Cardiovascular disease (CVD) was the leading cause of death worldwide in 2008, accounting for 17.3 million deaths per year of which 7.3 million are the result of myocardial infarction (MI).¹ CVD is the single largest cause of death in Ireland.² With an ageing population, prevalence of CVD is set to rise. Revascularising MI patients, whether percutaneously or surgically, is not the ultimate step in management but rather the first step in rehabilitation.

Cardiac rehabilitation: a positive intervention

Fifty years ago the standard management for patients post-MI was strict bed rest for a number of weeks. The realisation that bed rest actually hindered recovery and led to complications radically altered the rehabilitation of cardiac patients. 

Although initially focused only on exercise training, contemporary programmes focus on risk-factor modification and education. 

Cardiac rehabilitation (CR) is a process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health.³ Several studies have demonstrated that CR is a cost-effective intervention associated with improvements in quality of life, functional capacity, reduced mortality (25%) and morbidity, in addition to psychosocial benefits.⁴

Heretofore CR was confined to patients following MI and revascularisation. However, in recent years, patients with heart valve surgery, stable angina, heart failure, heart transplantation, peripheral arterial disease and cardiac devices are also being included. The barriers to participation in CR programmes vary from geographical location, lack of patient motivation, work and family commitments, depression and financial costs.^4,5 Despite the benefits, many patients, particularly ethnic minorities, the elderly and female patients, are often not referred.⁶

Phase I: Inpatient stage

Phase I is the inpatient hospital stage and begins once the patient is clinically stable. In the initial stage patients and families can be shocked by the diagnosis, often experiencing a sense of loss and grief. There are three predictable periods when the anxiety level is high: on admission; on transfer from the coronary care unit; and prior to discharge.⁷ 

Coronary care nursing staff are in an ideal position to commence elements of CR through the provision of patient education, the identification of any medical, social or functional issues, while also providing emotional support to both patient and family. The cardiologist sets the medical parameters for the patient while also encouraging active patient participation in CR. 

Educating the patient

Written information is vital during this early period through the provision of local booklets such as Take Heart: A guide to living well with Coronary Artery Disease. This booklet provides detailed information on diagnosis, risk factors, exercise prescription, activities of daily living and medications.⁸ Supplemental written information can also be provided should the patient require this. Literacy skills or any barriers to education such as difficulties with hearing or sight should be identified as early as possible so that education can be suitably tailored to the individual. 

The CR nurse will educate the patient and family about coronary heart disease (CHD), chest pain management, assess CHD risk factors and advise on risk-factor and lifestyle modifications. Patients are encouraged to set written goals on how they plan to achieve their lifestyle modifications. Referrals to other members of the multidisciplinary team such as dietitians, diabetes nurse specialists or physiotherapists can be arranged throughout the patient stay.

Mobilisation

Historically, patients were on bed rest for several weeks following an MI. However, now most patients can be gently mobilised within 12 to 24 hours, unless they have experienced a complicated MI. 

Mobilisation is staged and progressive based on the patient assessment and stable parameters. Risk stratification for exercise is based on the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) 2004 guidelines.⁹ Patients are introduced to methods of assessing exertion such as the Borg rate of perceived exertion scale. All patients are provided with a home walking programme which involves light-intensity walking gradually increasing in duration over six weeks. Patients are also advised on the importance of avoiding ‘breath-holding’, constipation, straining and heavy lifting.

Psychology assessment

Following a cardiac event many patients may be anxious or depressed. As anxiety and depression are strong predictors of mortality it is vital that patients’ psychosocial status is assessed using an appropriate tool such as the Hospital and Anxiety Depression Scale (HADS). Patients following rehabilitation with depression found that mortality was four times higher than non-depressed.¹⁰ The inclusion of family is very important at this stage as they may have concerns about impending discharge and gaining the support of family members might encourage the patient’s adherence to lifestyle modifications. 

Lifestyle factors

Many patients are afraid to ask about resuming sexual activity, however this can be resumed when the patient feels comfortable to do so – usually after four weeks. Erectile dysfunction is a common disorder with multiple factors.¹¹ Many patients return to work within four to six weeks, depending on type of activities. Patients are advised to contact their insurance company and licensing authority. Most patients may return to driving four to six weeks following MI. Professional drivers will require further evaluation.

Medication

Many patients admitted to hospital following an MI, who may never have taken any medications previously, are expected to take a number of new medications such as antiplatelet agents, ß-blockers, statins, fish oils and ACE-I/ARBs Therefore the importance of medication adherence is a vital part of CR. The rationale for the uses of each medication, expected duration and the side-effects are explained in detail by the CR nurse or pharmacist.

