Cardiac rehabilitation

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Cardiac rehabilitation (CR) is defined by the World Health Organization (WHO) as "the sum of activity and interventions required to ensure the best possible physical, mental, and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life". [1] CR is a comprehensive model of care delivering established core components, including structured exercise, patient education, psychosocial counselling, risk factor reduction and behaviour modification, with a goal of optimizing patient's quality of life and reducing the risk of future heart problems. [2] [3]

Contents

CR is delivered by a multi-disciplinary team, often headed by a physician such as a cardiologist. [4] Nurses support patients in reducing medical risk factors such as high blood pressure, high cholesterol and diabetes. Physiotherapists or other exercise professionals develop an individualized and structured exercise plan, including resistance training. A dietitian helps create a healthy eating plan. A social worker or psychologist may help patients to alleviate stress and address any identified psychological conditions; for tobacco users, they can offer counseling or recommend other proven treatments to support patients in their efforts to quit. Support for return-to-work can also be provided. CR programs are patient-centered.

Based on the benefits summarized below, CR programs are recommended by the American Heart Association / American College of Cardiology [5] and the European Society of Cardiology, [6] among other associations. [7] [8] Patients typically enter CR in the weeks following an acute coronary event such as a myocardial infarction (heart attack), with a diagnosis of heart failure, or following percutaneous coronary intervention (such as coronary stent placement), coronary artery bypass surgery, a valve procedure, or insertion of a rhythm device (e.g., pacemaker, implantable cardioverter defibrillator). [9]

Cardiac rehabilitation setting

CR services can be provided in hospital, in an outpatient setting such as a community center, or remotely at home using the phone and other technologies. [3] Hybrid programs are also increasingly being offered. [10] [11]

Cardiac rehabilitation phases

Inpatient program (phase I)

Engaging in CR before leaving the hospital can hasten patient’s recovery, as well as facilitate a smoother return to activities of daily living and roles once they return home. Many patients express anxiety about their recovery, especially after a severe illness or surgery, so Phase I CR provides an opportunity for patients to test their abilities in a safe, supervised setting.

Where available, patients receiving CR in the hospital after surgery are usually able to begin within a day or two. First steps include simple motion exercises that can be done sitting down, such as lifting the arms. Heart rate and blood oxygen levels are closely monitored by a therapist as the patient begins to walk, or exercise using a stationary bicycle. The therapist ensures that the level of aerobic and strength training are appropriate for the patient’s current status, and gradually progresses their therapeutic exercises. [12]

Outpatient program (phase II)

In order to participate in an outpatient program, the patient generally must first obtain a physician's referral. [13] It is recommended patients begin outpatient CR within 2–7 days following a percutaneous intervention, and 4–6 weeks after cardiac surgery. [14] [15] [16] This period is often very difficult for patients due to fears of over-exertion or a recurrence of heart issues. [17] [15] Shorter time to start is associated with better outcomes. [18]

Participation typically begins with an intake evaluation that includes measurement of cardiac risk factors such as lipids, blood pressure, body composition, depression / anxiety, and tobacco use. [3] A functional capacity test is usually performed both to determine if exercise is safe and to support development of a customized exercise program. [13]

Risk factors are addressed and patients goals are established; a "case-manager" who may be a cardiac-trained registered nurse, physiotherapist, or an exercise physiologist works to help patients achieve their targets. During exercise, the patient's heart rate and blood pressure may be monitored to check the intensity of activity. [13]

The duration of CR varies from program to program, and can range from six weeks to several years. Globally, a median of 24 sessions are offered, [19] and it is well-established that the more the better. [20]

After CR is finished, there are long-term maintenance programs (phase III) available to interested patients, [21] as benefits are optimized with long-term adherence. Unfortunately however, patients generally have to pay out-of-pocket for these services.

