Bethell, P Carson et al. Working party report on cardiac rehabilitation. British Heart Journal 1992 67: 412-8.
  2. GT O'Connor, JE Buring, S Yusuf et al. An overview of randomised controlled trials of rehabilitation with exercise after myocardial infarction. Circulation 1989 80: 234-44.
  3. NB Oldridge, GH Guyatt, ME Fischer, AA Rimm. Cardiac rehabilitation after myocardial infarction: combined experience of randomised controlled trials. Journal of the American Medical Association 1988 260: 945-50.
  4. DR Thompson. Counselling the coronary patient and partner. Scutari, London, 1990.
  5. JA Blumenthal, J Wei. Psychobehavioural treatment in cardiac rehabilitation. Cardiology Clinics 1993 11: 323-31.
  6. V Bittner, A Oberman. Efficacy studies in coronary rehabilitation. Cardiology Clinics 1993 11: 333-47.
  7. LA Levin, J Perk, B Hedback. Cardiac rehabilitation - cost analysis. Journal of Internal Medicine 1992 230: 427-34.
  8. PA Ades, D Huang, SO Weaver. Cardiac rehabilitation participation predicts lower rehabilitation costs. American Heart Journal 1992 123: 916-21.



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