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Contemporary Cardiac Rehabilitation Services

Barry A. Franklin, PhD

Cardiac Rehabilitation and Exercise Laboratories
Beaumont Rehabilitation and Health Center
Birmingham, Michigan, USA

The Clinical Practice Guideline on Cardiac Rehabilitation was derived from an extensive and review of scientific literature pertaining to prevention.1 This document addresses the role of exercise-based cardiac rehabilitation and the potential benefits to be derived, including a significant reduction in mortality, approximating 20% to 25%.2,3 It is apparent, however, that major changes will be required in the components and delivery of these services in the era of managed care. These include restructuring and amplifying the services that are currently provided, and offering group and home-based cardiac rehabilitation services to increase their availability.

Many uncomplicated post-myocardial infarction and coronary artery bypass patients are now being discharged from the hospital in <5 days. These patients are likely to be motivated to participate in outpatient rehabilitation services. Accordingly, staff efforts must be intensified to ensure initial contact before hospital discharge, if possible. The potential for permanent risk factor modification may also be heightened with earlier intervention. A 71 % smoking cessation rate has been reported at 1 year for patients who received a nurse-managed behavioral intervention at the time of hospitalization compared with a 45% success rate in those receiving usual care.4

A mere 11 % to 20% of patients with coronary artery disease participate in cardiac rehabilitation programs, highlighting the vast underutilization of these services, especially in older adults and women.1,5,6 Other groups who are underserved include poor/uneducated patients and minorities. In addition to traditional patient subsets (e.g., post-myocardial infarction, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty), eligibility should be expanded to include coronary patients with or without residual ischemia, compensated heart failure, cardiomyopathies, threatening ventricular arrhythmias, nonischemic heart disease, concomitant pulmonary disease, pacemaker or cardioverter-defibrillator implantation, heart valve repair or replacement, and cardiac transplantation.

In the era of managed, capitated health care, primary care physicians serve as the "gate keepers" for implementing secondary prevention programs. The fervor of the primary physicians' recommendation appears to be the single most powerful predictor of cardiac rehabilitation participation.6 Accordingly, efforts must be directed at proselytizing this group (and their cardiologist contemporaries) regarding the benefits of cardiac rehabilitation. Routine counseling by these physicians may have the additional impact of augmenting the modification of their patients' lifestyles.

Although hypertension, hyperlipidemia, obesity, and diabetes mellitus may be favorably affected by regular physical activity,7 exercise alone should not be expected to alter global coronary risk status. Contemporary cardiac rehabilitation programs should provide a menu of multifactorial services to meet individual patient needs, including exercise training, education and counseling about coronary risk reduction, return-to-work, medical surveillance and emergency support (when appropriate), and interventions to improve psychosocial functioning. Staff members (e.g., nurses, physiologists, physical therapists) may be assigned to a specific group of patients (a caseload), and comprehensive risk reduction plans should be formulated for every participant. Regression or limitation of progression of angiographically documented coronary atherosclerosis and/or significant reductions in cardiovascular morbidity and mortality has been achieved not only by drug therapy but by dietary intervention, disciplined exercise programs and behavior modification as well (Table I) 8-14

Table 1

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The degree of electrocardiographic (ECG) surveillance should be linked inversely with the cardiac stability of the patient. Self-monitoring (e.g., pulse rate, symptoms, perceived exertion) may suffice for many low-risk patients exercising at home or in community recreation facilities. Utilization of costly continuous or transtelephonic ECG monitoring will be increasingly scrutinized by those faced with the challenge of apportioning shrinking health care dollars. In those venues where it is available, instantaneous electrocardiography provides a simple and cost-effective alternative to screen for ST-segment displacement, electrical instability, and exercise intensity violators.15