Under-use of cardiac rehabilitation

CR is significantly under-used globally. [22] Rates vary widely. [23]

Under-use is caused by multi-level factors; a recent review is available. [24] At the health system level, this includes lack of available programs. [25] At the provider level, low referral rates are a major barrier. [26] [27] At the patient level, factors such as lack of awareness, transportation, distance, cost, competing responsibilities, and other health conditions are responsible, [28] but most can be mitigated. [29] Women, [30] ethnocultural minorities, [31] [32] older patients, [33] those of lower socio-economic status, with comorbidities, and living in rural areas [34] are less likely to access CR, despite the fact that these patients often need it most. [35] Cardiac patients can assess their CR barriers here, and receive suggestions on how to overcome them: https://globalcardiacrehab.com/For-Patients.

Strategies are now established on how we can mitigate these barriers to CR use. [36] [37] It is important for inpatient units treating cardiac patients to institute automatic/systematic or electronic referral to CR (see: https://www.ahrq.gov/takeheart/index.html). [38] It is also key for healthcare providers to promote CR to patients at the bedside. [39] The National Institute for Health and Care Excellence offer helpful recommendations on encouraging patients to attend CR.

Training more healthcare professionals to deliver CR can also help. [40] CR programs can also join a registry to assess and improve their utilization --among other quality indicators. [41] [42] Offering programs tailored to under-served groups such as women may also facilitate program participation. [43] [44] [45]

Benefits

Participation in CR may be associated with many benefits. [46] For acute coronary syndrome patients, CR reduces cardiovascular mortality by 25% and readmission rates by 20%. [47] [48] [ needs update ] The potential benefit in all-cause mortality is not as clear, however there is some supportive evidence. [49]

CR is associated with improved quality of life, improved psychosocial well-being, and functional capacity, [50] and is cost-effective. [51] In low and middle-income countries, there is some evidence that CR is effective in improving functional capacity, risk factors and quality of life as well. [52]

There appears to be no difference in outcomes between supervised and home-based CR programs, and both cost about the same. [53] Home-based CR is generally safe. [54] Home-based programs with technology are similarly shown to be effective. [55] [56] [57]

There are specific reviews on benefits of CR in patients with specific health conditions such as valve issues, [58] atrial fibrillation, [59] heart transplant recipients, [60] and heart failure. [61]

Cardiac rehabilitation societies

CR professionals work together in many countries to optimize service delivery and increase awareness of CR. [62] The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), a member of the World Heart Federation, is composed of formally-named Board members of CR societies globally. Through cooperation across most CR-related associations, [63] ICCPR seeks to promote CR in low-resource settings, [64] among other aims outlined in their Charter. [65]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Coronary artery disease</span> Reduction of blood flow to the heart

Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic plaque in the arteries of the heart. It is the most common of the cardiovascular diseases. Types include stable angina, unstable angina, and myocardial infarction.

<span class="mw-page-title-main">Cardiac arrest</span> Sudden stop in effective blood flow due to the failure of the heart to beat

Cardiac arrest, also known as sudden cardiac arrest, is when the heart suddenly and unexpectedly stops beating. As a result, blood cannot properly circulate around the body and there is diminished blood flow to the brain and other organs. When the brain does not receive enough blood, this can cause a person to pass out and become unresponsive. Cardiac arrest is also identified by a lack of central pulses and abnormal or absent breathing.

<span class="mw-page-title-main">Angina</span> Chest discomfort due to not enough blood flow to heart muscle

Angina, also known as angina pectoris, is chest pain or pressure, usually caused by insufficient blood flow to the heart muscle (myocardium). It is most commonly a symptom of coronary artery disease.

<span class="mw-page-title-main">Angioplasty</span> Procedure to widen narrow arteries or veins

Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.

<span class="mw-page-title-main">Statin</span> Class of drugs used to lower cholesterol levels

Statins are a class of medications that reduce illness and mortality in people who are at high risk of cardiovascular disease. They are the most commonly prescribed cholesterol-lowering drugs, and are also known as HMG-CoA reductase inhibitors.

<span class="mw-page-title-main">Implantable cardioverter-defibrillator</span> Medical device

An implantable cardioverter-defibrillator (ICD) or automated implantable cardioverter defibrillator (AICD) is a device implantable inside the body, able to perform defibrillation, and depending on the type, cardioversion and pacing of the heart. The ICD is the first-line treatment and prophylactic therapy for patients at risk for sudden cardiac death due to ventricular fibrillation and ventricular tachycardia.