Phase II: Post-discharge period

Phase II is the period following patient discharge and is a time when some patients can feel vulnerable. There are a number of CR strategies which can be employed during this phase to put the patient at ease, the most simple of which is telephone contact with the CR nurse who will reinforce the lifestyle modifications and provide reassurance and emotional support. Other strategies include educational sessions, home visits by the public health nurse service or heart manual programme (www.theheartmanual.com) and contact with their GPs who have a knowledge of the patient and their family history/circumstances. During this phase the value of phase III is explored and the patient is encouraged to attend phase III programmes.

Phase III: Exercise programme

Phase III is a structured outpatient education and exercise programme. Education is provided by the members of the multidisciplinary team, which ideally should include cardiologist, CR nurse, physiotherapist, pharmacist, dietitian, social worker, psychologist and occupational therapist. 

Individual monitoring

The mix of professionals varies depending on hospital resources. A family member is encouraged to attend phase III programmes as they may assist the patient to make the appropriate lifestyle modifications, particularly if responsible for shopping and cooking. Topics include risk-factor modifications, chest-pain management, cardioprotective diet, medication adherence, benefits of physical exercise activity, stress management and energy conservation. During these sessions vital signs, diet questionnaires, weight and waist circumference are recorded, allowing comparison with phase I measurements.

Risk stratification

The exercise programmes are supervised by the CR nurse and a physiotherapist or exercise physiologist. Programmes vary in duration from six to 12 weeks with classes twice to three times per week. Patients who are eligible to participate in a supervised exercise programme are risk stratified and an assessment of functional capacity is performed, taking into account any comorbidities.

Risk stratification assists with guidance in relation to exercise prescription, monitoring and supervision. CR centres vary as to the form of assessment. 

Ideally an exercise stress test prior to and on completion of the programme is performed depending on resources and patient suitability. Other alternatives include cycle ergometer, incremental shuttle walk test, six-minute walk test and Chester step test. There are a number of methods used to prescribe exercise, the Karvonen heart rate reserve method is one of the most commonly used. Telemetry monitoring is required for high-risk patients. Low-to-moderate-risk patients can use heart rate monitors. 

Phase IV: Long-term lifestyle modification

Phase IV is the long-term maintenance of risk-factor modification, with long-term follow-up in primary care. Community-based exercise professionals can obtain an accredited qualification from the British Association of Cardiac Prevention and Rehabilitation (BACPR).¹² The importance of local cardiac support groups is invaluable in that they provide an opportunity for patients to share and learn from others who have experienced cardiac issues. The benefits of CR are well documented and widely accepted. Factors which prevent their widespread adoption normally reflect the resources of the hospital and the way the programme is sold to the patient. While the former is, to some extent, outside the control of most medical professionals, all can work to improve the latter. 

References

1. Causes of death 2008, World Health Organisation, Geneva, http://www.who.int/healthinfo/ global_burden_disease/cod_2008_sources_methods.pdf
2. www.irishheart.ie
3. www.sign.ac.uk 
4. Dunlay S, Witt B, Allison T et al. Barriers to participation in Cardiac Rehabilitation. American Heart Journal 2009; 158 (5): 852-859
5. Everson, K, Fleury J. Barriers to outpatient Cardiac Rehabilitation participation and adherence. Journal of Cardiopulmonary Rehabilitation 2000; 20(4): 241-246
6. Grace S, Shanmugasegaram S, Gravely-Witte S et al. Barriers to Cardiac Rehabilitation – does age make a difference? Journal of Cardiopulmonary Rehabilitation 2009; 183-187
7. Woods S, Froelicher E, Halpenny C et al. Cardiac Nursing. 3rd ed. JB Lippincott, Philadelphia, 1995
8. Cardiac Rehabilitation working group, Cork and Kerry. Take Heart. A guide to living well with Coronary Artery Disease. 2nd edition.  Health Service Executive South 2011
9. American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs 4th Edition, Human Kinetics, USA, 2004
10. Mc Grady A, Mc Ginnis R, Badenhop D et al. Effects of depression and anxiety on adherence to Cardiac Rehabilitation.  Journal of Cardiopulmonary Rehabilitation 2009; 29(6): 358-364
11. Jennings C, Mead A, Jones J et al. Preventative Cardiology- a practical manual. Oxford University Press, Oxford, 2009
12. Thow M. Exercise leadership in Cardiac Rehabilitation- An evidence based approach. John Wiley & Sons Ltd, UK, 2006