Like all contemporary medical strategies, cardiac rehabilitation programs will require documentation of their efficacy and cost-effectiveness to hospital administrators and health insurers. Outcome analysis is an important part of this process and will include not only clinical parameters and quality of life, but also recurrent cardiac events as well as intermediate and health outcomes. The former are measurable physiologic changes, whereas the latter are those experienced or reported by patients; these may be beneficial or harmful.1

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Whereas long-term adherence to lifestyle changes is critical to improve patient outcomes, half or less of those who initiate health-related behavior change will continue. This is particularly true of women who have a 10% to 30% higher dropout rate than their male counterparts.16 Some reasons for this include the fact that women are less likely to own and drive a car, more likely to have a dependent spouse at home, and to have arthritis as a comorbid problem.5

Contemporary cardiac rehabilitation programs should incorporate tailored modifications and motivational strategies to enhance participant interest and adherence. These include assessing the patient's "readiness" for change, providing services that are designed to circumvent or attenuate common barriers to enrollment and adherence (e.g., transportation to and from the program), keeping goals short-term and attainable, using incentives accruing to periodic exercise testing and risk factor assessment, recruiting spouse support of the program, and archiving for the patient his or her recorded goal achievements. The exercise prescription should employ low-to-moderate intensity physical activity which has been shown to be as effective as more strenuous exercise in increasing functional capacity and high-density lipoprotein cholesterol,17 while reducing the risk of orthopedic injury.

Although traditional supervised group programs are associated with increased cost and extended travel time,18 considerable data are available regarding the safety, efficacy, and cost-effectiveness of this model.1 Such programs are also more appropriate for the growing medical complexity of candidates who may be at increased risk for future cardiac events. Further, supervised programs facilitate patient education both in regard to exercise and lifestyle changes for coronary risk reduction, provide variety and recreational opportunities, and offer staff reassurance and the potential for enhanced adherence, safety, and surveillance.1

Home exercise rehabilitation should be promulgated as an alternative, however, because of its lesser cost, increased practicability, convenience, and potential to promote independence and self-responsibility.18 For low-risk patients, medically directed, home-based rehabilitation and supervised group programs have shown comparable safety and efficacy. Dealing with smoking and hyperlipidemia can also be successfully achieved in a home-based rehabilitation setting.9,19 A variety of techniques may be used to facilitate monitoring and/or communication between patients managed at home and rehabilitation staff, including regular telephone contact, mail (e.g., completion of activity logs), fax, video recording, Intemet, and transtelephonic ECG monitoring.18,19

The treatment of coronary artery disease has evolved from simple lifestyle modification in the mid-to-late 60s, largely focused on early ambulation and exercise training, to an array of costly medical and surgical interventions that too often fail to address the underlying causes-high-fat and cholesterol diets, cigarette smoking, hypertension, and physical inactivity. Intensive measures to control hyperlipidemia with diet, drugs, and exercise, especially in combination, have now been shown to stabilize or even reverse the otherwise inexorable progression of atherosclerotic coronary artery disease. Added benefits include a reduction in anginal symptoms, decreases in exercise-induced myocardial ischemia, fewer recurrent cardiac events, and diminished need for coronary revascularization. As the millennium approaches, we must conclude as the late Herman K. Hellerstein, MD, summarized it in 1972 20: ". . . . a planned program featuring exercise training among other measures (i.e., aggressive modification of coronary risk factors) may tangibly reduce the risk of reinfarction and greater myocardial damage."