<span class="mw-page-title-main">Cardiovascular disease</span> Class of diseases that involve the heart or blood vessels

Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases, heart failure, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, arrhythmia, congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic disease, and venous thrombosis.

<span class="mw-page-title-main">Hypercholesterolemia</span> High levels of cholesterol in the blood

Hypercholesterolemia, also called high cholesterol, is the presence of high levels of cholesterol in the blood. It is a form of hyperlipidemia, hyperlipoproteinemia, and dyslipidemia.

<span class="mw-page-title-main">Atorvastatin</span> Cholesterol-lowering medication

Atorvastatin is a statin medication used to prevent cardiovascular disease in those at high risk and to treat abnormal lipid levels. For the prevention of cardiovascular disease, statins are a first-line treatment. It is taken by mouth.

<span class="mw-page-title-main">University of Ottawa Heart Institute</span> Hospital in Ottawa, Ontario

The University of Ottawa Heart Institute (UOHI) (French: Institut de cardiologie de l'Université d'Ottawa ) is Canada's largest cardiovascular health centre. It is located in Ottawa, Ontario, Canada. It began as a department in The Ottawa Hospital, and since has evolved into Canada's only complete cardiac centre, encompassing prevention, diagnosis, treatment, rehabilitation, research, and education.

<span class="mw-page-title-main">Acute coronary syndrome</span> Medical condition

Acute coronary syndrome (ACS) is a syndrome due to decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies. The most common symptom is centrally located pressure-like chest pain, often radiating to the left shoulder or angle of the jaw, and associated with nausea and sweating. Many people with acute coronary syndromes present with symptoms other than chest pain, particularly women, older people, and people with diabetes mellitus.

<span class="mw-page-title-main">External counterpulsation</span>

External counterpulsation therapy (ECP) is a procedure that may be performed on individuals with angina, heart failure, or cardiomyopathy.

P2Y<sub>12</sub> Protein-coding gene in the species Homo sapiens

P2Y12 is a chemoreceptor for adenosine diphosphate (ADP) that belongs to the Gi class of a group of G protein-coupled (GPCR) purinergic receptors. This P2Y receptor family has several receptor subtypes with different pharmacological selectivity, which overlaps in some cases, for various adenosine and uridine nucleotides. The P2Y12 receptor is involved in platelet aggregation and is thus a biological target for the treatment of thromboembolisms and other clotting disorders. Two transcript variants encoding the same isoform have been identified for this gene.

<span class="mw-page-title-main">Troponin I</span> Muscle protein

Troponin I is a cardiac and skeletal muscle protein family. It is a part of the troponin protein complex, where it binds to actin in thin myofilaments to hold the actin-tropomyosin complex in place. Troponin I prevents myosin from binding to actin in relaxed muscle. When calcium binds to the troponin C, it causes conformational changes which lead to dislocation of troponin I. Afterwards, tropomyosin leaves the binding site for myosin on actin leading to contraction of muscle. The letter I is given due to its inhibitory character. It is a useful marker in the laboratory diagnosis of heart attack. It occurs in different plasma concentration but the same circumstances as troponin T - either test can be performed for confirmation of cardiac muscle damage and laboratories usually offer one test or the other.

<span class="mw-page-title-main">Ticagrelor</span> Coronary medication

Ticagrelor, sold under the brand name Brilinta among others, is a medication used for the prevention of stroke, heart attack and other events in people with acute coronary syndrome, meaning problems with blood supply in the coronary arteries. It acts as a platelet aggregation inhibitor by antagonising the P2Y12 receptor. The drug is produced by AstraZeneca.

<span class="mw-page-title-main">Coronary ischemia</span> Medical condition

Coronary ischemia, myocardial ischemia, or cardiac ischemia, is a medical term for a reduced blood flow in the coronary circulation through the coronary arteries. Coronary ischemia is linked to heart disease, and heart attacks. Coronary arteries deliver oxygen-rich blood to the heart muscle. Reduced blood flow to the heart associated with coronary ischemia can result in inadequate oxygen supply to the heart muscle. When oxygen supply to the heart is unable to keep up with oxygen demand from the muscle, the result is the characteristic symptoms of coronary ischemia, the most common of which is chest pain. Chest pain due to coronary ischemia commonly radiates to the arm or neck. Certain individuals such as women, diabetics, and the elderly may present with more varied symptoms. If blood flow through the coronary arteries is stopped completely, cardiac muscle cells may die, known as a myocardial infarction, or heart attack.