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 References 

1.Wenger NK, Froclicher, ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CME, Dattilo AM, Davis D, DeBusk RF, et al. Cardiac Rehabilitation Guideline No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute. (AHCPR publication No. 960672, October 1995).
2.Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction: combined experience of randomized clinical trials. JAMA 1988;260:945-950.
3.O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr, Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234-244.
4. Taylo, CB, Miller NH, Yillen JD, DeBusk RE. Smoking cessation after acute myocardial infarction: effects of a nurse managed intervention. Ann Intern Med 1990;113:118-123.
5. Ades PA, Waldmann, ML, Polk DM, Cofiesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged >62 years. Am J Cardiol 1992;69:1422-1425.
6. Ades PA, Waldmann ML, MeCann WJ, Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med 1992;152:1033-1035.
7. Fletcher GF, Balady G, Blair SN, Blumenthal J, Caspersen C, Chaitman B, Epstein S, Sivarajan Froelicher ES, Froelicher VF, Pina IL, Pollock ML. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. Circulation 1996;94:857-862.
8. Omish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand R, Gould KI. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial, Lancet 1990;336:129133.
9. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, Williams PT, Johnstone IM, Champagne MA, Krauss RM, Farquhar JW. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation 1994;89:975990.
10. Kane JP, Malloy MJ, Ports TA, Phillips NR, Diehl JC, Havel RJ. Regression of coronary atherosclerosis during treatment of familiar hypercholesterolemia with combined drug regimens. JAMA 1990;264:3007-3012.
11. Brown G, Alberts JJ, Fisher LD, Schaefer SM, Lin J-T, Kaplan C, Zhao X-Q, Bisson BD, Fitzpatrick VP, Dodge HT. Regression of coronary artery disease as a result of intensive lipid lowering therapy in men with high levels of apolipoprotein B. N Engl J Med 1990;323:1289-1298.
12. Blankenhom DH, Azen SP, Kramsch DM, Mack WJ, Cashin-Hemphill L, Hodis HN, DeBoer LWV, Mahrer PR, Masteller MJ, Vailas LI, Alaupovic P, Hirsch LJ, and the MARS Research Group. Coronary angiographic changes with lovastatin therapy. The monitored atherosclerosis regression study (MARS). Ann Intern Med 1993;1 19:969-976
13. Waters D, Higginson L, Gladstone P, Kimball B, May ML, Boecuzzi SJ, Lespérance J, for the CCAIT Study Group. Effects of monotherapy with an HMG-COA reductase inhibitor on the progression of coronary atherosclerosis as assessed by serial quantitative arteriography. The Canadian Coronary Atherosclerosis Intervention Trial. Circulation 1994;89:959-968.
14. Watts GF, Lewis B, Brunt JNH, Lewis ES, Coltart DJ, Smith LDR, Mann JI, Swan AV. Effects on coronary artery disease of lipid-lowering diet, or diet plus cholestyramine in the St, Thomas' Atherosclerosis Regression Study (STARS). Lancet 1992;339:563-569.
15. Franklin BA, Reed PS, Gordon S, Timmis GC. Instantaneous electrocardiography: a simple screening technique for cardiac exercise programs. Chest 1989;96:174-177.
16.O'Callaghan WG, Teo KK, O'Riordan J, Webb H, Dolphin T, Horgan JH. Comparative response of male and female patients with coronary artery disease to exercise rehabilitation. Eur HeartJ 1984;5:649-651.
17. Blumenthal JA, Rejewski WJ, Walsh-Riddle M, Emery CF, Miller H, Roark S, Ribisl PM, Morris PB, Brubaker P, Williams RS. Comparison of high-and-low-intensity exercise training early after acute myocardial infarction. Am J Cardiol 1988;61:26-30.
18. DeBusk RF, Haskell WL, Miller NH, Berra K, Taylor CB. Medically directed at-home rehabilitation soon after clinically uncomplicated myocardial infarction: a new model for patient care. Am J Cardiol 1985;55: 251-257.
19. DeBusk RF, Houston Miller N, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE 111, Heller RS, Rompf J, Gee D, Kraemer HC, Bandura A, Ghandour G, Clark M, Shah RV, Fisher L, Taylor B. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med 1994;120:721-729.
20. Hellerstein HK. Rehabilitation of the postinfarction patient. Hovp Pract 1972; July:45-53.

Co-Authors: Linda Hall, PhD, and Gerald C. Timmis, MD

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© CETIFAC
Bioengineering
UNER
Update
Nov/26/1999