<span class="mw-page-title-main">Myocardial infarction</span> Interruption of blood supply to a part of the heart

A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck or jaw. Often such pain occurs in the center or left side of the chest and lasts for more than a few minutes. The discomfort may occasionally feel like heartburn. Other symptoms may include shortness of breath, nausea, feeling faint, a cold sweat, feeling tired, and decreased level of consciousness. About 30% of people have atypical symptoms. Women more often present without chest pain and instead have neck pain, arm pain or feel tired. Among those over 75 years old, about 5% have had an MI with little or no history of symptoms. An MI may cause heart failure, an irregular heartbeat, cardiogenic shock or cardiac arrest.

A diagnosis of myocardial infarction is created by integrating the history of the presenting illness and physical examination with electrocardiogram findings and cardiac markers. A coronary angiogram allows visualization of narrowings or obstructions on the heart vessels, and therapeutic measures can follow immediately. At autopsy, a pathologist can diagnose a myocardial infarction based on anatomopathological findings.

Major adverse cardiovascular events is a composite endpoint frequently used in cardiovascular research. Despite widespread use of the term in clinical trials, the definitions of MACE can differ, which makes comparison of similar studies difficult.

References

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  14. ↑ Zhang Y, Cao H, Jiang P, Tang H (February 2018). "Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study". Medicine. 97 (8): e9785. doi:10.1097/MD.0000000000009785. PMC   5841979 . PMID   29465559.
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  20. ↑ Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL (November 2017). "Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis". Mayo Clinic Proceedings. 92 (11): 1644–1659. doi:10.1016/j.mayocp.2017.07.019. hdl: 10315/38072 . PMID   29101934. S2CID   40193168.
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  32. ↑ Koehler Hildebrandt AN, Hodgson JL, Dodor BA, Knight SM, Rappleyea DL (September 2016). "Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A Systematic Review". Journal of Cardiopulmonary Rehabilitation and Prevention. 36 (5): 320–330. doi: 10.1097/HCR.0000000000000183 . PMID   27496250. S2CID   10829735.
  33. ↑ Grace SL, Shanmugasegaram S, Gravely-Witte S, Brual J, Suskin N, Stewart DE (2009). "Barriers to cardiac rehabilitation: DOES AGE MAKE A DIFFERENCE?". Journal of Cardiopulmonary Rehabilitation and Prevention. 29 (3): 183–187. doi:10.1097/HCR.0b013e3181a3333c. PMC   2928243 . PMID   19471138.
  34. ↑ Leung YW, Brual J, Macpherson A, Grace SL (November 2010). "Geographic issues in cardiac rehabilitation utilization: a narrative review". Health & Place. 16 (6): 1196–1205. doi:10.1016/j.healthplace.2010.08.004. PMC   4474644 . PMID   20724208.
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  36. ↑ Santiago de Araújo Pio C, Chaves GS, Davies P, Taylor RS, Grace SL (February 2019). "Interventions to promote patient utilisation of cardiac rehabilitation". The Cochrane Database of Systematic Reviews. 2019 (2): CD007131. doi:10.1002/14651858.cd007131.pub4. PMC   6360920 . PMID   30706942.
  37. ↑ Aljehani R, Grace SL, Aburub A, Turk-Adawi K, Ghisi GL (April 2023). "Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers". Healthcare. 11 (8): 1196. doi: 10.3390/healthcare11081196 . PMC   10138187 . PMID   37108029.
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  39. ↑ Santiago de Araújo Pio C, Gagliardi A, Suskin N, Ahmad F, Grace SL (August 2020). "Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course". BMC Health Services Research. 20 (1): 768. doi: 10.1186/s12913-020-05619-2 . PMC   7439558 . PMID   32819388.
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